Platelet rich plasma (or PRP as it is often called) is a relatively new technique for treating various musculoskeletal injuries. It is growing in popularity, most likely because many professional athletes have used it.

What is platelet rich plasma or PRP treatment?

The procedure of PRP injection begins with the practitioner drawing blood from the patient and spinning it in a centrifuge to isolate the blood plasma. Among other things, the blood plasma contains certain growth factors that are helpful for tissue healing. Although practitioners may utilize different techniques for preparing the solution, the isolated sample is injected into the injured area to help speed up the healing process.

What is the cost of PRP injections?

Through several of my patients who have tried this technique, the prices seem to range. It seems that most conditions require several injections (spread out over a period of time) with each injection costing approximately two hundred dollars. It is my understanding that it is not usually covered through extended health insurance.

Does platelet rich plasma work?

Perhaps it depends on who or what you listen to. Some notable professional athletes will tell you that it works. If you prefer to listen to the unbiased scientific studies that have been performed, you’d probably say “not sure”. Numerous studies have been performed for different tissues (lateral epicondyle of the elbow, achilles tendon and plantar fascia) yet the results seem to be conflicting. Several studies found saline (placebo) injections to have the same efficacy as platelet rich plasma injections. In my opinion, PRP injections may be a viable treatment option for some patients. Obviously, it has become popular for a reason. I do have to say that it’s interesting how a treatment approach with limited scientific evidence to support its efficacy has become so popular. Hopefully, more randomized controlled trials will be performed using large samples of patients so that we can provide more evidence based recommendations to patients. Nevertheless, I’ve attached a link to an interesting article written in the New York Times about PRP injections and the power of professional athlete endorsements. Thanks to Dr. Mark Kubert of Clearpath Chiropractic in Guelph who tweeted this article!

http://www.nytimes.com/2011/09/05/health/05treatment.html?pagewanted=all

Looking for help with an injury?   Email us – info@burlingtonsportstherapy.com

References
Foster TE, Puskas BL. Platelet-rich plasma: from basic science to clinical application. American Journal of Sports Medicine 2009; 37(11): 2259-2272.

It’s always easier to understand a condition when we simplify it. This happens quite often in the world of physical rehabilitation. An example in the knee would be the diagnosis of patellofemoral syndrome. This is a term that many practitioners use to describe a patients knee pain, yet it doesn’t specifically distinguish between various causes of pain in this area. Quite often patients are diagnosed with a condition in the shoulder called impingement. Again, this is helpful for some patients so that they can understand their condition better, but it is still a very vague term.

Shoulder Impingement Causes

Impingement of the shoulder is much like the name implies; certain structures get pinched which causes pain. This is obviously a very simple explanation of a very complex topic. There are various different types and different causes of impingement in the shoulder. For the practitioners out there, we know there is internal and external impingement. Internal impingement involves compression of tendons (usually) between the head of the humerus and the glenoid labrum. External impingement involves compression of the rotator cuff tendons or the subacromial bursa between the humeral head and the acromion process.

Functional Shoulder Impingement

At this point I’ve probably already confused the average reader, so the rest of this blog will focus on something more interesting; the various causes of secondary or “functional” impingement. This category of impingement is somewhat fixable in a clinical setting with the help of a manual practitioner.

Decreased Shoulder Movement

For some people, their shoulder impingement is associated with a loss of movement in the shoulder. Specifically, it would be a loss of internal rotation (turning your arm inward). This is something we can detect clinically and can give us clues to various dysfunctions in a patients shoulder. Among other things, this loss of movement alters the axis of motion in the shoulder which can lead to impingement.

Altered Shoulder Blade Movement

The scapula (shoulder blade) can move in a sub-optimal pattern leading to impingement of the shoulder. Termed scapular dyskinesis, the altered movement has a cascading effect on various shoulder tissues. Scapular dyskinesis has various causes and types, but the take-home point is that it can eventually lead to internal impingement in the shoulder.

Rotator Cuff Dysfunction

The various rotator cuff muscles have different prime movements. Together they can serve to depress or hold the humeral head down during abduction. When there is dysfunction in the rotator cuff muscles you can lose this ability and the humerus can translate upwards (resulting in impingement). Of note, rotator cuff injury can also lead to external impingement.

SLAP Lesion

A SLAP lesion refers to damage in the cartilaginous labrum of the shoulder. The labrum lies directly against the head of the humerus, so damage in this area can “get in the way” when we move the shoulder.

Shoulder Instability

Some people have too much laxity in their shoulders. This can be from repeated trauma or can simply be the way they are “built”. In this case, the patient’s humerus translates upwards and compresses various tissues (which is impingement).

