Common Injures of Tennis Players, Their Causes and Treatments

Tennis is a pretty popular sport played all over the world. Matches can be long and there are high forces being generated over and over in the shoulder and elbow. This can result in injuries from overuse in the shoulder and elbow. There are also a lot of quick movements for stopping, starting, and changing direction and this can cause acute injuries in the lower body. This article discusses many common tennis related injuries, why the occur and some basic treatment guidelines.

Changes in equipment have improved performance allowing a faster racquet head which causes higher ball speeds and more spin, but these changes may also be causing increased injury. Increases in racquet and string stiffness will cause an increase in vibration which is transmitted to the arm, and this can create increased forces for the muscles in the arm. Different grips have also been shown to be associated with increased rate of certain injuries. For those using a western or semi-western grip it is more common to have injuries on the pinky side of the wrist and arm, where as those using the eastern grip are more likely to have injuries on the thumb side of the forearm.

Common shoulder injuries are related to the repetitive overhead movements, including the high forces during serving. These include labral injuries, impingements, and rotator cuff injuries and biceps tendonitis. Diagnosis is usually based on physical examination, but can sometimes MRI is requested. Usually treatment for these injures can be non-surgical, improving shoulder blade and muscle function. However sometimes this doesn’t work and surgery is needed to repair damaged tissues.

The most common elbow injury in recreational tennis players is lateral epicondylitis, or tennis elbow. It is more common in recreational players because they tend not to have the correct wrist angle for their back hand, compared to professionals. Most cases will respond well to rest and physical therapy including stretching and strengthening. Sometimes using a larger grip racquet or a brace can improve time to return to playing. If these treatments are not successful the next step is to try a corticosteriod injection and as a last resort surgery to remove the injured area of the tendon, can be very effective.

Injuries in the trunk include abdominal strains. These are usually related to the forces involved in serving. Treatment of abdominal strains includes rest, sometimes even from such simple activities as walking. Then gradual stretching and strengthening before beginning an aerobic conditioning program. Abdominal injuries can last up to or more than six months depending on the severity of the injury, so patience is often required to allow a slow return to play.

Low back injuries can be from a muscle strain or spasm in lumbar muscles. This usually presents with pain or stiffness just located in the back, usually from overuse. A more serious back injury can be from a disc herniation, which can include back pain, leg pain or both. Both these can be treated with rest, over the counter pain killers, and physical therapy. For herniated discs more awareness of movement in the lumbar spine for daily activities and exercises is important. Generally surgery is not needed for these injuries, but time for return to sport can vary a lot. Surgery is usually only indicated if there is frank weakness, bladder dysfunction or persistent pain that isn’t responding to conservative management.

In the lower body, hip and ankle injuries are the most common. They usually involve muscle strains in the hip or ligament sprains in the ankle. Both these types of injuries should respond to rest, ice and physical therapy to improve strength and balance. With ankle sprains, the treatment will be based on the grade of injury and may include a short period of immobilization and then the use of tape or bracing to prevent re-injury.

Fortunately there are successful treatments for most tennis injuries and it usually only means a short time away from the sport. There is also some good research being done on prevention programs to help minimize muscle imbalances and improve form to decrease these chronic injuries of tennis players.

What is the deal with Platelet-Rich Plasma?

Recent treatments for joint pain due to cartilage damage are focusing in the area of less invasive solutions, and platelet-rich-plasma (PRP) is of interest to many clinicians and researchers alike. Platelets are particles in the human bloodstream that contain biological building blocks for tissues such as cartilage. The building blocks in platelets that are theorized to assist in healing include various growth factors and cytokines. The benefit of PRP are that it is a low cost and minimally invasive technique using the client’s own blood, however there is little known about the optimal method for preparing the PRP for the specific purpose of cartilage repair. It is important to find the most beneficial mixture because the growth factors and cytokines that will be released onto the client’s tissue could have very different and potentially detrimental results with only small changes in the concentrations. This particular study was conducted to investigate two different formulas, which have previously been shown to be beneficial, on human cartilage cells and the effects these different formulas will have on these cells.

In this study, blood from ten healthy male subjects was used to prepare two PRP solutions as well as a platelet poor solution (PPP) as a third comparison. The first platelet preparation (P-PRP) had a relatively low concentration of platelets and very few leukocytes. The second preparation (L-PRP) had high concentration of both platelets and leukocytes. The researchers tested these three preparations on cartilage taken from four male subjects all over the age of sixty-two with grade II osteoarthritis who were undergoing major knee surgery, meaning that they had pretty worn cartilage. The cartilage samples were broken down to extract the actual chondrocytes, which are the cells in charge of building new cartilage. Then the samples of chondrocytes were placed in the PRP formula for seven days. There were three preparations of each of the formulas; five, ten and twenty percent concentration of each PRP in order to assess various dose possibilities. Seven days was chosen because the clinical protocol includes a follow up injection at that time.

The growth of the chondrocytes was measured at one hour, three and seven days; genetic markers were measured at seven days; and hyaluronan and lubricin protein levels were also checked at the seven-day marker.

All three preparations increased growth of the chondrocytes, at all three times, but the P-PRP had a significantly increased cell growth on the seventh day. The genetic expressions tested also seemed to favor the P-PRP formula for stimulus of chondrocyte growth, however it appears that the L-PRP also promoted this growth, but through different pathways involving the leukocytes present in this formula. Surprisingly the PPP formula was also able to change the genetic expression similarly to the P-PRP samples, and it is theorized that simply having the plasma proteins and growth factors present in blood plasma will also positively affect cartilage repair. The L-PRP chondrocytes tended to secrete more hyaluronan, but both the L-PRP and the P-PRP caused similar secretion of lubricin. Both hyaluronan and lubricin are involved in joint lubrication.

The findings of this study suggest that more research is needed in this area, and there needs to be consideration taken into account as to the actual biological process that you want to be happening. This study has shown that different formulas of PRP and even PPP all seemed to provide positive effects on the cartilage, but through different pathways, indicating that some formulas could be more useful for different patients depending on their history.

Treatment of Muscle Injuries: Contusion, Strain, or Laceration

There are three major types of muscles injuries: contusion, strain, or laceration. Contusion is caused by a direct and compressive force such as a direct blow. Muscle strain is more often the result of tensile force (tension) beyond what the muscle can stretch. And of course, a laceration or cut is the result of sharp trauma through the skin and fascia down to the muscle.

The successful treatment of muscle injuries depends on understanding what phase of healing is taking place. In the early days (first week) after an injury, the body mounts an inflammatory response. This is sometimes referred to as the destructive phase.

It is during this period of time that the macrophages are released. Macrophages are from the immune system and are designed to destroy damaged, bleeding, or injured cells. Application of the R.I.C.E. approach (Rest, Ice, Compression, Elevation) is the most often recommended treatment during this early acute phase of muscle injury.

But there is really no convincing evidence that this treatment is an effective way to treat soft tissue injuries. In fact, in animal studies, scientists have shown that applying ice too long can actually reduce blood flow to the area impairing recovery. And other studies using compression bandages right away after injury (within the first five minutes) does not decrease the amount of swelling or speed up healing.

Whether or not to immobilize the muscle (in a splint or cast) remains a point of debate and controversy. On the one hand, keeping the muscle from moving during the early healing (destructive) phase can minimize the gap that develops when the ruptured muscle stumps pull apart. As the body sets up a collagen scaffold that will be filled in with repair cells, a smaller gap between the injured tissue means a smaller scar.

On the other hand, immobilizing the damaged soft tissue too long can cause excessive scarring. Since scar tissue is less flexible, the muscle is at risk of reinjury under lower loads or force compared with normal, healthy muscles. And there is clear evidence that early movement aids the regenerating muscle fibers to heal in an organized fashion. With early mobilization and better tissue alignment, fewer adhesions can form.

