Chiropractor Chandler AZ

PLATELET-RICH PLASMA PROLOTHERAPY FOR SHOULDER PAIN

The shoulder joint is one of the most important joints in the body because it allows the wide range of motion to the arm. It is a complex structure, secured in place by muscles, tendons, and ligaments. Due to its high mobility, it is also susceptible to injuries. Shoulder injuries are quite common among athletes. A shoulder injury can also occur during everyday activities as well. The prevalence of shoulder injuries is higher in people above the age of 45 and is more common in women as compared to men. In 2006, 7.5 million people were reported to have shoulder problems such as shoulder and upper arm sprains and strains. 4.1 million people were reported to experience shoulder pain due to a rotator cuff injury.

ANATOMY OF THE SHOULDER JOINT

The shoulder joint is made up of three bones:

• Humerus – Upper arm bone
• Scapula – shoulder blade
• Collarbone – Clavicle

The scapula has a rounded socket in which the head of the humerus is fitted. This socket is called the glenoid. The head of the humerus is secured into the glenoid with the help of a combination of tendons and muscles. These tissues are called the rotator cuff. Rotator cuff tissues cover the head of humerus and attach it to the scapula.

RISK FACTORS OF A SHOULDER INJURY

The following factors can increase the risk of having a shoulder injury:

• Age: The risk of shoulder injuries increases with age. People above the age of 40 are more susceptible to a shoulder injury.
• Sport: Certain sports such as swimming, tennis, archery, and baseball which involve repetitive arm motions, increase the risk of a shoulder injury.
• Occupation: Certain occupations like construction related jobs such as carpentry or house painting that require repetitive arm movements increase the risk of shoulder damage.
• Genetics: Some shoulder injuries such as rotator cuff injuries can sometimes be caused by genetics.

CAUSES OF SHOULDER INJURIES

Most shoulder injuries can be sorted into four categories:

• Tendon inflammation and tendon tear
• Instability
• Arthritis
• Fracture

Less common causes can be:

• Tumours
• Infection
• Nerve-related problem

BURSITIS

Bursae are the small fluid-filled sacs that are located in joints and act as cushions between bones and soft tissues. They help reduce the friction between muscles and the bones. Excessive use of the shoulder joint leads to inflammation of the bursa in the shoulder joint, known as subacromial bursitis. The tissues in the shoulder become inflamed and painful which makes it difficult to perform activities like combing hair and getting dressed.

TENDINITIS

Tendinitis is caused by wear and tear of the tendons over a long period of time. Acute tendinitis can be caused by overhead activities, while chronic tendinitis can be caused by degenerative diseases like arthritis or age. The most commonly affected tendons in the shoulder are the rotator cuff tendons. Due to inflamed tendons, shoulder joint movements are hindered.

TENDON TEARS

Acute injury to the shoulder or a degenerative change can lead to splitting and tearing of the tendon. A tendon tear can be partial or complete. In the case of a complete tear, the tendon is pulled away from its attachment to the bone, making shoulder joint movement very painful and difficult.

INSTABILITY

If the head of the humerus is forced out of the glenoid, it is called shoulder joint instability. It can be caused by sudden injury or from overuse. It can be a partial dislocation of the head of humerus or a complete dislocation in which the head of humerus comes out of the socket. Loose or torn muscles, tendons, and ligaments lead to repetitive dislocation. Recurring dislocation causes pain and unsteadiness in shoulder joint movements and increases the risk of developing arthritis in the shoulder joint.

ARTHRITIS

Arthritis is a very common cause of shoulder pain, especially in elderly people. There are many types of arthritis, but the most common type of arthritis in the shoulder is osteoarthritis. The symptoms of arthritis such as inflammation, pain, and stiffness start during middle age. It develops slowly and the pain gets worse with time. Arthritis can be caused by sports or work injuries, chronic wear and tear, rotator cuff tears, infection and inflammation of the joint lining.

FRACTURE

Shoulder fractures involve the clavicle, humerus, and scapula. In older people, shoulder fractures are caused by a fall. In younger people, shoulder fractures are caused by injuries such as car accidents or sports injuries. Fractures cause severe pain, swelling, and bruising in the shoulder.

DIAGNOSIS OF SHOULDER PAIN

MEDICAL HISTORY

The doctor takes the history of the patient to determine the cause of shoulder pain. As shoulder pain is caused and intensified with certain activities, a detailed history will help to determine the cause of the shoulder pain.

PHYSICAL EXAMINATION

In the case of shoulder pain, a complete physical examination of the shoulder is required. The doctor will look for physical abnormalities, swelling, muscle weakness, and tenderness. The doctor will also observe the shoulder's range of motion and strength.

X-RAYS

X-rays give a picture of the shoulder that shows the injuries to the bones that make up the shoulder joint.

MRI AND ULTRASOUND

These imaging studies help to create the picture of soft tissues and help to identify the ligament and tendon injuries in the shoulder joint.

COMPUTED TOMOGRAPHY (CT) SCAN

A CT scan provides a very detailed view of the bones in the shoulder area, highlighting any abnormality in the shoulder joint.

