Labral Tears in the Shoulder

The labrum is a cartilaginous cup which circles the shallow shoulder socket (the glenoid) to make the socket deeper.  The labrum supports and stabilizes the shoulder joint.

Shoulder Labrum

Injury to the labrum typically occurs from repetitive trauma in overhead throwers, such as in baseball.  It can also occur from a traction injury to the arm, such as lifting a heavy object off the ground or getting your arm jerked.

Typical symptoms include pain in the front of the shoulder or deep inside the joint.

Treatment options initially  include physical therapy which is designed to restore range of motion and strength to the shoulder.  Often times shoulder arthroscopy is recommended where the damaged labrum is identified and then repaired using suture anchors to sew the labrum back in place.

Surgical Repair of Labrum

At the Centeno-Schultz Clinic we have developed x-ray guided techniques to safely inject the labrum.  Once a small needle is appropriately placed, we inject a very small amount of contrast(dye) to confirm accurate placement.  The  x-ray pictures below illustrate the labrum being outlined with contrast. There are two pictures one of which is looking from the side where you can see the thin black line outlining the labrum and an oblique view in which you are looking down into the cup.

Oblique View of Labral Injection

Lateral View of Labral Injection

If a tear is present, a patient’s own stem cells can then be injected.  Regenexx allows a patient to have their own expanded mesenchymal stem cells (MSC)  injected directly into the damaged area.  Mesenchymal stem cells will differentiate into the cartilage which makes up the labrum.

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The Importance of Blood Supply

Blood supply to a given structure provides essential nutrients for growth, maintenance and repair.  Some structures such as the heart have a rich blood supply with multiple arteries.  Other structures have a very limited, tenuous blood supply which places them at risk for impaired growth, repair and potential cellular death. The lumbar intervertebral disc is such a structure.  While it is the cornerstone of our spine and bears the weight of our bodies as we walk, its blood supply is extremely limited.

What does this mean?  If injuries occur the lumbar disc has limited capability of repairing itself due to its very limited blood supply.  The result is a slow insidious degeneration of the lumbar disc characterized by reduction in disc height and signal.  The MRI  below on the left illustrates a degenerative L5/S1 disc.  The blue arrow identifies the spinal cord, the red arrow is pointing to the cerebral spinal fluid and the black arrow identifies the L3/4 disc.  Note the L3/4 disc has a white signal within the disc which represents hydration.  It also is identical in height and brightness to the disc above it.  Both of these discs are normal.  The white arrow identifies a degenerative L5/S1 disc which is black in color with reduction in height in comparison to the adjacent discs.

Degeneration of lumbar spine

 With injury there is also a propensity to develop bulges since the integrity of the side wall (annulus fibrosis) is compromised. 

Disc Bulge

 If sufficient damage occurs, a disc bulge can progresses to a disc herniation where an portion of  the inner contents of the disc (nucleus pulposus) are extruded.

Lumbar Disc Herniation

In a previous blog I discussed the importance of platelets and the four major growth factors they contain:   Platelet-derived growth factor (PDGF), transforming growth factor beta (TGF-b), vascular endothelial growth factor (VEGF) and epithelial growth factor (EGF). Vascular endothelial factor is responsible for angiogenesis (the creation of  new blood vessels).  These new blood vessels can provide essential nutrients to repair damaged tissue.  At Regenexx we injected concentrated VEGF adjacent a degenerative disc with the hope of improving blood flow and initiating repair.  Please see MRI results below.  On the left are MRI images of the L5/S1 disc prior to therapy.  Note there is a reduction in height and brightness of the L5/S1 disc.  On the right are MRI images of the same L5/S1 disc after therapy.  Note an increase in the height and the signal of the disc.  There is significant improvement in the disc height and signal.  What is the significance?  This is a patient who despite prior back surgery continued to have pain.  After therapy at Regenexx the patient had near complete resolution of pain as well as MRI evidence of lumbar disc repair.

Before and after therapy of L5/S1 Disc

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Platelet Rich Plasma

What do Pittsburgh Steelers’ Hines Ward and Troy Polamalu have in common?  They have both used their own blood to treat ligament and tendon injuries.  The therapy is called platelet-rich plasma (PRP) and involves the injection of concentrated platelets and plasma to the area of damage.  Instead of injecting steroids, which can lead to tissue damage and tendon rupture, physicians are now injecting a patient’s own blood products to stimulate healing.

What is PRP?  It is a concentrate of a patient’s own platelets.  In our bodies, normal platelet counts range between 150,000/μl and 350,000/μl with an average of  200,000/μl.  Animal and human studies have demonstrated that soft tissue healing enhancement only occurs when the concentration of platelets (PRP) is greater than 1,000,000/μl.  This is a concentrate of 5x the amount normally present in our bodies.

How is it made?  A small amount of a patient’s own blood is placed in a centrifuge which separates the red blood cells from the platelets.  A teaspoon of the remaining substance is injected into the damaged tissue.