Scar tissue formation and tissue regeneration takes place in stages during the repair and remodeling phase. Repair occurs two to six weeks after the injury. Remodeling begins around week seven and extends weeks to several months following the initial trauma.

The process of tissue regeneration and scar formation is orderly but complex. The formation of scar tissue undergoes several steps from immature scar tissue to mature scar development. Connective tissue scarring is strong to help prevent further injury or rerupture but it is not as flexible as the myofibrils of normal, healthy muscle.

Treatment also depends on the severity of muscle injuries (mild, moderate, or severe). Accompanying swelling, loss of motion, tearing of muscle fibers, and loss of function help determine how the muscle injury is classified. Mild injuries usually have only minor swelling and pain with no loss of motion or function. Complete rupture of a muscle will be obvious when the patient cannot contract or use that muscle to move the body part (e.g., arm, leg).

Whereas nonsteroidal antiinflammatory drugs (NSAIDs) were once routinely prescribed after muscle injury, more recent (animal) testing has brought about a change in thinking here as well. For example, there is evidence that these drugs can delay the destruction of damaged cells thus slowing repair and regeneration of the muscle tissue. Likewise, the use of steroids has been shown (again in animals only so far) to permanently impair healing.

Right now, researchers are studying other pharmacologic agents in the treatment of muscle injuries. Other potential therapies under investigation include platelet-rich plasma, curcumin, angiotensin II receptor blockers, and suramin. Each of these approaches has a different benefit and effect on the healing tissue. Nonpharmacologic options being studied include therapeutic ultrasound and hyperbaric oxygen therapy.

With the large number of people engaged in athletics and sports that result in muscle injuries, finding more effective treatments is important. Aiding and enhancing the healing process can help to prevent chronic pain and dysfunction and perhaps even prevent injury recurrence.

For competitive athletes, effective treatment that can get them back on the playing field or court would be very welcome. Understanding the type and severity of injury and planning treatment specific to the body’s healing responses with minimal delay in return to sports is the goal.

Harvest of Bone Marrow Cells from The Posterior Iliac Crest is Recommended

More research is focused now on tissue regeneration for bone repair in humans. Stem cells from the person’s own bone marrow have two major advantages: the patient does not experience cell rejection and this source of stem cells avoids the controversy over the use of embryonic stem cells. Stem cells are useful because they can divide and develop into any type of cell in the body (including bone or cartilage).

Surgeons can remove or aspirate stem cells from the sternum (breast bone), vertebrae (spinal bones), and iliac crest (top of the pelvic bones). Studies are ongoing to investigate the effect(s) of removing stem cells from these areas and comparing results among the various harvest sites.

In this study, use of stem cells were compared between the anterior iliac crest and posterior iliac crest. Twenty-two adult donors (ages 18 to 72) participated in the study. A total of 20 mL of bone marrow was withdrawn using a collecting needle (skin puncture) in three places along the iliac crest.

The cells were taken to a lab and processed. The different types of cells were separated and counted in the first step of the process. Then the cells were prepared in such a way to allow them to replicate (grow and multiply) over a period of 14 days. The total number of cells was recounted with a particular focus on one type called connective-tissue progenitor cells. These cells are especially useful for repair of connective tissue.

Connective-tissue progenitor cells are somewhat limited in bone marrow tissue. And usually the number of stem cells used in tissue repair is in the millions. So finding the site with the best yield will be helpful. However, there are many, many different factors that can affect the total yield of these cells. Site of harvest in only one. The age and sex of the patient may make a difference. And although 14 days was the time period used in this study, it’s possible that other time periods would yield different results.

The results of this study showed that bone marrow harvest of cells that become connective-tissue progenitor cells was better from the posterior iliac crest. In fact, there were 1.6 times more of these cells in the posterior compared with the anterior iliac crest.

The number of stem cells collected and the speed at which they reproduced was the same between the two harvest sites. The two sites also produced an equal number of other types of cells useful for cartilage repair, formation of fat, and glycosaminoglycans needed for smooth joint motion. In summary, stem cells from the posterior iliac crest produce a greater yield of progenitor cells needed for bone repair.

Results After Surgery for Leg Compartment Syndrome in Military Personnel

Patients with compartment syndrome of the lower leg face the possibility of symptoms coming back after treatment, complications from surgery, and the need for a second operation. In the case of young military personnel, medical discharge due to an inability to return to full duty may be the final outcome.

In this study, surgeons from the United States Army report on the long-term results of 611 (mostly male) soldiers who had surgery for chronic exertional compartment syndrome of the lower leg. Although the study included only military personnel, nonmilitary (civilian) competitive athletes and runners often develop this condition, too. Rates of return to activity and rates of disability are therefore of interest to a broad range of surgeons and patients.

Compartment syndrome describes a condition in which fluid (swelling or blood) builds up inside one or more of the individual compartments of the leg. The “compartments” are easier to understand if you think of each group of muscles and tendons as being surrounded by a protective sheath or lining of connective tissue called fascia. There are individual compartments on the front, sides, and back of the lower leg.

In each compartment, the fascia fits closely to the outer layer of the soft tissue it surrounds — like a sleeve or envelope. The structures are lubricated with a glistening fluid that allows everything to slide and glide against each other. There isn’t a lot of give or room for increased volume of fluid from swelling.

When an injury occurs that leads to swelling, the increased pressure inside the sleeve or envelope cuts off blood supply to the muscles. The muscle cells start to necrose or die. Left untreated, this necrosis can progress to the point of gangrene. Years ago, this problem was labeled “march gangrene” when it occurred in soldiers.

Other soft tissue structures inside the compartment such as nerves can get pinched or compressed. The effect is like a crush injury with damage to the nerves. All of these effects can be irreversible (permanent). Compartment syndrome of the leg occurs in soldiers due to overexertion from exercise. One or both legs can be affected.

Soldiers have daily, intense, high-demand physical requirements. Marching and running with heavy packs while wearing stiff boots along with routine weight training and aerobic exercise adds to the physical stress placed on the lower legs.

Treatment can be successful with a conservative approach including rest, activity modification, and antiinflammatory medications. But more often, surgery (fasciotomy) to cut the surrounding fascia and release the constrictive soft tissues is required. Even with surgical decompression, complete recovery doesn’t always happen.

As this study showed, almost half (44.7 per cent) of the patients had a recurrence of their painful symptoms after surgery. More than one-quarter (27.7 per cent) could not resume their previous level of activity. And a smaller group (5.9 per cent) had to have a second surgery because the first fasciotomy was not successful. Not all revision surgeries are successful either. In this study, only 14 per cent reported complete pain relief after the second operation.

In the military population, complications after surgery were the most likely reason for medical discharge. Infection, nerve pain, poor wound healing, blood clots, and complex regional pain syndrome were reported in 15.7 per cent of the soldiers.

In summary, this large study of the long-term results following surgical fasciotomy for chronic exertional compartment syndrome of the lower leg showed a poor outcome for many of the patients. Young, physically active patients expecting to return to full activity (and in the case of military personnel: return to full active duty) may be disappointed. One in five will have a failed surgery and ongoing pain and symptoms.

New Guidelines for Antibiotic Use Before Dental Procedures

If you have a joint replacement or implant of any kind, you will want to pay attention to these three new Clinical Practice Guidelines. They have been approved by the American Academy of Orthopaedic Surgeons and the American Dental Association Council on Scientific Affairs:

  • Routine use of antibiotics before dental work for people with hip or knee replacements may not be necessary.
  • Use of topical antimicrobial (mouth rinse) is still by patient preference and according to the dentist’s judgment for each individual person.
  • Anyone with a joint implant should be encouraged and educated in proper oral hygiene.

    The evidence for these clinical practice guidelines is limited to inconclusive. This means that the results from currently available research are either unconvincing or show little advantage of one approach over another. So where does that leave us?

