Published 3/28/2026
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Robert L. Parisien MD, FAAOS, FAANA
Rotator cuff tears represent one of the most common causes of shoulder pain and dysfunction, particularly among aging, athletic, and labor-intensive populations. These injuries range from partial-thickness tears to massive full-thickness disruptions and are often associated with tendon degeneration, poor vascularity, and limited intrinsic healing potential.
Despite advances in surgical technique and rehabilitation protocols, rotator cuff repair failure rates remain clinically significant, particularly in large or chronic tears. As a result, there has been growing interest in biologic strategies aimed at improving tendon healing and restoring the native enthesis. Orthobiologic therapies — biologically derived substances such as platelet-rich plasma, stem cells, or growth factors used to enhance the body’s natural healing processes in the treatment of musculoskeletal injuries and degenerative conditions — have emerged as a promising adjunct in the regenerative treatment of rotator cuff pathology.
Biology of rotator cuff healing
The rotator cuff tendon-bone interface is a complex, fibrocartilaginous enthesis designed to withstand high mechanical loads. Following injury or surgical repair, healing typically occurs through the formation of fibrovascular scar tissue rather than true regeneration of the native enthesis. This inferior tissue quality contributes to compromised mechanical strength and higher retear rates. Factors such as patient age, tear chronicity, fatty infiltration, muscle atrophy, and systemic comorbidities further impair healing. Orthobiologics seek to enhance the biologic milieu by modulating inflammation, stimulating cell proliferation, promoting angiogenesis, and improving extracellular matrix deposition.
While not an orthobiologic, corticosteroids should be discussed in the context of their impact on rotator cuff infection and repair. Multiple clinical studies have demonstrated that corticosteroid injection administered within one month before arthroscopic rotator cuff repair is associated with a significantly increased risk of postoperative infection. Elevated infection rates have also been reported when corticosteroids are administered at the time of rotator cuff repair or within the first month following surgery. This association has been observed across large databases and cohort studies evaluating both superficial and deep surgical site infections. The timing of corticosteroid exposure relative to surgery appears to be a critical factor, with the highest risk occurring in the immediate perioperative and early postoperative periods. These findings underscore the importance of avoiding corticosteroid injections in close temporal proximity to arthroscopic rotator cuff repair.
Platelet-rich plasma may improve re-tear rates and structural morphology but clinical outcomes are inconclusive
Platelet-rich plasma (PRP) is one of the most widely studied orthobiologics in rotator cuff disease. PRP is derived from autologous blood and contains a high concentration of platelets that release growth factors such as platelet-derived growth factor (PDGF), transforming growth factor-β (TGF-β), vascular endothelial growth factor (VEGF), and insulin-like growth factor-1 (IGF-1). These mediators play a key role in tendon healing by immunomodulation, enhancing cellular recruitment, collagen synthesis, and angiogenesis.
Clinical studies evaluating PRP in rotator cuff tears have yielded mixed results. In nonoperative management of partial-thickness tears and tendinopathy, PRP injections have demonstrated modest improvements in pain and function in selected patient populations. In the surgical setting, PRP has been used as an adjunct at the tendon-bone interface during arthroscopic repair. Meta-analyses suggest that while PRP may not consistently improve short-term clinical outcomes, it may reduce retear rates in small to medium tears and improve structural healing on imaging. Variability in PRP preparation methods, platelet concentration, leukocyte content, and timing of application remains a major limitation in interpreting the literature.
Early studies show promising outcomes with BMAC-enhanced repairs
Bone marrow aspirate concentrate (BMAC) represents another biologic approach aimed at enhancing rotator cuff healing. BMAC contains mesenchymal stem or stromal cells (MSCs), hematopoietic progenitor cells, platelets, and cytokines capable of promoting tissue regeneration. It is important to note that while mesenchymal stromal cells refer to heterogeneous, multipotent connective tissue-derived cells with supportive and immunomodulatory functions, these cells differ from true pluripotent stem cells, denoting cells capable of differentiating into virtually any cell lineage, a level of developmental potential not characteristic of true MSCs
Early clinical studies have shown encouraging results with BMAC augmentation during rotator cuff repair. Improved tendon integrity, reduced retear rates, and enhanced MRI healing characteristics have been reported, particularly in larger or high-risk tears. However, the absolute concentration of stem cells in BMAC is relatively low, and outcomes may be influenced by patient age, harvest site, and processing techniques. Larger randomized controlled trials are needed to better define the clinical indications and long-term benefits of BMAC in rotator cuff pathology.
Adipose‑derived MSCs show potential in tendon healing, with clinical research still evolving
Adipose tissue is another rich source of MSCs and has gained interest due to its relative abundance and ease of harvest. Microfragmented adipose tissue and stromal vascular fraction (SVF) contain adipose-derived stem cells, growth factors, and extracellular matrix components that may support tendon healing. Preclinical studies suggest adipose-derived MSCs can improve collagen organization and biomechanical strength at the repair site.
Clinical evidence in rotator cuff disease remains limited but continues to evolve. Early investigations suggest the therapy has potential benefits in pain reduction and functional improvement for partial-thickness tears and chronic tendinopathy. Regulatory considerations currently limit the widespread use of enzymatically processed SVF in many jurisdictions, and standardization remains a challenge.
Scaffold-based biologics and augmentation patches offer structural support and may improve healing when paired with PRP or BMAC
Biologic scaffolds, including extracellular matrix (ECM)-based patches derived from human or animal sources, represent another orthobiologic strategy. These scaffolds provide a structural framework that supports cellular infiltration and tissue remodeling while reducing mechanical strain on the repaired tendon. When combined with biologic agents such as PRP or BMAC, scaffolds may further enhance regenerative potential.
Clinical studies have demonstrated reduced retear rates and improved tendon thickness with patch augmentation, particularly in massive or revision rotator cuff repairs. However, cost, risk of inflammatory reactions, and variable integration remain important considerations.
Nonoperative applications of orthobiologics
Beyond surgical augmentation, orthobiologics play an expanding role in nonoperative management. PRP and cell-based injections have been explored as alternatives for patients with partial tears or early degenerative disease or those who are poor surgical candidates. These treatments aim to reduce pain, improve function, and potentially slow disease progression. While symptomatic improvement has been reported, evidence supporting true structural regeneration in nonoperative settings remains limited.
Variability, limited evidence, and regulatory and cost issues hinder wider adoption
Despite growing enthusiasm, several challenges hinder the widespread adoption of orthobiologics in rotator cuff care. Heterogeneity in biologic formulations, lack of standardized protocols, variable regulatory oversight, and inconsistent outcome measures complicate interpretation of existing studies. Additionally, many biologic therapies are not covered by insurance, raising concerns regarding cost-effectiveness and equitable access.
Conclusion
Orthobiologics represent a rapidly evolving frontier in the regenerative treatment of rotator cuff tears. Continued high-quality research and standardized protocols will be essential to fully integrate orthobiologics into evidence-based rotator cuff care.
Robert L. Parisien, MD, FAAOS, FAANA, is a board certified orthopaedic sports medicine surgeon and associate professor at the Icahn School of Medicine at Mount Sinai in New York, specializing in minimally invasive and cartilage restorative arthroscopic surgery of the shoulder, hip and knee. Dr. Parisien serves as a team physician for the US Ski & Snowboard and USA Fencing teams and previously provided court-side care as a player physician at the US Open Tennis Championships in New York.