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Orthopedics

We no longer offer PRP and Stem Cell procedures until further scientific evidence of its efficacy. We do PROLO Therapy for specific orthopedic conditions.

Rotator Cuff Tendinopathies: A case for regenerative injection therapies?

 Rotator Cuff Tendinopathies: A case for regenerative injection therapies?

A painful shoulder is one of the most common complaints seen by orthopaedists.  Athletes who participate in repetitive overhand throwing sports such as baseball, basketball, and volleyball are at increased risk for shoulder injuries.  The same holds true for those who work in an occupation requiring overhead activity.  Pain and dysfunction to the shoulder(s) can also arise from normal aging.  The term rotator cuff syndrome is often used when referring to tearing within the rotator cuff tendons.

 

Anatomically, the rotator cuff is made up of four tendons: supraspinatus, infraspinatus, subscapularis and the teres minor.  These tendons originate along the scapula and attach at various points along the head of the humerus.  Within the shoulder there are several bursa which normally facilitate smooth gliding of the tendons and muscles.

Many painful conditions related to overuse that encompass the rotator cuff tendons and surrounding soft tissues, are commonly referred to as rotator cuff tendinopathy.  Rotator cuff tendinopathy is a very complex, multifactorial process involving both intrinsic (within a tendon) and extrinsic (outside of a tendon) factors.  Clinically, patients often complain of pain with specific motions such as reaching overhead, with lifting, and often at night when sleeping on the affected shoulder. Loss of normal range of motion may also be present with forward elevation of the shoulder and with abduction (moving arm away from the body).  Weakness and further loss of motion often result from disease progression. These symptomatic complaints may be caused by underlying degenerative changes within the tendons resulting in mechanical overload. Additionally, compression on the tendon(s) caused by bony structures may also accompany the forementioned intrinsic factors.

 

The combination of a good detailed patient history of complaints, a sound physical examination, and an MRI of shoulder can help the physician provide the proper clinical diagnosis and direct treatment.  Traditionally, treatment for tendinopathies has included NSAIDs, physical therapy, and corticosteroid injections.  Many can be successfully managed utilizing these non-surgical treatments.  As previously mentioned, rotator cuff tendinopathy is a complex condition and in some cases traditional treatments fail to help improve symptoms.   While there are varying surgical options depending on the specific underlying issue(s), the risks of the procedure and outcomes must be weighed.

In the last decade, the use of regenerative injection therapies for rotator cuff tendinopathies, has been developed and continues to evolve. Prolotherapy, Platelet-Rich Plasma (PRP), and even stem cell therapies have been applied.  Presently there is limited data to support regenerative injection therapies as a part of a standard medical treatment plan for rotator cuff tendinopathies.  However, its use has been reported with increasing frequency by the media among professional athletes.

A few randomized controlled trials and prospective studies utilizing Prolotherapy and/or PRP have been published in the last few years. Outcome measures have focused on pain scales, patient satisfaction, and disability indexes (Western Ontario Rotator Cuff Index, Shoulder Pain and Disability Index).  The results for the most part have been positive.  Further studies to show efficacy are needed.

 

References:

Bertran H, Reeves KD, Bennett CJ, Bicknell S, Cheng AL. Dextrose Prolotherapy versus Control Injections in Painful Rotator Cuff Tendinopathy. Arch Phys Med Rehabil. 2015 Aug 21.

Scarpone M, Rabago D, Snell E, Demeo P, Ruppert K, Pritchard P, Arbogast G, Wilson JJ, Balzano JF. Effectiveness of Platelet-rich Plasma Injection for Rotator Cuff Tendinopathy: A Prospective Open-label Study. Glob Adv Health. Med. 2013 Mar;2(2):26-31.

 

 

 

Regenerative Injection Therapies for Hip Bursitis

Regenerative Injection Therapies for Hip Bursitis

Trochanteric bursitis, or hip bursitis, as it is commonly referred to as, is a common orthopedic condition that normally is self-limiting. The condition refers to inflammation of a fluid filled sac (bursa) that sits along the outside of the hip. This area, known as the greater trochanter, is formed from the upper end of the femur bone. This is attachment point for muscles and tendons and is an area where friction may develop. The body’s response to friction is to produce bursa tissue.

What causes bursitis and what are the common symptoms?