    Let’s go back to the beginning and review what has already happened and why these recommendations must be reviewed and updated periodically. In the past, there has been a routine practice of prescribing prophylactic (preventive) antibiotics for patients with joint replacements having dental work done.

    The goal was to avoid infection, which can have serious complications for anyone with a joint replacement. Bacteria in the mouth can travel through the bloodstream and seems to have a preference for the joints. Once a joint with an implant is infected, serious damage and destruction can occur. Another surgery may be needed to clean the joint or even to remove and replace the implant.

    But as you probably already know, the overuse of antibiotics has resulted in stronger, more resistant bacteria called superbugs. Since only two per cent of the people who have hip, knee, or spine implants develop infections, why should everyone be on preventive antibiotics? And since some studies are showing that dental procedures don’t increase the risk of infection, each patient must be considered on a case-by-case basis.

    The trick is to figure out which patients are at increased risk for infection and see if taking prophylactic antibiotics reduces their chances of serious implant complications. It seems that rates of bacterial infection might vary depending on the dental procedure being done. For example, it would seem that pulling a tooth or more invasive procedures might have a higher risk rating. But some people develop infections just from flossing or brushing their teeth.

    Studies looking for individual risk factors (e.g., age, sex, number of dental procedures done) that might explain these differences have yielded contradictory results. Some researchers have looked into various types of antibiotics used to see if that might make a difference. Others have examined the use of different topical antimicrobials (mouth rinses) and how many times it is necessary to use them to prevent infection. As the clinical practice guidelines indicate, there isn’t enough conclusive evidence to recommend for or against the use of oral antimicrobials.

    In summary, with so much left unknown (inconclusive, indirect, or inadequate evidence), dentists must evaluate the risks and benefits of each dental procedure for individual patients who have joint replacements. Right now, there is no known direct link between dental procedures and infection of joints or implants.

    In the end, patient, physician, and dentist must work together to come to an agreement about what is best for each one and plan treatment accordingly. For right now, these three clinical practice guidelines (based on best current evidence) are offered to aid in selecting the plan of care for this group of patients. They are not “stand alone” recommendations but should be considered along with all other factors.

  • Rethinking Osteoarthritis as Just a Wear-and-Tear Disease

    Three things are clear from ongoing research: 1) obesity is on the rise in the United States, 2) more people are experiencing osteoarthritis (OA), and 3) there is a direct link between obesity and osteoarthritis.

    None of that may surprise you. What is new and notable is the fact that research is showing osteoarthritis (OA) is more than just a wear-and-tear disease. Excess load and weight is certainly a factor. But there may be some “hidden” (less obvious) variables that are just as important (if not more important) contributing to joint degeneration and OA.

    What are those less obvious risk factors? Obesity does cause local biomechanical changes in the joint reducing shock absorbing ability and increasing load and force on the joint cartilage. Eventually the joint starts to break down. But fat cells (referred to as adipose tissue) also activate inflammation that is system-wide (throughout the entire body).

    It turns out this low-grade inflammation has a direct and pathologic effect on the musculoskeletal system (especially bone and cartilage). Fat is not just a store house of energy. It is also a very active endocrine (hormone producing) gland. Blood tests confirm that this is the case with elevated levels of inflammatory markers measured in obese people.

    Scientists haven’t fully unraveled how obesity, systemic inflammation, and joint changes are all connected. But they are finding out more and more each day that may eventually help find a drug to prevent or at least manage osteoarthritis. This proinflammatory state of the obese body is also suspected as a contributing cause of hypertension, insulin resistance, and high cholesterol levels.

    It is important to note that obesity is not the only reason joint osteoarthritis develops. Age, sex (female), family history, race, previous injury, and lifestyle are all known risk factors for osteoarthritis (OA). That’s why OA is considered a multifactorial disease. Of all those risk factors, only obesity is considered modifiable (in other words, a risk factor you can do something about).

    There isn’t anything you can do to change your age, your past history of injuries, or family history. And even though it can be a challenge, weight loss is one way to change the biomechanical and systemic effects that lead to joint damage and degeneration. In fact, physicians are starting to think of weight loss as one of the most effective treatment approaches to osteoarthritis. Likewise, weight loss can directly affect chronic pain obese people experience from pressure on the surrounding soft tissue structures.

    If you are overweight to the point of being considered obese, you know that weight loss isn’t easy. Many health care professionals recommend education to prevent weight gain first. But for those whose body mass index (BMI) indicates they are already past ‘normal’ and in the overweight or obese zone, weight loss is still advised.

    Strategies for successful weight loss include diet and exercise, behavioral counseling and incentive programs, and/or possibly bariatric surgery. Slow, gradual, but steady weight loss is always preferred because maintaining weight loss is just as challenging as losing the weight in the first place. Negative side effects of bariatric surgery (e.g., decreased bone mass, increased risk of bone fractures, failure with weight gain) make this approach less desirable.

    In summary, joint osteoarthritis is no longer considered just a “wear-and-tear” type of arthritis. Obesity and the excess weight and load associated with obesity are major factors. But now we know there are inflammatory effects of adipose (fat) tissue that also contribute to joint destruction. Weight loss and exercise aren’t always easy solutions but they are the most successful in addressing all of the local and systemic effects of obesity.

    Drug Treatment for Osteoporosis of the Upper Extremity

    Osteoporosis (decreased bone mineral density) is a very common disorder affecting the skeleton. In a patient with osteoporosis, the bones begin losing their minerals and support beams, leaving the skeleton brittle and prone to fractures.

    In the U.S., 10 million individuals are estimated to already have the disease and almost 34 million more have low bone mass, placing them at increased risk for osteoporosis. Of the 10 million Americans affected by osteoporosis, eight million are women and two million are men. Most of them over age 65.

    Half of all bone fractures are related to osteoporosis. More than 300,000 hip fractures occur in the United States every year. A person with a hip fracture has a 20 percent chance of dying within six months as a result of the fracture. Osteoporotic-related fragility fractures can also affect just the arm.

    In fact, each year in the United States, one-quarter of a million adults (250,000) experience bone fractures of the arm from this condition. A fragility fracture is a bone break that occurs without significant trauma. The person could just be lifting a cup of coffee, turning a key in the door lock, or picking up a small book when the bone fractures. The underlying osteoporosis is the reason for these fractures.

    One-third (34 per cent) of fragility bone fractures of the arm affect the wrist for women. In men, this figure is closer to 17 per cent. But even one osteoporosis-related fracture increases the risk two to four times for another fracture later. This is serious because many people who have a fracture related to osteoporosis spend considerable time in the hospital and in rehabilitation.

    Hand surgeons treating upper extremity fractures associated with osteoporosis will need to address this condition. Assessing for risk factors (e.g., older age, female, postmenopausal, decreased testosterone, Asian or European ancestry) and asking about a past history of any previous low-energy fractures is important. It may be necessary to order a DEXA scan to evaluate the severity and extent of the bone thinning.

    Treatment with dietary supplementation (e.g., calcium, vitamin D), hormones, bisphosphonates (e.g., Boniva, Fosamax, Reclast), and biologic therapy (e.g., monoclonal antibodies) are often advised. And some patients may want to pursue alternative therapies such as additional drug therapy with calcitonin, strontium, hormone replacement therapy, and/or estrogen receptor modulators.

    Referral from the orthopedic or hand surgeon to a specialist with advanced knowledge of osteoporosis may be a good idea. This could be the primary care physician, a rheumatologist, or an endocrinologist. They will be familiar with the appropriate medications to prescribe and any contraindications (reasons NOT to prescribe certain drugs). Having one physician supervise all aspects of care and management of this condition is important to prevent future fractures from occurring.

    Vitamin D: What’s All the Fuss?

    Calling all athletes — and coaches, physical therapists, sports trainers, and sports health physicians who work with them! Here’s a review on the essentials of Vitamin D you won’t want to miss.

