Dot is a New Yorker whose passion is swimming.

She has a long history of shoulder pain that never got in the way over decades of swimming. In early September of 2013 she had a severe attack of right shoulder pain that went on for several months. Her diagnosis was shoulder impingement syndrome which lead to progressive fraying and tearing of the supraspinatus tendon. She attributed the pain to more frequent swimming sessions.

Her pain was so bad that it impacted her ability to carry items and lie on her right shoulder while sleeping. The pain even woke her up at night.

Learn more with this short video on shoulder impingement syndrome

Imaging

September, 2013- MRI right shoulder noted a severe supraspinatus tendinosis at the insertion on the humerus with a focal full thickness tear (yellow arrow).

September, 2013- A right shoulder ultrasound evaluation noted tendinosis and a partial to complete tear of the supraspinatus tendon (red arrow) and bony irregularity (blue arrow) indicating tissue overload and incomplete healing for many years.

Management

Early September, 2013- Several sessions of physical therapy severely exacerbated her pain so she had to stop.

September, 2013- Ultrasound-guided supraspinatus tendon insertion corticosteroid injection- slightly helpful but not with longstanding improvement.

Platelet-rich plasma therapy

Late September, 2013- Platelet-rich plasma procedure into the right supraspinatus insertion with 50% improvement after several weeks.

Early October, 2013- Platelet-rich plasma procedure into the right supraspinatus insertion with a total of 90% improvement after several weeks with an eventual return to swimming.

December, 2015- The patient remains pain-free. A follow-up ultrasound image of the supraspinatus tendon noted increased tendon thickness (red arrow) and decreased bony insertion irregularity (blue arrow) which is associated with the healing process.

A very grateful patient

What is regenerative medicine?

Your body is constantly focused on the repair, replacement and maintenance of tissues in your body. Tissues such as nerves, bone, tendon, muscle, ligament and connective tissue need constant maintenance to function properly. Long-standing disease, injury or poor lifestyle and dietary choices can overwhelm your body’s natural repair mechanisms creating a cascade of breakdown. At first micro-injuries can occur which go unnoticed. Overtime repeat injury at the same location builds up resulting in a macro-injury that can be very noticeable when it interferes with your daily or recreational activities. This is the time you consider a physician’s visit.

Conventional treatments such as corticosteroid injections decrease inflammation and pain and delay the repair of tissues. Physical therapy is helpful in improving biomechanics which changes with the onset of pain and tissue damage as your body finds ways to limit further injury and pain. Surgery can help repair severe injuries but it is focused on salvaging the remaining tissues. New regenerative treatments have been found to restart and promote the healing process giving tissues a second chance to return to normal. Different approaches are used, based on the type of tissue injury and can include a subcutaneous perineural injection series, nerve hydrodissection, fascial interrogation or barbotage, prolotherapy, platelet-rich plasma and stem-cell based therapies. These therapies are gaining popularity as emerging clinical experience and research validates their utility and superiority in tissue repair compared with conventional treatments.

What steps are involved in regenerative medicine techniques?

The first step in regenerating tissue is to correctly and accurately identify the source of the injury or pain. This can be a challenge as by the time the patient is seen in the office their body has accommodated to the pain resulting in biomechanical deterioration. Biomechanical deterioration places surrounding tissue at risk of injury as well as potentially creating several layers of painful tissues.

The first step is a comprehensive history and physical examination by an experienced physician. This may be accompanied by dynamic musculoskeletal ultrasound imaging or magnetic resonance imaging (MRI) to determine the status of the underlying tissues. A treatment plan is then decided upon based on review of all the data. Treatments can include:

Perineural therapy (Neural prolotherapy)

Perineural therapy involves the use of micro-injections to treat the small nerves within the fascia that often endure chronic nerve compression due to poor posture or biomechanics.

Nerve hydrodissection

Nerve hydrodissection is an ultrasound technique for nerve compression which is used to free compressed nerves from surrounding soft tissues. This allows the blood supply to the local nerve tissue to recover which decreases nerve sensitivity.

Fascial interrogation/barbotage

Fascial interrogation/barbotage is an ultrasound technique for soft tissue compression which is used to soften sclerotic and fibrotic fascial tissues that have sustained chronic and prolonged tissue overload.

Prolotherapy

Prolotherapy has been traditionally used to strengthen ligaments and tendons using a proliferation agent or newer agents such as platelet-rich plasma (growth factors) and stem cells.

Platelet-rich plasma (PRP)

Platelet-rich plasma entails isolation and concentration of platelets from your blood followed by placement at the site of injury. Platelets contain a large and concentrated amount of growth factors that, when released, hone in on the damaged tissue and signal for the recruitment of stem cells to repair the region.

Stem cells

Stem cells are used similarly but can be more robust and entail the isolation of stem cells directly from either bone marrow or fat. These treatments are a good option should an individual have insufficient success with simpler treatments and can offer superiority by beginning the process of tissue repair to promote long-term success.

How can I maximize the effect of regenerative treatments?

Healing is not independent of your biochemical and nutritional status. The more you can optimize your diet and nutritional status, the higher the likelihood of a great outcome. It is also important to maintain and improve your overall musculoskeletal strength and flexibility as well as optimize your sleep habits and decrease your stress levels. Finally, you should quit smoking, frequent alcohol consumption and any other substance abuse.

What else do I need to know about these treatments?

Regenerative treatments take patience and should not be considered a quick fix. When they are effective they are considered more permanent than conventional treatments. You have the best chance of having a great result with patience and some hard work on your part.