1. Injections (Steroids – Hyaluronans)
Injections are regularly used to treat shoulder and elbow pain, as well as being a useful aid to diagnosis.
Steroids have traditionally been used for this, can be very effective in giving pain relief when the tissues are inflamed but they do have a number of side effects.
Hyaluronans (HA) are a new alternative to steroids and offer a number of benefits over steroids.
HA naturally occurs in joints. It acts as a lubricant and shock absorber, as well as providing adequate nutrition to the cartilage.With wear and tear (joint degeneration) the natural HA in the joint is reduced. This has led to the development of HA injections (known as viscosupplementation).
HA injection works by restoring the normal balance between the breakdown and production of HA in the joint. It also coats the pain receptors and inflammatory cells in the joint. These effects mean that it can decrease pain and stiffness of the joint. It also restores the physiological elasticity to the joint fluid making the joint more mobile and daily activities are made easier. HA viscosupplementation is beneficial for patients who have experienced or may experience adverse effects with antiinflammatory medications (NSAIDs). It can be mixed with local anaesthetics and injected safely into the shoulder joint
2. PRP (Platelet Rich Plasma)
Growth Factors are an essential part of the body’s healing process. These are molecules that trigger the various stages of the healing of tendons, ligaments and bones.
When injury occurs, the damaged cells and exposed collagen proteins stimulate an inflammatory process. Platelets are the first cells to arrive at the injured site and release growth factors which start the healing process. This is followed by leukocytes (white blood cells) which also release growth factors. The white cells then start clearing the site of debris. At about 7 days growth factors activate fibroblasts to produce type 3 collagen forming a strong scar tissue. After about 21 days the scar tissue starts to be replaced with normal tissue (type 1 collagen) and the healing process proceeds to completion.
Since platelets found in blood are a very rich source of growth factors scientists have worked at utilising platelets from a patient’s own blood, by isolating, concentrating and activating the platelets to increase the growth factor content four fold. In addition, useful white cells are also included to assist healing further by reducing inflammation and fighting infection. This is known as Platelet Rich Plasma (PRP).
Many studies suggest that platelet rich plasma may help in the healing process by concentrating the growth factors all at once in the correct location. PRP has been used since the 1970s, but research and technology have advanced rapidly demonstrating it’s advantages and applications for many tendon and bone injuries.
Because the materials used in the treatment are derived from your own body, the chance of adverse drug reactions is eliminated, making the process completely safe. In addition, with the use of closed PRP systems, no other product or material is allowed to enter during the PRP production process. The systems can also be completely automatic, which allows for consistent reproducible concentrates of PRP.
PRP is currently used for tennis elbow, rotator cuff injuries, muscle injuries, fractures, many other tendon, ligament and bone injuries and lately in early stages of osteoarthritis.
Blood is withdrawn, spun in a centrifuge for 10 minutes at 200 RCG and separated into its various components. The bottom layer contains most of the red blood cells, while the top layer consists mostly of plasma and platelets. This top layer is the PRP (Platelet-Rich Plasma) which is taken out and the Red Blood Cells discarded. As a concentrated source of platelets, PRP contains several different growth factors and other cytokines that accelerate and enhance the healing of bone and soft tissue. The PRP is then activated under AdiLight-2 for 10 minutes since this has been shown to significantly reduce pain and further accelerate healing. While PRP treatment (without photoactivation) is fast becoming a popular new treatment for muscular and skeletal injuries, it is also known to cause aggravated pain in the affected area for 2-10 days after injection. Once the PRP is prepared, it is injected back into the affected area.
Types of growth factors in PRP
1. Platelet derived growth factor (PDGF). It is a protein produced by platelets, macrophages and endothelial cells and stored in the platelets healthier granules. It is released when the platelets group together thus starting the coagulation cascade. The connective tissue cells of this area respond by initiating a replication process.
2. Vascular endothelial growth factor (VEGF). This has immune acid similarity of 24% to PDGF beta but joins different receptors and so provokes different biological effects. It is a powerful mitogene for endothelial cells and produces angiogenic actions in VEVO.
3. Transforming growth factor (TGF). This is a super family of proteins that includes morphogenic bone proteins and others. It has three fundamental functions.
Modulates cell proliferation (it is a suppressor).
Increases the synthesis of extra-cellular cell matrix.
