Have you ever strained your shoulder? I was reminded yesterday that just a few years ago I "pulled something", couldn't raise my arm without the other arm helping out, and was looking at WEEKS off of the rowing team. Unacceptable! Prolotherapy worked wonders and worked quickly, so I asked one of our local prolotherapists to write an article about it, which I am happy to share with you here.
Thank you to Dr. Justin Adams for being part of a well functioning integrative medical team, and for describing his work in this article:
Tom is an active 40-year old and avid volleyball player, who came in to our office complaining of right shoulder pain that began gradually about 6 months prior to our visit. Though there was no acute injury, he states that he first noted the pain after a game. Since that time it had gotten gradually worse, so that now he has pain with any overhead activity, especially volleyball. He cannot sleep on that shoulder and it has gotten to the point where it is even painful to take a sweater on and off or to reach back and get his seatbelt on.
The above patient's story is classic for a chronic rotator cuff injury. The onset can be insidious or acute, and patients often have pain with overhead and reaching activity or pain when trying to sleep on that side. These types of injuries are exceedingly common. In 2008, close to 2 million people in the U.S. saw their doctors for rotator cuff problems.1
On physical examination, Tom has weakness, restricted active range of motion and pain with moving and resisted strength testing. A musculoskeletal ultrasound of the shoulder was performed. His shoulder joint moved well passively and there was no evidence of bursitis, but a partial thickness tear of the supraspinatus tendon was seen, with thickening of the tendon and the increased blood flow typical of a chronic injury.
The shoulder joint is a “ball and socket” joint. It is the joint of three bones: the scapula (shoulder blade), clavicle (collar bone) and humerus (upper arm bone). The head of the humerus is the “ball” of the joint and fits into a “socket” or cup formed by the scapula and clavicle and associated connective tissues. The rotator cuff consists of 4 muscles (the supraspinatus, infraspinatus, subscapularis and teres minor). These muscles hold the “ball” in the “socket” so that the shoulder can move smoothly and also participate in certain movements of the shoulder. If the rotator cuff is sprained or torn, patients can experience weakness and pain, especially with overhead activity.
Tom had received a cortisone shot from his primary care physician approximately 3 months before, which had relieved symptoms somewhat for a couple of weeks, but they had returned.
A corticosteroid shot (such as cortisone) can sometimes be useful to temporarily decrease the thickness of the tendon and relieve this impingement. However, cortisone does nothing to actually heal an injured tendon and in some cases may actually weaken the tendon and increase the risk of a complete or full-thickness tear.
Tom was not satisfied with his brief response to his cortisone injection. He was participating in physical therapy, which was helping with strength and range of motion. However, he was frustrated by his inability to play volleyball or to do work around the house. He was not excited about the idea of surgery and wanted to know if there were any other options. We discussed regenerative injection therapy (RIT) as a possible solution for him.
RIT (also known as prolotherapy) involves the injection of pro-inflammatory substances into the site of chronic connective tissue disfunction. When we injure ourselves, we disrupt connective tissues and cause bleeding and the release of inflammatory chemicals into the site of injury. These tissues then recruit other cells to the area, first to clean up dead and damaged tissue and then to grow new, healthy functional tissue. This process occurs over approximately 4-6 weeks following an injury. After that, the healing response slows considerably. RIT restarts this healing process by causing a small, non-traumatic “injury” or bruise to the area of dysfunction. This stimulates the same healing cascade seen in a traumatic injury but without significant damage. Patients will generally experience a mild exacerbation of pain in the 2-3 days following treatment then notice gradual improvement in pain and function over next 6-8 weeks.
Tom agreed that RIT sounded like a good alternative to help to heal his shoulder. Multiple small injections were made into Tom's tender areas. Ultrasound was used to guide the needle into identified tears. Tom tolerated the procedure very well. He was told that he may continue with daily activity as much as he could tolerate and to continue with his physical therapy exercises. Exercise encourages blood flow, which leads to healing. Active patients like Tom are often pleased to hear that they do not have to stop the activities that they love while undergoing treatment.
Many different substances are used in RIT. “Classic” prolotherapy involves the injection of concentrated glucose into areas of dysfunction. This causes a micro-injury to the cells in the area to stimulate a healing response. In more recent years there has been increasing use of Platelet-Rich-Plasma (PRP) for RIT. For this, a patient's blood is drawn and processed to isolate the platelets in blood, where the growth factors reside. This process increases the number of growth factors at the sight of injury, helping to accelerate the healing process. Finally, stem cells derived from fat (harvested from the patient using a specialized lipo-suction technique) can be used to provide a stem cell source as well as a structure for new growth.
At his 6 week follow up visit, Tom was doing much better. His strength and range of motion were greatly improved and he was back to playing volleyball. In total, he said that he was about 70% better. We repeated his treatment and saw him back in an additional 6 weeks. At that time, he was pain-free and back to full activity. A repeat ultrasound showed resolution of his tears with normal tendon thickness and blood flow.
Regenerative injection therapy can be helpful for pain and dysfunction in many different areas. These include the back and neck, knees, elbows, wrists and ankles. It can be helpful for arthritis and joint instability. There are very few risks of treatment and a growing body of scientific literature supports its use.
For more information please go to www.ritdoc.net
1.American Academy of Orthopedic Surgeons. Web site topic: Rotator cuff tears. Last edited May 2011. Accessed May 1 2012. www.aaos.org
2.Jo D, Ryu K, Yang S, Kim M, The effects of prolotherapy on Shoulder pain. Korean J of Anexthesiology, May 2004, 46(5): 589-592.
3.Sanchez, et al. platelet-rich therapies in the treatment of orthopedic sports injuries. Sports Medicine. 2009; 39(5): 345-354.
4.Aldeman, et al. Stem Cell Therapy in Regenerative Medicine. Background, Theory and Protocols. Journal of Prolotherapy, 2011; 3(3): 689-708.
Personal details and names have been changed to protect patient privacy.