Trochanteric bursitis typically develops gradually. Injury to the lateral (outside) part of the hip, an overuse injury such as standing for prolonged periods of time, poor posture, lower spinal related disorders, calcium deposits in the surrounding tendons, a sudden change in a workout or training routine, a leg length discrepancy, and other medical conditions such as rheumatoid disease, gout, or thyroid disease can cause hip bursitis. Bursitis also may develop following a hip replacement.

Pain usually develops along the outside of the hip and may begin to radiate downward. There may be tenderness along the bony ridge that forms the greater trochanter. There may be pain with standing from a seated position or with stair climbing. As the disease progresses, increased stiffness within the hip may lead to a limp. Sufferers of hip bursitis often complain of increased pain at night while lying on the affected side.

Treatment for trochanteric bursitis may include activity modification, rest, non-steroidal anti-inflammatory (NSAID) medication, and physical therapy and corticosteroid injections. As systematic review published by Lustenberger et al (2011) found that as many as 33% of patients treated required a second corticosteroid injection to alleviate symptoms of hip bursitis while some had 5 injections!

Surgical management of trochanteric bursitis may be recommended for those who have tried and failed all of the conservative treatment options and still remain symptomatic.
A 2014 study published by the American Academy of Orthopaedic Surgeons (AAOS), compared a single corticosteroid injection to a single platelet rich plasma (PRP) injection for chronic hip bursitis. Twenty patients were included in each group. Outcomes were measured based on validated outcome questionnaires that looked at pain levels, function, and stiffness. Patients treated with PRP had greater improvements in post-treatment scores and had lasting effect (at 1 year after injection) whereas those treated with a cortisone injection had scores that returned back to pretreatment levels within 3 months. The results of the small study appear promising, but further well controlled studies are needed to fully delineate the effectiveness of PRP injections for hip bursitis.
At present, the medical literature is very limited on studies looking at PRP injections and Prolotherapy for hip bursitis. There are a few case reports about patients being successfully treated with either PRP or Prolotherapy. Both PRP and Prolotherapy appear safe and may offer suffers long lasting relief.

Hip bursitis is one of the most common causes of pain in the adult population. It is normally a condition that can be treated non-surgically for most. Unfortunately, some will not improve with treatment resulting in a chronic condition that is much harder to cure. Regenerative injection therapies such as PRP and Prolotherapy should be considered if clinical improvements are not seen early in the treatment process.

References:
Lustenberger DP, Ng, YV, Best TM, Ellis TJ. Efficacy of Treatment of Trochanteric Bursitis: A Systematic Review. Clin J Sports Med. 2011 Sept: 21(5): 447-453.
Monto RR. Paper #778. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 11-15, 2014; New Orleans

Platelet Rich Plasma (PRP) Therapy in Orthopedics

Platelet Rich Plasma (PRP) has been used since the 1970’s. The last decade has seen tremendous focus on PRP applications in musculoskeletal medicine. The potential for PRP to promote tissue healing following injury or disease is attractive to many physicians, researchers, and patients alike. Unlike medications or cortisone injections which suppress or mask the underlying problem, PRP shows the potential to heal. The risk of disease transmission is limited since PRP is derived directly from a patient’s own blood. On the flip side, there is significant variability in PRP concentrations from one patient to another. This combined with different methods of preparing PRP, timing, and the selection of activating agents all present challenges in studying and standardizing treatment protocols.

Published studies of PRP use in adults and in animal models have shown promise for a number of orthopedic related conditions. This is especially the case for tendon and soft tissue injuries. The specific mechanism of how PRP works remains elusive, but several well controlled studies have shown positive outcomes with no significant adverse events.

In simplest form, when an injury occurs, the body’s own platelets release co-factors that stimulate recruitment of mesenchymal stem cells (MSCs) to the site of injury. Additionally, inflammation is reduced during this cascade of events and healing is promoted. Some of the known components of PRP included platelet-derived growth factors, insulin-like growth factor, transforming growth factor-beta, fibroblast growth factor-2. Each of these have differing functions in the healing and reparative process.

To date, many professional athletes have been treated with PRP injections. Success rates that appear in the published literature and across the web vary considerably. Some are reported at greater than 90%. Caution must be exercised in interpreting these results as outcome measures vary. Again it is very difficult to compare studies or even one individual versus another due to the issues described above.

We are just beginning to understand how PRP can be used and how effective it can be in the treatment of certain orthopedic conditions.