Produces an immune-suppressor effect.
4. Insulin like growth factor Types i and ii. These are found in large quantities in the bone. They increase the number of osteoclastic multinucleated cells. The differentiation and Type I collagen biosynthesis.
5. Fibroblast Growth Factor (FGF). Stimulates angiogenesis, endothelial cell proliferation and collagen synthesis.
6. Connective Tissue Growth Factor (CTGF). Promotes angiogenesis, cartilage regeneration and fibrosis and platelet adhesion top top
Evidence for the benefits of PRP
Platelet Rich Plasma (PRP) is not a new an experimental technique. It has been widely studied since the early 1980’s and the first publication on it’s benefits for muscle healing was published in 1986 . Since then there have been many in-vitro clinical studies demonstrating it’s benefit in enhancing the healing process in numerous areas of the body:
- Tennis Elbow
Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Am J Sports Med 2006;34:1774 – 1778.
- Rotator Cuff
DeOrio JK, Cofield RH. Results of a second attempt at surgical repair of a failed initial rotator cuff repair. J Bone Joint Surg Am 1984;66:563 – 567.
PIETRO S. RANDELLI, PAOLO ARRIGONI, PAOLO CABITZA, PIERO VOLPI MD, & NICOLA MAFFULLI. Autologous platelet rich plasma for arthroscopic rotator cuff repair. A pilot study. Disability & Rehabilitation. 2008
- Achilles tendon
Sanchez M, Anitua E, Azofra J, Andia I, Padilla S, Muljika I. Comparison of surgically repaired Achilles tendon tears using platelet-rich fibrin matrices. Am J Sports Med . 2007;35:245 – 251.
- Muscles tears:
Jodczyk K J, Bankowski E, Borys A. Stimulatory effect of platelet-breakdown products on muscle regeneration. Zentralbl Allg Pathol 1986; 131 (4): 357-61.
- Knee Surgery
Everts PA, Devilee RJ, Oosterbos CJ, Mahoney CB, Schattenkerk ME, Knape JT, van Zundert A. Autologous platelet gel and fibrin sealant enhance the efficacy of total knee arthroplasty: Improved range of motion, decreased length of stay and a reduced incidence of arthrofibrosis. Knee Surg Sports Traumatol Arthrosc 2007;15:888 – 894.
- Medial collateral ligament of the knee:
Hildebrand K A, Woo S L, Smith D W, Allen C R, Deie M, Taylor B J, et al. The effects of platelet-derived growth factor-BB on healing of the rabbit medial collateral ligament. An in vivo study. Am J Sports Med 1998; 26 (4): 549-54.
Batten M L, Hansen J C, Dahners L E. Influence of dosage and timing of application of platelet-derived growth factor on early healing of the rat medial collateral ligament. J Orthop Res 1996; 14 (5): 736-41.
3. Stem cells
It has been shown that stem cells may be able to help with joint pain and increase function in patients with severe arthritis.
The following steps describe in detail what happens in a degenerating joint, before and after the injection of stem cells:
In a degenerating joint with severe arthritis, the lining of the joint (called the synovial lining) becomes thickened with macrophages. These cells destroy the cellular debris and help clean up the garbage in the joint.
The problem with arthritis is that the cartilage breakdown products activate the macrophages in the synovial lining of the joint and that these activated macrophages in turn start breaking down more cartilage.
The stem cells that have been injected into the defective area, detect and then bind and deactivate the macrophages, preventing their ability to further destroy the joint.
At the same time, the stem cells produce variety of proteins (mainly “helper” growth factors), that activate the body’s internal ability for regeneration, promoting this way tissue repair.
Finally, part of the injected cells will be differentiated into cartilage, completing this way a cascade of events that take place into the osteoarthritic joint.
The inactivation of the macrophages and the secretion of “helper” growth factors explains the long-term anti-inflammatory effect seen with stem cells. This mechanism of action shows how stem cells may decrease pain and swelling. The above model also suggests that stem cells have a disease modifying effect, by restoring the balance of cells within the joint: there is an increase in the number of “facilitating” stem cells and a decrease in the number of “destructive” macrophages, reducing this way the self-destruction of the joint.
Collection of a small amount of adipose tissue – fat tissue – using a small punch biopsy (5mm).
Proliferation of the cells: The stem cells are expanded for approximately 3-5 weeks to obtain an adequate amount of cells.