ELECTROMYOGRAM

It is helpful in evaluating the nerve function in the shoulder.

Arthrogram

It is an X-ray study in which a dye is injected into the shoulder to get a better picture of the shoulder joint and the surrounding muscles and tendons.

TREATMENT OF SHOULDER PAIN

Lifestyle change

Rest, altering activity, and physical therapy is helpful in improving shoulder strength and flexibility. Avoiding activities that can increase the shoulder injury such as overexertion or overdoing activities is also helpful.

Medication

Painkillers and anti-inflammatory medication are prescribed to relieve the shoulder pain. In the case of extreme pain, corticosteroid injections are also prescribed, but they are effective for a short period of time.

Surgery

90% of shoulder pain injury problems are resolved with medication and lifestyle changes. Certain problems such as recurring dislocation and rotator cuff tears cannot be treated with these conventional methods and surgery is inevitable. Surgery can either involve arthroscopy to remove scar tissues or repair torn tissues, or it can be an open procedure for shoulder replacement.

Alternative treatment option

The shoulder problems in which surgery is inevitable are those that involve damaged or weakened muscles, ligaments, tendons, and bones. These cannot be treated by conventional methods because the conventional method cannot regenerate these structures. Thus, any alternative treatment option that can regenerate these structures can be helpful in treating these conditions without surgery.

An alternative treatment option known as Platelet-Rich Plasma Prolotherapy is known to promote the self-healing properties of the body to repair the damaged part. It is a type of Prolotherapy that uses the platelet-rich plasma derived from the patient's own blood to initiate and accelerate the self-healing at the site of injury.

In platelet-rich plasma (PRP) Prolotherapy, the blood is drawn from the patient under sterile conditions. The blood is then centrifuged to separate the platelet-rich plasma from the rest of the components. It is then injected back at the site of injury. The major role of platelets is in blood clotting, but they contain alpha particles that are rich in growth factors, thus platelets also play an important role in tissue repair. After the PRP is injected into the body, it goes through the following stages to repair the damage:

• INFLAMMATION PHASE that lasts for 2-3 days. In this phase, growth factors are released.
• PROLIFERATION PHASE that lasts for 2-4 weeks. It is vital for musculoskeletal regeneration.
• REMODELLING which lasts over a year. In this phase, collagen is matured and strengthened

Side effects associated with this method are minimal. There is no risk of a blood-borne disease transfer and an allergic reaction. The only risks involved are an infection, no relief of pain, neurovascular injury, and scar tissue formation. Loss of limb or death is rare, but possible.

Platelet-rich plasma is proven to be helpful for rotator cuff tears. A research study published in 2012 said that PRP Prolotherapy was effective in stimulating repair of partial thickness tears of rotator cuff tendons.

Frozen shoulder is a condition in which the shoulder capsule becomes thickened. PRP prolotherapy was evaluated as a treatment option for frozen shoulder in a research done in January 2016, the results showed functional improvement and a decrease in shoulder pain. Also, PRP showed no side effects in the patient.

Studies have shown that platelet-rich plasma Prolotherapy increases tendon repair without scar formation. Another study showed a 60% improvement in the patients treated with platelet-rich plasma Prolotherapy for damaged tendons.

PRP prolotherapy is also reported to prevent arthritis from worsening. It not only prevented the damage caused by degeneration, but also repaired the damaged tendons, ligaments, bones, and muscles in the arthritic shoulder.

In the case of fractures, PRP increases the bone cell formation and accelerates the repair process.

For treating shoulder injuries and relieving shoulder pain, PRP Prolotherapy is a very promising treatment option, but more research is required to establish the optimal guidelines for use of PRP Prolotherapy for shoulder pain.

Combining Conservative Treatments with PRP

Combining prolotherapy and stem cell treatments with physical therapy, sports therapy, massage therapy, and exercises enhances recovery and pain free function. People have often tried many of these treatments prior to injection therapy. Combining these treatments with PRP and stem cells maximizes recovery and tissue repair.

Low Level Laser Treatments

1. ACCELERATED TISSUE REPAIR AND CELL GROWTH

Photons of light from lasers penetrate into tissue and accelerate cellular growth and reproduction. Laser therapy increases the energy available to the cell so it can work faster, better, and quickly get rid of waste products. When cells of tendons, ligaments, and muscles are exposed to laser light they repair and heal faster.


2. FASTER WOUND HEALING

Laser light increases collagen production by stimulating fibroblasts. Collagen is the building block of tissue repair and healing. Laser therapy increases fibroblast activity and therefore collagen production to speed healing.

3. REDUCED FIBROUS TISSUE FORMATION

Low-level laser therapy decreases scar tissue formation. Scar tissue can be a source of chronic pain and poor healing. By eliminating excessive scar tissue and encouraging proper collagen production, painful scars and chronic pain is reduced.

4. ANTI-INFLAMMATION

Laser therapy causes vasodilatation (increases size of capillaries) which increases blood flow. The treatments also increases lymphatic drainage to decrease swelling or edema. Therefore, laser therapy reduces swelling caused by bruising or inflammation while speeding the recovery process.