    Most likely by now, you have heard something about the perils of low vitamin D. Without it, we can suffer low bone mass, decreased immune function, and altered physical performance. Any of those (and especially all in combination) can pose serious problems for athletes.

    For example, bone fractures and muscle injuries associated with low vitamin D can sideline athletes for an entire season. Frequent colds, flus, and other more serious illnesses from a compromised immune system can lead to days without practice and poor performance. The athlete may not miss a day but still isn’t at the “top of their game” so-to-speak.

    In this article, medical staff at the Hospital for Special Surgery in New York City answer the following questions: Who is at risk? Why? And what can be done about it? The biggest known risk factors are limited sun exposure (based on where athletes live), the use of sunscreen, and athletes with dark skin pigmentation.

    To elaborate just a bit, these factors limit the skin’s absorption of ultraviolent B (UVB) rays from the sun needed for vitamin D production in the body. Living, practicing and playing indoors (especially in the northern latitudes) is a direct cause of low UVB radiation. But living in a sunny climate may be thwarted by the increased use of sunscreen products. We use these to keep UVB rays from contributing to skin cancer.

    Before anything can be done about low vitamin D, it is essential to know what your vitamin D levels are. This can be done with a simple blood test. But that’s where simplicity ends because experts say there is no clearly known optimal level of vitamin D to shoot for. Right now, the various levels are determined by measuring total serum 25-hydroxyvitamin D (25(OH)D3) and defined as:

    Deficient: 25(OH)D3 is less than 20 ng/mL
    Insufficient: level is 20 to 31 ng/mL
    Intoxication: blood levels are higher than 150 ng/mL
    Sufficient: at least 30 ng/mL up to 50 ng/mL

    Having “sufficient” blood levels of vitamin D means the body can absorb calcium from our diet to keep bones healthy. And sufficient levels prevent the cascade of biologic events that occur in the body when vitamin D drops too low. For athletes, the end-result is protection from stress fractures, bone fractures, and soft tissue injuries of muscles, tendons, and ligaments.

    How do we really know athletes are at risk? Maybe they are young enough and healthy enough to be just fine. Well, we do know because blood tests taken in preparation for surgery to treat sports injuries show that more than half of the athletes tested were vitamin D insufficient. One-third of that group wasn’t just vitamin D insufficient — they were in the deficient zone. And maybe that’s why they injured themselves in the first place.

    Several individual studies of National Football League players also showed lower levels of vitamin D (if not insufficient levels) among players with muscle injuries. And a study of elite Australian gymnasts came up with the same findings.

    How can this problem be addressed? First, prevention should be dealt with through diet and appropriate sunlight exposure and careful use of sunscreen. Vitamin D supplementation through over-the-counter products can be used for some individuals. Others will need prescription strength capsules. All vitamin D supplementation should be done with the guidance of a physician as doses must be adjusted based on blood work.

    In summary, although this article is focused on the effects of low Vitamin D on athletes, this is a problem that can (and does) affect people of all ages from young to old. The authors recommend a blood test to determine levels of total serum 25(OH)D3 for high-risk athletes (or others at risk).

    Treatment should be applied to those individuals with low (insufficient or deficient) vitamin D. Taking large (supraphysiologic) doses of Vitamin D supplements is NOT recommended as a way to enhance athletic performance. There are an equal number of studies that show higher levels of vitamin D could lead to kidney (and other tissue) damage.

    Bugs in Joint Replacements

    One of the biggest reasons joint replacements fail is due to joint infection. Bacteria (sometimes referred to as “bugs”) and fungi can travel through the bloodstream. These pathogens can be carried by the blood to anywhere in the body including the joints. Once in the joint, they can form a biofilm on the surface of the implant.

    Periprosthetic infection (in or around the joint) can develop anytime from early on (within the first six weeks of surgery) up to months or years later. Diagnosis can be a challenge. For example, this effect doesn’t show up on ordinary imaging studies such as X-rays. And it isn’t usually until the patient develops serious symptoms such as fever, nausea, and fatigue that there is even any awareness of the problem.

    In some cases, a channel from the joint out through the skin (called a sinus tract) is the first sign of a problem. The patient develops pain and oozing (infectious) drainage that sends him or her to the physician or clinic for help.

    It isn’t always clear from the results of tests to diagnose periprosthetic joint infection that there is a problem. A suspected (but not confirmed) infection must be evaluated more carefully because if treatment is delayed or not given at all, the joint can (and often does) loosen. The result can be chronic pain and disability. Sorting out loosening implants from septic (infectious) causes and aseptic (without infection) causes is important in planning the most appropriate treatment.

    When present, fluid from the sinus tract or directly from the joint is aspirated (collected) and tested for bugs (bacteria) or fungi. Whenever joint infection is suspected, blood tests are ordered to look for inflammation. If two specific blood tests (ESR and CRP) are elevated, then aspiration is required. Tissue biopsy may also be ordered.

    The presence of potential risk factors for periprosthetic joint infection raises a red flag. These can include older age, low socioeconomic status (poor nutrition and self-care), obesity, male gender, and knee implant. Poor general health due to comorbidities (other diseases) such as diabetes, cancer, or rheuatoid arthritis are additional risk factors.

    Additionally, anyone who has had a previous joint replacement in the same joint is at increased risk of infection. Patients receiving a joint replacement who were in surgery for more than three hours or who received a blood transfusion from a donor (rather than using their own blood) face an increased risk of periprosthetic infection.

    Even when diagnosed in a timely fashion, treatment isn’t always so straightforward or easy. Because of the biofilm that forms around the joint, the pathogens stick tight. They don’t always show up on blood tests. In the meantime, they become resistant to antibiotics.

    The surgeon may be able to irrigate (wash out) the joint to remove these pathogens and keep them from spreading. But sometimes nothing short of removing the implant works. All the more reason why early recognition of a developing infection and quick intervention are important (to save the joint if possible).

    In summary, early identification of infected joints after joint replacement surgery requires awareness of many things. Patients must keep in mind what symptoms might be the first sign of an infection. Physicians should review risk factors and target patients at high risk for joint periprosthetic infection. Closer follow-up for a longer post-operative period of time may be warranted for anyone with red flag risk factors.

    Diagnostic testing and evaluation is not a simple process. There is hope that more sensitive and reliable diagnostic tests can be developed. Researchers are currently looking for telltale biomarkers in synovial fluid. Simple, inexpensive strips have been designed that can use one drop of synovial fluid to detect an enzyme present with bacterial infections. Other molecular techniques to detect fungi, viruses, bacteria, and other pathogens are also under investigation.

    Advice to Orthopedic Surgeons About Worker Compensation Patients

    Fact: Results after upper extremity (shoulder or arm) surgery for worker compensation patients are worse than for non-worker compensation patients.
    Fact: Worker compensation patients take longer to recover after shoulder/arm surgery compared with non-worker compensation patients treated for the
    same thing.
    Fact: Worker compensation patients are much slower to return to their jobs at a preinjury level compared with non-worker compensation patients.
    Fact: More worker compensation patients change jobs because of continued pain after surgery compared with non-worker compensation patients.
    Fact: Fewer worker compensation patients return to employment at all compared with non-worker compensation patients.

    The question is: what are the truths behind these facts? Should orthopedic surgeons approach the treatment of worker compensation patients differently than non-worker compensation patients? And if so, what is advised? The topics of worker compensation and outcomes of upper extremity surgery are taken on by surgeons from two well-respected schools of medicine in the Northeastern United States (Albert Einstein College of Medicine and University of Medicine and Dentistry in New Jersey).

    Despite many safety measures in place, the number of workers who suffer shoulder and arm injuries on-the-job each year in the United States is significant. In fact, more days or work are lost each year now from shoulder injuries than for low back pain (which was always the number one cause of absenteeism). Recovery from work-related injuries can be complicated by the fact that workers are financially compensated for bodily injury in the work place. It is tempting to assume that financial gain is the reason for unfavorable outcomes and worse prognoses for these workers.