How does it work?   Platelets contain several significant growth factors, which enhance tissue repair.  The most important growth factors in PRP are platelet-derived growth factor (PDGF), transforming growth factor beta (TGF-b), vascular endothelial growth factor (VEGF) and epithelial growth factor (EGF).

What are the advantages?  It is a non-surgical therapy utilizing a patient’s own cells, and therefore is not associated with allergic reaction or transmission of disease.  At the Centeno-Schultz Clinic we use PRP for repair of ligament, tendon and muscular injury.

Administration of Stem Cells

Patients are becoming increasingly aware of the use of adult stem cells in the treatment of various disorders.  In a previous blog I have outlined the critical differences between allogenic adult stem cells and autologous stem cells where the former is associated  with a risk of disease transmission.

Another key issue to consider is the route of administration.  Some companies outside the United States are currently offering the intravenous delivery of adult stem cells for regenerative tissue therapy.

IV Infusion

 How effective are these therapies?  Unfortunately,  Fischer et. al.  demonstrated that the majority of the administered stems cells failed to make to their targeted destination because they were trapped in the lung.  This is similar to the first-pass effect seen in drug delivery systems where a disproportionate amount of a drug is trapped as it passes through the liver.

A reliable stem cell delivery system is essential to the success of the stem cell therapy.  If you have a knee problem, for example,  you want the autologous stem cells injected directly into the area of damage.  At Regenexx, autologous mesenchymal stem cells are injected under fluoroscopic (x-ray) guidance to ensure accurate placement. 

Fluoroscopic assisted injection

 Regenexx enables a patient the opportunity to use their own stem cells to repair damaged tendons, ligaments and damaged cartilage surfaces via a needle-in, needle -out procedure, which  eliminates the risks associated with surgery and anesthesia.

Mesenchymal Stem Cells

There are various types of adult stem cells. The type of adult stem cells which are associated with tissue repair are called mesenchymal stem cell (MSC). These specific stem cells are capable of repairing damaged tendons, ligaments, intervertebral disc and fractured bones. There are two major sources of mesenchymal stem cells:  bone marrow derived and adipose (fat) derived.  Bone marrow stem cells are obtained via a needle which is inserted into iliac crest.  Adipose stem cells are typically collected during a liposuction.

Why is this important?  Bone marrow derived mesnechymal stem cells has been demonstrated to be superior in their ability to repair cartilage, tendon and ligament when compared to adipose derived cells.  Bunnell demonstrated  that  adipose stem cells are biologically similar, although not identical, to mesenchymal stem cells derived from the bone marrow. Vidal demonstrated that equine bone marrow derived mesenchymal stem cells have far greater regenerative properties for damaged cartilage than adipose derived cells.  Kisiday also demonstrated  that bone marrow derived mesenchymal stem cells have superior ability to repair and change into cartilage.

If you have an orthopedic condition and elect to use stem cell therapy, bone marrow derived stem cells offer the best success.  Regenexx exclusively utilizes autologous bone marrow derived mesenchymal stem cells  for damaged  ligaments, tendon, and cartilage.

Adult Stem Cells

Stem cell therapy and its applications continue to expand on a daily basis.  The use of your own  stem cells is termed autologous.  The use of someone else’s stem cells is termed allogenic.  Animal studies demonstrate a significant problem when utilizing allogenic therapy: the transmission of genetic diseases.

Ueda et. al.,  demonstrated that is was possible to give osteoporosis to a normal young mouse by implanting them with stem cells from an old mouse with osteoporosis.  This is very concerning and warrants caution when considering the use of allogenic stem cell therapy.  Until we understand all the complexities of genes, injecting stem cells and their inherent genes from one patient into another is a significant risk.

Regenexx utilizes a patients own stem cells and therefore there is no risk of transmission of disease.  Regenexx has demonstrated clinical successes in the treatment of lumbar disc bulges, tendon and ligament tears and healing of fractured bones.

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Stem Cell Accountability

Human nature being what it is, there has been an unfortunate increase in the number stem cell therapies which are available and proclaim success  for a large number of disorders.  This has occurred domestically as well as internationally with hybrids  which recruit the patients here in the Unites States only to ship off the cells overseas.

In response, the International Society Stem Cell Researchers (ISSCR) has created a comprehensive set of guidelines for  stem cell therapy.  Patients and their physicians must be aware of these guidelines.  I will summarize two of the guidelines and comment how Regenexx has addressed the standard.

1)  Stem cells from other people (allogenic) are more risky and require closer monitoring.  Research would suggest that stem cells from a donor  may carry a  genetic disease transmission risk.  What does this mean?  Stem cells from one patient when used in another patient may transmit serious diseases.  In the animal model for example when a young mouse is injected with stem cells from a mouse with known osteoporosis, the younger mouse develops osteoporosis.   Regenexx acknowledges this significant risk and therefore only uses a patients own stem cells.  These  cells are referred to as autologous.