5. PAIN RELIEF

Cold laser therapy decreases pain by blocking pain signals to the brain. Some nerve cells sense pain and send signals to the brain. Chronic pain can be caused by overly active pain nerves. Specific wavelengths help "shut off" the pain signals, thereby eliminating your pain.

Low level lasers are excellent at decreasing inflammation, which also increases pain nerve activity. Cold laser therapy also increases endorphins and enkephalins, which block pain signals and decreases pain sensations. Overall, laser therapy reduces painful nerve signals and reduces your perceived pain.

6. INCREASED BLOOD FLOW

Blood carries nutrients and building blocks to the tissue while carrying waste products away. Increased blood flow to tissues increases and enhances cellular healing. Cold laser therapy increases the formation of capillaries in damaged tissues. Specific laser frequency also increases blood flow to the area treated to enhance injury repair.


7. INCREASED REPAIR AND REGENERATION

Low level lasers increase enzyme activity to improve metabolic activity which affects cell repair and regeneration. The enzymes are turned on "high" to speed the healing.

8. NERVE FUNCTION AND REPAIR

Nerves heal very slowly. Lasers speed up this process. Damage to nerves causes numbness, pain, muscle weakness, and altered sensations. Laser therapy treatments enhance nerve function, healing, and reduce pain.

9. INCREASED ENERGY PRODUCTION - ATP

ATP is like gasoline for cells, it is the energy source that cells operate. Injured cells often have low levels of ATP, which decreases their ability to heal and repair. By increasing ATP and "gasoline storage levels," cells have more ATP for healing and repair. Increased mitochondrial production is very important with nerve pain.

10. ACUPRESSURE AND TRIGGER POINTS

Low-level laser therapy decreases trigger points and stimulates acupuncture points to decrease muscle and joint pain.

We combine low-level laser therapy with a variety of techniques and treatments. Cold laser therapy can be used alone as a single treatment modality or in conjunction with other chiropractic, physical therapy, massage therapy, or medical treatments.

Conservative Treatments

Therapeutic treatments for addressing soft tissue injuries involve massage therapy, manual therapy, trigger point therapy, Graston Technique, or Active Release Technique. These treatments increase blood flow, decrease muscle spasms, enhance flexibility, speed healing, and promote proper tissue repair.

When these treatments are incorporated into a treatment plan, patients heal faster and are less likely to have long-term pain, soft tissue fibrosis, or scar tissue in the injured muscle. These soft tissue treatments are incorporated with cold laser, therapeutic exercise, and flexibility programs.

Treatment for shoulder injuries often requires a variety of exercises, stretches, conservative treatments, medical treatments, and home therapies. Shoulder injuries can become chronic if the appropriate steps are not taken.

Elbow injuries often occur in people with severe or chronic shoulder injuries. People begin trying to alter their shoulder motions to protect it. Unfortunately these altered body mechanics tend to overwhelm the muscles and tendons around the elbow. People often develop a secondary cubital tunnel syndrome, lateral epicondylitis, tricep tendonitis, medial epicondylitis, pronator teres syndrome, double crush, carpal sprains, wrist tendinitis, de quervain's tendonitis, finger extensor strains, or carpal tunnel syndrome.

Treatment for elbow injuries can be extensive if the tendinosis is severe. Mild strains can be treated at home with RICE, home stretches, and exercises. Don't wait for damage to both the shoulder and elbow to seek treatment and therapy.

Many people do have arthritis or degenerative changes in their elbow, wrist, finger, or thumb joints. Arthritis does not mean you will always have pain in the joints. Degenerative arthritis means the structural integrity of the bones have changed which alters its gliding, sliding, and hinging motions.

The more severe the arthritic changes, the easier it becomes to aggravate the joint and produce pain. Low-level laser therapy is excellent at decreasing pain and inflammation in arthritic hand and wrist joint, especially when cold lasers are combined with prolotherapy or stem cell treatments.

The upper extremity works as a comprehensive unit performing many of the repetitive tasks at home, work, and recreational sports. Injuries to one area of the musculature often indicates that additional damage has been incurred by other muscles.

Many therapeutic exercises can help restore proper strength and endurance to the elbow flexor muscles. Isometric exercises are often the initial treatment exercises, followed by single plane rubber band exercises for elbow flexion, extension, pronation, and supination movements. Dynamic exercises involving stability ball push-ups can be performed on the wall or floor. The more unstable the surface, the more effort and stabilization is required of all the upper extremity muscles.

Push-ups on a stability ball enhances neuromuscular learning throughout the neck, scapula, shoulder, upper arm, and lower arm muscles. Additional strength exercises can be found on the arm and shoulder strengthening pages.

BIBLIOGRAPHY:

Alderman, D. D., & Robbins, S. C. (2012). Platelet Rich Plasma Prolotherapy For Rotator Cuff Tears. Practical Pain Management, 21-23.

Aslani, H., Nourbakhsh, S. T., Zafarani, Z., Ahmadi-Bani, M., Ananloo, M. E., Beigy, M., et al. (2016). Platelet-Rich Plasma for Frozen Shoulder: A Case Report. Arch Bone Jt Surg, 90–93.