    But from a review of studies done in this area, several factors have come to light that might help explain the differences in results. First, worker compensation patients tend to be younger and expected to be more physically active on-the-job compared with non-worker compensation patients with the same injuries. Returning to preinjury levels of activity may differ between these two groups. Workers must get back to their preinjury level of work activities (e.g., pushing, pulling, or lifting heavy objects, operating heavy equipment). Non-worker compensation patients may be having trouble performing less difficult tasks (e.g., brushing teeth, caring for a child, dressing).

    The type of surgery performed may vary from study to study. Results from arthroscopic shoulder surgery are not always the same compared with other surgical techniques (e.g., open surgery or mini-open approaches). The use of alcohol and/or tobacco (known to delay wound healing and recovery) are additional factors to be considered. It is possible that ongoing pain, shoulder stiffness, and lower function after surgery may be worse in some patients as a direct result of these lifestyle factors.

    Sometimes pinpointing results after surgery can be difficult. For example, some worker compensation patients do return-to-work but are unable to meet the higher work demands or end up at a lower functional level than before their injury. And sometimes the type of injury and surgery required affect outcomes (e.g., results after elbow surgery are usually worse than after rotator cuff (shoulder) surgery). Worker compensation patients are also more likely to need a second surgery but whether or not this is to regain a higher level of physical function was not reported.

    Based on these observations, what advice do the authors give orthopedic surgeons? First, do not assume that financial gain is the cause of delays in recovery or worse outcomes for worker compensation patients. But second, be aware of these statistics even while (third) considering the greater physical demands and stresses each worker compensation patient will face in the workplace. Each state has its own unique worker compensation rules and regulations. Knowing local laws related to return-to-work will help the surgeon when advising each patient. The surgeon should be honest with workers about expected outcomes. And finally, anyone who lingers past the allotted amount of time should be referred to vocational rehabilitation for retraining when progress reaches a plateau.

    Vitamin D Recommendations for Athletes

    You wouldn’t think athletes with their strong bones and muscles would need any Vitamin D supplementation. But according to this group of researchers, there are sports health benefits to taking Vitamin D supplements. Some of those benefits actually come in the form of prevention. That is — preventing the musculoskeletal events that can occur when someone is Vitamin D deficient (e.g., bone fractures, musculoskeletal pain, frequent illness).

    You may know from recent news stories that Vitamin D is made in the body when the skin is exposed to ultraviolet B rays from the sun. But fears about skin cancer have reduced sun exposure through the use of sunscreen products.

    People living in certain (Northern) regions of the globe don’t receive enough of the essential sun rays even without sunscreen. And obesity has also reduced the amount of Vitamin D available in the body because it is a fat-soluble vitamin. This means fat cells store the vitamin rather than allowing the body to use those essential substances.

    Because very little Vitamin D comes from natural food sources, some products like cereals and milk are Vitamin D fortified. But even with these dietary sources, most people (children and adults) are considered Vitamin D deficient and in need of supplementation. Athletes and sports participants are no exception.

    If better peak musculoskeletal and neuromuscular performance depends on optimal Vitamin D levels, then how much is best? Enough? Too much? And do indoor athletes need more Vitamin than outdoor athletes? In this report, results of studies suggest the following:

  • Indoor athletes do need more Vitamin D supplementation than outdoor sports participants. BUT outdoor athletes must be aware of seasonal differences in sun exposure and supplement accordingly.
  • Outdoor athletes should have their blood tested in early autumn to adjust for seasonal differences in sun exposure.
  • There is no extra advantage of having a blood value of more than 50 ng/mL of vitamin stores in the body.
  • Differences in skin pigmentation must be taken into consideration. African Americans (and other dark-skinned individuals) need up to ten times more sun exposure to reach the same levels of Vitamin D in the body compared with Caucasian or light-skinned athletes.
  • The athlete who is tested as Vitamin D deficient (less than 30 ng/mL of 25(OH)D — the measure used to assess blood levels) should take 50,000 IU of Vitamin D3 each week for eight weeks or until blood tests show a steady level of at least 25(OH)D.
  • Sunshine is still nature’s perfect solution to strong muscles, teeth, and bones. Adequate exposure to ultraviolet rays that stimulate production of Vitamin D in the body avoid any excess accumulation or toxicity in the body. That’s because the body has special feedback loop to prevent this negative effect.

    Research has not been done to show what blood levels of Vitamin D are linked with optimal sports performance for each individual athlete. As mentioned, exceeding 50 ng/mL doesn’t seem to provide any additional benefit. We do know that performance is enhanced by exposure to ultraviolet rays. Studies from more than 50 years ago showed less pain with sports injuries, improved reaction times, faster speeds, and greater endurance in athletes with adequate vitamin stores in the body.

    Likewise, it is clear that the effects of too-low levels of Vitamin D include severe muscle weakness, loss of muscle tone, generalized body pain, increased falls, and bone deformities. Athletes who have enough Vitamin D have fewer colds and flus. And they may have the added benefit of faster recovery from inflammation after bouts of overtraining.

    Vitamin D supplementation isn’t just a good idea for athletes. It’s clear that anyone at risk for (or who already has been diagnosed with) diabetes, cancer, heart disease, high blood pressure, depression, asthma, multiple sclerosis, and other autoimmune or chronic disorders with an inflammatory cause can benefit from Vitamin D supplementation.

  • How To Treat Gout Flare-Ups

    For some reason, more and more people in the United States are experiencing acute episodes of gout, an inflammatory type of arthritis. Painful joint symptoms associated with gout are caused by the deposit of uric acid crystals in the joint and in the surrounding soft tissues. The most typical pattern is an attack that affects the big toe but other joints such as the elbow, wrist, fingers, and even the shoulder can be involved.

    Anyone who has ever suffered an attack of gout knows just how painful it can be. The red, tender, and swollen joint can be so painful that even the touch of a sock or sheet can be excruciating.

    Before starting treatment, the physician will make sure the problem isn’t a case of joint infection from cellulitis or septic arthritis. If there is any doubt about the diagnosis, a small amount of fluid can be drawn out of the joint. The fluid will be analyzed in the lab in order to make the final diagnosis. If it’s really gout, there will be urate crystals seen under the microscope. Sometimes those crystals are visible around the painful joint so the lab test isn’t needed.

    Treatment is determined based on whether this is an acute episode or more of a chronic problem with recurring episodes. Chronic gout is defined as having more than two acute attacks in a 12-month period of time.

    In the acute phase, patients are reminded not to drink alcohol (beer or liquor) or eat foods with purines in them (e.g., red meat, sea food). It is important to stay hydrated as dehydration is a risk factor for acute flare-ups. The use of diuretics for any reason (control blood pressure, weight loss) can contribute to dehydration. Patients must be aware of these facts and act accordingly.

    Medications such as antiinflammatories, corticosteroids, colchicine, or interleukin 1 inhibitors may be prescribed. The choice of medication depends on the patient’s age, severity of the gout attack, and other health factors such as the presence of diabetes and kidney function.

    Older adults are at greater risk for heart problems so some of the medications may not be appropriate for them. Anyone who has gastrointestinal problems or who is already taking antiinflammatory medications may do better with one of the newer medications (e.g., colchicine). Sometimes an injection of cortisone is very helpful. There must be no infection present in the joint and only one joint involved. The physician will evaluate each individual patient when making recommendations for the use of medications.

    For patients with chronic gout, a slightly different approach may be taken. There are medications available that will lower the urate level. Allopurinol is one of those medications. If allopurinol isn’t a good choice (say someone has kidney disease and can’t take allopurinol), then there are some back up choices (e.g.,probenecid, febuxostat).

    Most cases of gout flare-ups go away on their own with a few days time. Patient self-management of diet and lifestyle to prevent flare-ups is really the first and most important step in managing acute gout that can become chronic. Physicians looking for typical pharmaceutical (drug) regimens for the management of gout will find a table in this article useful. The table compares drugs used in the treatment of acute or chronic gout, adverse effects to watch out for, and when to avoid using each one.