Rejuvenation and priming of stem cells: The application of this methodology leads to a final cell population that is composed mainly of younger and therefore more potent stem cells. Additionally, the stem cells are activated (“primed”), so that they possess an enhanced chondrogenic potential (they have an improved ability to regenerate cartilage tissue).
Injection: After the cells have been grown, they are tested by our lab scientists for their quality and they are then sent to the doctor for simple injection into the precise area of injury
4. Physiotherapy – Kinesiotherapy
Shoulder & elbow surgery cannot be performed in isolation and requires the expertise of specialist therapists to get the best results. In addition physiotherapy and kinesiotherapy is the final treatment for a large number of shoulder & elbow non surgical pathologies.
In our practice we use specially designed rehabilitation protocols for every surgical or any other shoulder & elbow pathology. These protocols are used by experienced therapists at the Shoulder & Elbow Department of The Royal Liverpool and Broadgreen University Hospitals in UK which is considered a center of excellence for these pathologies.
Arthroscopy is commonly known as ‘key hole surgery’. usually two or three 5mm puncture wounds are only required, avoiding large wounds and scars.
Most shoulder operations can now be done by arthroscopy, rather than open surgery.
Arthroscopic surgery has the following advantages over open surgery, since smaller incisions are made and there is less dissection to surrounding structures.:
1. Recovery is usually quicker after arthroscopic surgery
2. Post-operative pain is usually less.
3. The operations can be done as a Day case
4. There may be less complications of surgery
The shoulder joint is examined using a tiny telescope with television camera introduced through a small ‘key hole’. This telescope and camera is known as the Arthroscope. It allows the surgeon to see the area where he or she is working on a TV screen. Through other small incisions, the surgeon can insert special instruments.
The types of disorders that can be diagnosed with arthroscopy include tears, swelling, abnormal formations, detachments, loose fragments (loose bodies), and arthritis.
Arthroscopic surgery of the elbow is challenging because of the joint’s anatomy. The bones lie close together, and nerves and blood vessels are located very close to the joint. Therefore, the doctor must be especially careful when inserting the arthroscopic instruments into the joint.
Although it is a difficult procedure, arthroscopic surgery is often the ideal choice for treating certain elbow conditions. An injury or arthritis can damage the ends of the bones and cause bone spurs to develop. These spurs can be painful and make it hard to move the elbow. We can remove the spurs by using special tools, such as a burr, inserted into the joint through the portals or small incisions. After the spurs are removed, the elbow moves more easily and with less pain.
An elbow arthroscopy introduces an arthroscope (small ‘telescope’) into the elbow joint through several small 2-3 millimeter incisions.
The arthroscope is used to identify the location of the loose bodies and the spurs.
The loose bodies can be removed by using the arthroscope in addition to small grasping instruments. The bone spurs can be removed by visualizing the spur with the arthroscope and using a small burr to remove the spur.
These arthroscopic procedures take about 30-120 minutes and are done on an day-case basis (without an overnight stay in the hospital).
6. Open Surgery
Open surgery may be necessary in shoulder and elbow pathologies such as fractures or arthritis. In specific cases, open surgery can be done through small incisions of just 4 – 5 centimeters and in all cases we use the less traumatic surgical approaches for better results and faster rehabilitation.
In addition, patient should know that recovery and rehabilitation is related to the type of surgery performed inside the shoulder or the elbow, rather than whether there was an arthroscopic or open surgical procedure.
There are always some risks with any surgery, even arthroscopic procedures. These include possible infection, and damage to surrounding nerves and blood vessels. However, modern surgical techniques and close monitoring have significantly minimized the occurrence of these problems.
After surgery, some pain, tenderness, and stiffness are normal. You should be alert for certain signs and symptoms that may suggest the development of complications.
Fever after the second day following surgery
Increasing pain or swelling
Redness, warmth, or tenderness which may suggest a wound infection
Unusual bleeding (some surgical wound drainage is normal and, in fact, desirable)
Numbness or tingling of the arm or hand
Some surgical procedures require hospitalization for a number of days.
After surgery it is important that patient continue a shoulder exercise program with daily stretching and strengthening. In general, patients who faithfully comply with the therapies and exercises prescribed by the surgeon and physical therapist will have the best medical outcome after surgery.