2)The use of animal components to grow stem cells must by replaced human components.  Stem cells are commonly cultured in Fetal Calf Serum (FCS).  There are multiple concerns with this practice including transmission  of infectious processes such as mad cow disease.  Fetal Calf Serum is not appropriate for human use.  Regenexx uses  a patient’s own blood to grown and expand their stem cells.  Regenexx has not and never will use fetal calf serum.

Adult Stem Cells

What are adult stem cells? They are cells within our body that can renew themselves and turn into other cells (differentiate).   Conceptually they can be thought of as the repairmen of the body. They live inside us in various tissues, poised to leap into action to repair damage as it occurs.  The problem is that as we age or get larger injuries,  our bodies are unable to recruit sufficient number of stem cells to fully  repair the area of damage.

There are many different types of adult stem cells but the most common are called hematopoetic stem cells.  What does this mean.  These are adult stem cells that will change (differentiate) into blood (hematopoetic)  products such as red blood cells or platelet.  Hematopoetic stem cells are easy to obtain from a peripheral blood or from bone marrow.  They are very plentiful in both blood and bone marrow. Unfortunately many ” stem cell therapies” are employing these hematopoetic stem cells due to the abundance and ease to access.  Such is the case with bone marrow aspirate concentrates which are bedside units that concentrate cells obtained from one’s bone marrow. 

Bone Marrow Aspirate Concentrate Unit

 Unfortunately for patients, despite the advertised claims, these cells can only differentiate into blood products.

Stem cells associated with regeneration of damaged tendon, ligament, bone or disc are termed mesenchymal stem cell (MSC). 

Mesenchymal Stem Cell

 MSC’s can not be harvested from blood nor can they be obtained in clinically significant numbers from bedside bone marrow aspirate concentrates.  Herein lies the critical difference between current therapy and Regenexx.  Regenexx isolates MSC’s and then expands them so that you as a patient have the critical number of MSC’s to repair damaged tissue.  Regnexx uses your own stem cells and expands them for a variety of orthopedic aplications.

Criticial Differences in Bone Marrow Derived Stem Cell Therapies

The bone marrow is rich in stem cells.  These cells are typcially obtained by a technique referred to as a  bone marrow aspirate where a needle is placed into  the iliac crest and cells are withdrawn through a syringe. 

Bone Marrow Aspirate Concentrate Unit

Withdrawing cells in this fashion is called aspiration.  Bone marrow aspiration is a common practice for obtaining stem cells.  A popular technique is to take the bone marrow aspirate ( the cells obained from the bone marrow aspiration)  and spin it down in a centrifuge thereby creating a concentrate of bone marrow nucleated cells.  This technique is called BMAC:  Bone Marrow Aspirate Concentration.   The concentrated bone marrow aspirate contains stem cells and has been termed and advertised as ‘stem cell concentrate.”   There are several units commercially-available.

 There are many different types of stem cells in bone marrow. Stem cells that are crticial for regeneration of cartilage, tendon and ligament are very specific and are called mesenchymal stem cells.

A crtical question which has recently been studied is what is the concentration of  mesenchymal stem cells from commerically available  units.  Equally important, is the question of whether or not the concentration of stem cells from BMAC can made a difference clinically.XXXX demonstrated that bedside bone marrow concentrate machines utilizing a 60cc bone marrow aspirate can produce between 70,000-90,000 mesenchymal stem cells.  What does this mean?  Animal research and data collected at Regenexx suggests that millions of  mesenchyml stem cells are required to repair cartilage, tendon and muscle injuries.  Furthermore unlike the BMAC units, Regenexx expands the number of mesenchymal stems stem to approximately 100-1,000 times the number obtained from BMAC.  So in considering stem cell therapy it is essential to understand both the type and absolute number of stem cells injected since both will play a critical role in the success of a procedure.

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Valgus and Varus Alignment

Valgus and varus describe the alignment between two anatomical segments.  Valgus  refers to outward angulation of the distal segment of a bone or joint.  Varus is the opposite of valgus and refers to inward angulation of the distal segment of a bone or joint. To better understand these concepts, see the  illustration below.   A line is drawn along the long axis of the proximal segment.  Another line is drawn along the long axis the distal segment.  When comparing the two lines,  focus on the the distal segment’s alignment with respect to the proximal segement. 

 The illustration on the left depicits valgus in which the distal segment of the joint is angulated outward.

The illustration on the right is an example of varus.

What is the significance?    Look at the x-rays below.

 

Misalignment of one bone in relation to other places disproportionate forces on the joint with resultant excessive wear and tear on the meniscus, ligament and cartilage.  At the Centeno-Schultz Clinic we emphasis correct joint aligment through various therapies including IMS, prolotherapy, physical therapy and the use of unloader braces.  If there has been excessive wear of the cartilage,  there is a novel technique which allows patients to use there own stem cells.

 

 

 

Valgus;  – femur internally rotated, and tibia externally rotated.  Problems:  maliagnilgment as results from asymmetric wear of the posterior aspect of the lateral femoral condyle  patellofemroal tracking problems. patellar maltracking. posterolateral instability