    Best “Recipe” for Treatment of Tendons with Platelet-Rich Plasma

    Platelet-rich plasma (PRP) (also known as blood injection therapy) is a medical treatment being used for a wide range of musculoskeletal problems. Platelet-rich plasma refers to a sample of serum (blood) plasma that has as much as four times more than the normal amount of platelets. This treatment enhances the body’s natural ability to heal itself and is used to improve healing and shorten recovery time from acute and chronic soft tissue injuries.

    It has been used for years after plastic surgery and surgery on the mouth, jaw, and neck. It seems to promote bone graft healing. Researchers have found a way to combine this substance with other chemicals to make it into a putty or gel that can be painted on a surgical site to speed up healing.

    Blood injection therapy of this type has been used for knee osteoarthritis, degenerative cartilage, spinal fusion, bone fractures that don’t heal, and poor wound healing. This treatment technique is fairly new in the sports medicine treatment of musculoskeletal problems, but gaining popularity quickly.

    And that brings us to the current dilemma facing researchers: what is the best “recipe” for this concoction? Is there some amount of platelets and white blood cells that will give the best results? What is that ratio? Now that we know platelet-rich plasma (PRP) treatment works, it’s time to refine the “formula” so-to-speak.

    To aid in that research, veterinarians from Cornell University in New York are doing some studies using blood and tendon tissue from horses to investigate the effect of various platelet to white blood count ratios. They prepared and analyzed the results on healing for four different concentrations of platelet:white blood cells.

    One reason this type of research is even needed comes from previous studies that showed a “Goldilocks effect” of platelet-rich plasma treatment. It has been observed that too low or too high a concentration of platelets yields inferior results or poor outcomes. This study is an effort to find the “just right” concentration of these two important ingredients in the platelet-rich plasma (PRP) treatment.

    Other studies have shown that the exact composition of PRP does influence the amount of growth factor and catabolic cytokine concentrations, which in turn affect how well PRP works. Since platelets increase signals to stimulate healing and leukocytes increase molecules that signal inflammation, it’s important to study the way platelets and leukocytes influence the effects of PRP on tendon healing.

    The hypothesis (theory) of these researchers was that having a product with reduced leukocyte (white blood cell) count or one with increased platelets would give the best results. Their specific task was to find out which combination of these two products gave the best results. They started with three groups that had the same amount of platelets but different levels of leukocytes (low, medium, and high). A fourth group with high platelets and high leukocytes was also included.

    They found that the high levels of white blood cells (the leukocytes) caused increased inflammation. This was true no matter what platelet to leukocyte ratio used. Inflammation will delay or slow healing with the possibility of more scar tissue. At least from an animal model, it looks like reducing the amount of leukocytes in platelet-rich plasma (PRP) therapy might help stimulate the best healing response with the least amount of scar tissue. Increasing the amount of platelets does not counteract the inflammatory effect of the leukocytes.

    Of course, this was just one set of differing concentration ratios and in animals with normal tendon tissue. More studies are needed to further define the optimum blend in humans and for different conditions.

    Nutraceuticals for Patients with Arthritis

    If you suffer from joint pain associated with arthritis, it’s likely you’ve heard of or even tried some (if not all) of the following supplements: glucosamine, chondroitin, fish oil, thunder god vine, capsaicin, SAMe, and curcumin.

    Didn’t find the one you are taking or have taken? That’s because this is just a partial list of many products called nutraceuticals on the market for arthritis. The word nutraceutical is a combination of nutritional supplement and pharmaceutical (medication or drug).

    Physicians know that these products are not going to go away. If anything, the number of people taking these nutraceuticals for osteoarthritis or rheumatoid arthritis will continue to grow. That’s why the information in this article is so timely and important. It is an update for physicians on the use of nutraceuticals for joint disease. It was written by orthopedic surgeons in Australia. The purpose is to aid physicians in understanding these therapies and knowing how to counsel patients when taking them.

    The supplements recommended are slightly different depending on whether the underlying joint disease is osteoarthritis (OA) or rheumatoid arthritis (RA). Fish oil is the one supplement used for both conditions. As the name suggests, the oil comes from fish and contains omega-3 fatty acids. It is a natural anti-inflammatory that is not made by the human body.

    Studies show that fish oil does decrease joint tenderness and morning stiffness. Patients taking fish oil have also been able to decrease the use of nonsteroidal antiinflammatory drugs (NSAIDs). Physician should let patients know it can take eight to 12 weeks for the full benefit of fish oil to kick in.

    As with all drugs and supplements, fish oil can have adverse side effects for some people. These may include gastroesophageal reflux (GERD), diarrhea, headaches, and a lingering fish taste in the mouth or odor on the breath. Studies are still needed to see if fish oil can prevent or delay the progression of osteoarthritis (OA).

    As for other supplements used for OA, glucosamine and chondroitin top the list. These can be taken separately or combined together to aid in the formation of joint cartilage. They may also help prevent inflammation and the breakdown of joint cartilage. Studies done so far support the long-term use of these supplements. Patients taking them for at least one (up to three) years have fewer joint replacements compared with patients receiving a placebo (sugar pill).

    Another popular supplement taken by seniors for joint pain is SAMe, which stands for S-adenosylmethionine. Now you can see why the name SAMe is preferred! Each cell of the body creates its own SAMe. In the joint, it thickens and protects cartilage while also preventing joint pain. Taking SAMe as a supplement seems to improve pain and function.

    In the treatment of rheumatoid arthritis (RA), many patients find relief with capsaicin. Capsaicin contains an enzyme that gives chili its “heat.” Used as a cream rubbed over and around a painful joint, it creates irritation of the skin. This, in turn, activates nerve fibers in the skin. The end-result is to distract the brain-body from recognizing joint pain.

    Thunder god vine is a Chinese herb that can be taken as a pill or applied as a skin cream. Unlike some of the other supplements taken for joint pain that must be taken for months to years to be beneficial, thunder god vine provides pain relief and decreased joint swelling in the first 10 to 14 days. There are some potential adverse side effects though such as anemia, kidney problems, headache, hair loss, upset stomach, and even male infertility.

    Physicians will find this update and summary on nutraceuticals for arthritis joint pain helpful when answering patients’ questions. The information provided will guide physicians in giving evidence-based counsel about what to take, when to take it, and how long to take any of these supplements.

    Exercise Should Be the First Treatment for Tendinopathy

    Tendon repair can be tricky business. When the process gets interrupted for any reason, the tendon may get stuck in a lose-lose situation. Too much inflammation (and even sometimes not enough inflammation) can result in a process that produces a problem we call tendinosis or tendinopathy.

    Tendinopathy refers to any tendon that has been damaged in some way but is no longer in the acute inflammatory phase, which would be called a tendinitis. Examination of tendon tissue in patients who have had chronic pain over months and sometimes even years shows scarring and fibrosis but no active fluid, swelling, or white blood cells at the site needed for healing.

    What can be done to kick the tendon out of this no-win situation and back into a healing strategy? Treatment efforts are many and varied. The latest idea being tried is called platelet-rich plasma or blood injection therapy.

    The patient’s own blood is drawn and processed to collect the platelets. Then those platelets (suspended in a solution of the blood’s plasma) are injected into the damaged tendon. Platelets have lots of growth factors that get to work stimulating the repair process once again.

    Another approach tried has been shockwave therapy (SWT). Pulsations (vibrations) from this treatment create a mini-trauma to the tissues. The hope is to restart the healing process. Low-intensity ultrasound has also been used in the same way.

    The old standby: corticosteroid injections are still used but there are more and more doubts about using this treatment. Steroid injections may have a short-term benefit but nothing that lasts. The negative effects on the tendon reduces tendon strength. Tendon rupture may not be worth the initial pain relief provided.

    Surgery to clean the area up and restore blood supply to the tendon has some positive benefits. Mid-term results show significant pain relief and improved function after three years. Nerves that have grown inside the scar tissue can be one cause of the persistent pain experienced with some tendinopathies. The surgeon can try using a motorized shaver or radiofrequency to destroy these nerves.

    Any of the treatment approaches mentioned so far have potential complications and limited favorable results. Studies are not conclusive yet to suggest one treatment rises above all others as the best. That brings us to the next possibility: exercise. There is very little cost involved, no postoperative complications to deal with, and the potential for proper tendon repair.

    The downside of exercise as a treatment for tendinopathy is the patient’s own patience and cooperation. It does take time for consistent exercise to support the body’s innate ability to heal itself. But studies show that eccentric exercise has the ability to enhance tendon repair and even cause the nerve to pull back from the tendon.

    During an eccentric muscle contraction, the muscle and its tendon starts in a shortened position and then lengthen as the body part moves. A daily program over a period of six weeks’ time results in good outcomes with pain relief, improved function, and without adverse effects.

    Though time-consuming this exercise approach can be successful. When supervised by a physical therapist, motivation and compliance improve. The risk of reinjury is also less. Heavy, slow eccentric load may work better than static stretching or fast eccentric load. Combining static stretching with slow eccentric movements has been shown to be very helpful in a few studies. More studies are needed to pinpoint the most effective way to introduce and progress eccentric exercise. But for now, the research consistently shows the positive benefit of exercise as a first-line of treatment for tendinopathy.

    Not All Platelet-Rich Plasma Treatments Are the Same

    There are at least 16 different collection kits available on the market for platelet-rich plasma. They are not all the same and the differences may make affect results of studies trying to determine the effectiveness and long-lasting benefit of this treatment. In this article, orthopedic surgeons from Northwestern University School of Medicine in Chicago discuss the contents and preparation of these platelet-rich plasma kits.

    Platelet-rich plasma (PRP) (also known as blood injection therapy) is a medical treatment being used for a wide range of musculoskeletal problems. Platelet-rich plasma refers to a sample of serum (blood) plasma that has as much as nine times more than the normal amount of platelets. This treatment enhances the body’s natural ability to heal itself and is used to improve healing and shorten recovery time from acute and chronic soft tissue injuries.

    The injectable substance is created by first drawing the patient’s own blood and putting it in a special machine called a centrifuge. The centrifuge spins around at a fast rate and separates the various component parts of blood based on density and weight. The heavier red blood cells sink to the bottom faster than the lighter white blood cells and platelets.

    Depending on how the blood sample is processed, the final amount of platelets and platelet-rich plasma can vary considerably. Some kits include an activator to speed up the process of clot formation (healing) but there is a potential downside. Adding an activator (e.g., calcium chloride or thrombin) can decrease how long the growth factors released by the platelets are available.

    There is some research that has shown activators aren’t really needed. PRP preparations with and without activators have the same effectiveness. But other differences in PRP injections may make a difference and that is an area for future studies. Large, prospective, and randomized trials are needed to compare results using different PRP kits for each individual problem treated.

    Safety is another area of concern and potential study. Since the product comes from the patient’s own blood, there is little risk involved. Rejection is not an issue. Local skin reactions, inflammation, and pain have been reported.

    The positive benefits of speeding up healing are actually only part of the effectiveness of PRP. At least one study has shown that PRP increases the body’s ability to fight off staph infections and E. coli. The antimicrobial action of PRP is an added bonus to the patient.

    More and more studies are showing promising results using PRP for musculoskeletal problems. The focus turns now to preparation and classification of commercially available PRP preparation systems. Some kits are categorized according to the amount of platelets in the final sample. Others look at fibrin (clotting substance) and leukocyte (white blood cell) content. The presence (or absence) of an activator further classifies these products.

    For anyone interested in comparing the various commercially available PRP kits, the authors of this article provided a table reviewing six key areas. Each system is named and described according to blood volume drawn, final PRP volume, and final platelet concentration (compared with whole blood). Whether or not an activator is added is noted (along with which activator is included). And finally, the white blood cell concentration and amount of fibrinogen are listed for consideration.

    Choosing the Right Method for Obtaining Platelet-Rich Plasma

    Platelet-rich plasma (PRP) (also known as blood injection therapy) is a medical treatment being used for a wide range of musculoskeletal problems. Platelet-rich plasma refers to a sample of serum (blood) plasma that has as much as four times more than the normal amount of platelets. This treatment enhances the body’s natural ability to heal itself and is used to improve healing and shorten recovery time from acute and chronic soft tissue injuries.

    Platelets are part of the blood that circulate around the body ready to help with blood clotting should you have a cut, broken bone, injury that bleeds internally, or any other type of injury. Besides containing clotting factors, the platelets release growth factors that help start the healing sequence. With a concentrated amount of platelets, larger quantities of these growth factors are released to stimulate a natural healing response. Plasma is the clear portion of the blood in which all the other blood particles such as platelets, red blood cells, and white blood cells travel.

    Blood injection therapy of this type has been used for knee osteoarthritis, degenerative cartilage, spinal fusion, bone fractures that don’t heal, and poor wound healing. This treatment technique is fairly new in the sports medicine treatment of musculoskeletal problems, but gaining popularity quickly.

    In theory, blood injection therapy could be used in any area where a rapid healing response is desired such as the tendon-muscle junction, muscle injuries, torn ligaments, damaged joints, or inflamed tissue (e.g., plantar fasciitis).

    Torn tendons and ligaments don’t always heal well because they have a poor blood supply. Connective tissues such as ligaments and tendons heal by filling in with scar tissue that doesn’t bear the brunt of large loads well. This increases the risk of re-injury. Other available treatments for chronic tendon problems do not necessarily improve the tendon’s ability to heal in the same way that PRP does. And injections of PRP don’t have the side effects that can occur with steroid injections or long-term use of non-steroidal anti-inflammatory drugs (NSAIDs).

    The platelet-rich plasma therapy has been around long enough now to start studying it more carefully. Researchers have found that the platelet-rich plasma preparation varies significantly from sample to sample. That means patients aren’t always getting the same amount of platelets and growth factors. This has been shown to be true from one treatment to the next and even from one patient to the next. The question comes up: why the differences?

    To find out, researchers from the University of Connecticut sampled blood from eight people on three separate occasions (baseline or first blood draw, fourteen days later, one month later). Each sample was analyzed for each patient at each of those time periods.

    They used three different lab techniques to harvest the platelets: 1) a single-spin technique (referred to as LP), 2) an alternative single-spin method (the HP method, and 3) a double-spin (DS) technique. Each technique is carefully described for the reader including the number of minutes spun and the revolutions per minute.

    In all cases, the HP (alternative single-spin separation method) gave the best results with the highest percentage of white blood cells and platelets. The one-step LP method far outperformed the other two methods.

    There were clear differences in outcomes not only with the differing techniques used but also for the different times the samples were taken for each individual. The question naturally arises: why would platelet levels and white blood cell levels vary over time for the same person? The authors suggest age could make a difference. Or there could be a physiologic reason why these variations exist that we just don’t know about yet.

    What the study does show is that the method of separation when obtaining platelet-rich plasma makes a difference in the number of white blood cells and platelets collected. Physicians may want to take this fact into consideration when selecting the method used.

    For example, it might be helpful to choose the method that matches the intended use of the plasma. One thing to keep in mind is the fact that too many white blood cells can actually cause an overreaction in the tissues. And too much inflammation at certain points in the healing process may not be a good idea.

    Perhaps the double spin method (yields lower levels of platelets and white blood cells) would work best when a mild healing response is needed. Likewise, there may be times and situations where increased antibacterial and an increased immune response would be helpful. In those cases, the single-spin method might be the most useful.

    Risks and Benefits of Blood Injection Therapy

    Any time a new treatment technique is tried approval depends on how well it works, long the effects last, and the balance between risks and benefits. Risks usually include problems during the procedure and complications after the treatment. One of the new treatments for orthopedic conditions currently being studied is called platelet-rich plasma or blood injection therapy.

    Platelet-rich plasma (PRP) is a medical treatment being used for a wide range of musculoskeletal problems. Platelet-rich plasma refers to a sample of serum (blood) plasma that has as much as four times more than the normal amount of platelets. Once activated in response to an injury, platelets release active proteins and growth factors. This treatment enhances the body’s natural ability to heal itself and is used to improve healing and shorten recovery time from acute and chronic soft tissue injuries.

    PRP has been used for years after plastic surgery and surgery on the mouth, jaw, and neck. It seems to promote bone graft healing. Researchers have found a way to combine this substance with other chemicals to make it into a putty or gel that can be painted on a surgical site to speed up healing.

    Blood injection therapy of this type has been used for knee osteoarthritis, degenerative cartilage, spinal fusion, bone fractures that don’t heal, and poor wound healing. This treatment technique is fairly new in the sports medicine treatment of musculoskeletal problems, but gaining popularity quickly.

    The clinical benefit for acute injuries, chronic musculoskeletal problems, and even degenerative conditions is being studied in many areas across the United States and Canada. In this meta-analysis, researchers from the Center for Evidence-Based Orthopaedics at McMaster University in Canada report on the efficacy (benefits) of platelet-rich plasma use for a variety of orthopedic conditions.

    A meta-analysis means a large number of studies with small-to-medium numbers of participants are combined or pooled together. This method increases the n (number of patients involved) and allows for more meaningful statistical results. Sometimes smaller studies are high-quality but without the necessary number of patients involved, the results are limited in providing evidence that a treatment (such as PRP) is beneficial.

    The authors provide a very nice summary describing how studies are evaluated for quality of evidence. For example, randomized, controlled trials are usually the highest quality. Patients are placed in different treatment and control groups by random draw. No one in the study knows what treatment they are actually receiving. In a double-blind study, even the physicians giving the treatments don’t know what treatment each patient is getting.

    Studies are “downgraded” in quality when there is a lack of blinding, large numbers of patients lost during the follow-up, or an early stop of the study for any reason. Studies can be upgraded or downgraded depending on how well matched the subjects are in terms of age and similarities or differences in the physical condition being studied. Quality of evidence can also be downgraded if there are large discrepancies between studies. And the quality of evidence can be graded as high, moderate, low, or very low.

    When studies use different ways of measuring outcomes, it becomes more difficult to compare the results. When the outcomes are inconsistent among the participants (some get betters, others don’t or some get a little better while others are much better), then results are considered “imprecise” or “uninformative.”

    In this study, an attempt was made to combine studies using autologous blood (the patient’s own blood) to treat an orthopedic injury. The studies had to be randomized or prospective (patients are studied as the treatment is given) and there had to be a control group. The control group did not receive the platelet-rich plasma treatment but a placebo or pretend solution. The main measure of benefit (efficacy) was pain using a specific tool to measure pain (the Visual Analog Scale or VAS).

    The group of researchers did a thorough search of the literature for published studies, unpublished studies, presentations at professional meetings and abstracts presented at annual meetings of orthopedic societies.

    They found 895 articles on the subject but only 33 studies that qualified to be included. There was a general lack of standardization among the studies reviewed. This means the way the studies were conducted was different enough to create problems in comparing results (like comparing apples to oranges — both fruit but different colors, tastes, and textures).

    For example, studies ranged in size from 10 to 165 patients. Follow-up was a broad ranged from five days to two years. A closer look at the studies also showed there were differences in the way platelet-rich plasma was prepared among the studies. And the area of the body treated varied from shoulder to elbow, knee to lower leg, and spine.

    In terms of pain control and improved function as a result of decreased pain, only six studies showed a benefit of the platelet-rich plasma (PRP) injection. One study even showed the control group had the best results. The remaining studies could not show a benefit of PRP over placebo.

    The inability to conclude that PRP is an effective treatment for bone and soft-tissue injuries may have more to do with the lack of standardization in study design and different way outcomes were measured. As a result, the authors summarize by saying the evidence is unclear that platelet-rich plasma is an effective treatment for orthopedic conditions.

    They suggest future high-quality studies are needed to identify best use of PRP (acute traumatic lesions, chronic conditions, degenerative diseases). It will be important to uncover risks of this treatment approach and weigh the benefits against the risks for each condition.

    Future studies also need to have good design with high-grade evidence and measurable outcomes that can be compared from study to study. Follow-up should be long enough to tell if there is a long-term benefit to patients. And there needs to be a focus on the different results obtained based on various ways blood is processed to create platelet-rich plasma.

    What Do We Know About Psoriatic Arthritis?

    You’ve probably seen the old commercial that talks about “the heartbreak of psoriasis.” But it isn’t just the skin lesions that create so much trouble for patients. Up to half of all patients with psoriasis develop disabling arthritis. And psoriatic arthritis (PsA) is chronic, inflammatory, and deforming.

    In this review article, surgeons from New York University Hospital for Joint Diseases bring us up-to-date on this condition. They discuss causes, symptoms, the diagnosis, and treatment. Complications of medical management and outcomes of treatment are also presented.

    Fortunately, psoriasis only affects a small portion of the adult population in the United States (somewhere between 0.6 to less than five per cent). Men and women who develop psoriatic arthritis are usually in their 30s and 40s. Skin changes may appear first but some people notice joint pain, stiffness, and swelling before they break out.

    The reason psoriatic arthritis occurs still remains somewhat of a mystery. There is a genetic link for some patients associated with trauma or infection. But exactly why the immune system goes haywire in this fashion is not clearly understood.

    Studies show that there are actually five different types of psoriatic arthritis based on clinical presentation. In all cases, the hands are the main area affected but the toes, spine, and sacroiliac joints can also be involved. The different patterns are seen in which joints are affected, whether the condition is symmetric (affecting both hands at the same time), and the severity of the joint destruction.

    There is no special blood or lab test that can diagnose the problem. Most of the time, the diagnosis is made based on the physician’s examination and observations of the patient. Of course, X-rays clearly show joint erosion, damage, and deformities in the later stages of the disease. X-rays of the hands, feet, and spine are recommended to make sure all areas affected are identified and treated.

    Treatment is really a matter of medical management. In fact, it could be said that “it takes a village” to treat psoriatic arthritis. Dermatologists, rheumatologists, medical doctors, and physical therapists must work together to guide the patient and prevent as much damage as possible.

    The specific treatment approach used is individual and based on symptoms and severity of the disease. It is recognized now that early aggressive treatment with medications to control the disease process is important. Medications typically prescribed include antiinflammatories and disease modifying antirheumatic drugs (DMARDs).

    New treatment called biologic treatment uses special immune-blocking agents to stop the inflammatory process at different points in the cascade of events leading to the effects of this disease. If there is severe joint destruction and damage, surgery may be needed to reduce pain and improve function. A variety of different surgical procedures can be used including debridement (cleaning the joint of thick tissue and debris), joint fusion, and joint replacement.

    A major concern after surgery is skin infection. The skin lesions called psoriatic plaques often harbor bacteria that can lead to wound infections. Complications from infection can lead to further joint destruction and even systemic infection resulting in death.

    Studies reporting the long-term results of surgical management of psoriatic arthritis are limited. In general, there appears to be some improvement in pain and function but stiffness and recurrent, progressive disease are common.

    For anyone newly diagnosed with psoriatic arthritis (or even someone with long-term disease), this article provides a thorough review of the condition and its treatment. Physicians treating patients with psoriatic arthritis may also find the update helpful. The authors suggest there is a need for future studies to report on the results of treatment to help guide physicians, surgeons, and patients in making the choice that will yield the best outcomes.