Treatment for Shoulder Impingement

In an effort to be more specific and delineate the various causes of shoulder impingement this blog may actually confuse many readers. The take-home point is that sometimes your practitioner may simplify things so you understand them easier. Impingement of the shoulder can be a very complex condition with various causes. Due to this, there are various different ways to properly fix it. For some people, manual treatment and the use of therapeutic modalities are necessary. For others, specific exercises and rehabilitation strategies are indicated.  Active Release Technique, Graston and Laser Therapy are all common methods for treating shoulder pain.  Unsure what to do? Give us a call!

To contact our Burlington clinic – info@burlingtonsportstherapy.com

References
Cools AM, Cambier D, Witvrouw EE. Screening the athletes shoulder for impingement symptoms: a clinical reasoning algorithm for early detection of shoulder pathology. British Journal of Sports Medicine 2008; 42: 628-635.
Tate AR, McClure P, Kareha S, Irwin D. Effect of the scapula reposition test on shoulder impingement symptoms and elevation strength in overhead athletes. Journal of Orthopaedic & Sports Physical Therapy 2008; 38(1): 4-11.
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Fascia. Many of you have likely heard this term used more and more over recent years. This is perhaps due to the surge of new research on the topic and therefore the renewed interest within the manual medicine community.

What is Fascia?

Fascia can be defined as a sheet or band of fibrous connective tissue enveloping muscles, organs and other soft tissue structures of the body. Fascia is divided into three separate layers that work closely with one another. The most superficial layer (fascia superficialis) lies directly beneath the skin. The middle layer (fascia profundus) has connections with fascia superficialis and directly overlies the muscles. The deepest layer (deepest fascia or dural tube) directly surrounds and protects the central nervous system.

Why do we care about fascia?

The medical community has long known about the existence of fascia however, the role that it plays in movement and biomechanics of soft tissues has often been over looked. In order to understand this important role, you must first understand the complex anatomy of the layers themselves and their relationship with the other. For the purpose of this blog we’ll keep it short and simple, focusing on the 2 most superficial layers.

Dysfunction in Fascia

Although the primary function of fascia is to sustain and protect the underlying soft tissue with strong connections, it is imperative that each layer maintain a certain degree of independent motion. This is necessary so that our skin has the ability to slide along the muscle as well as all the muscle fibres among themselves. If this were not the case, we would not be able to move our joints to the extent that we can as they would be limited by our skin and muscles.

The Effect of Scar Tissue

So why has there been a shift in focus to fascia when it comes to soft tissue injuries? When a soft tissue injury occurs a process takes place to heal the area which involves alterations to the connective tissue. This process includes the formation of tissue fibrosis and scarring (scar tissue). This scarring within the connective tissue or fascia creates not only a relative weakness in the area (as the new connective tissue has less tensile strength and non uniform alignment) but also creates a bond between tissue layers, leaving a lack of relative movement in the area.

Treatment for Fascia

The focus of treatment for these injuries is to break up the scar tissue at the site of the injury and encourage a proper reorganization of the surrounding connective tissue and fascia. Methods that we commonly use to treat soft tissue injuries involving the fascia are Graston Technique, Active Release Technique and Low Intensity Laser Therapy. If you have a soft tissue injury that just doesn’t seem to be getting better, or an injury that seems to get better but somehow returns, it could mean that there is a change in the fascia or connective tissue in the area which must be returned to normal before proper function can be restored!

Our Burlington Clinic can be reached at – info@burlingtonsportstherapy.com

References
Van der Wal, J. The Architecture of the Connective Tissue in the Musculoskeletal System – An Often Overlooked Functional Parameter as to Proprioception in the Locomotor Apparatus. International Journal of Therpeutic Massage and Bodywork 2009; 2(4):1-15.
Spina, Andreo. Targeting Fascia – Rethinking the approach of soft-tissue treatment. Canadian Chiropractor 2011; 16(3):27-29

Are your knees painful? For many of our patients, the warm weather brings more activity which leads to more stress on irritable arthritic joints. Osteoarthritis of the knee is one of the more common conditions that we see at our clinic. Since it is one of those conditions that can interrupt our activity level, any form of prevention or management is important.

Knee Arthritis

Knee Arthritis

Osteoarthritis is a form of degenerative arthritis that can occur at any age but is more prevalent as we mature. It is often associated with “wear and tear” on the joint, and the symptoms can include pain, swelling, joint deformity and mechanical symptoms like locking or popping. It is important to remember that osteoarthritis affects both the biochemistry (the cells) of the joint and the biomechanics of the joint (the way the joint moves).

Treatment for Arthritis

To treat the cellular level of arthritis our clinic utilizes laser therapy. As mentioned in a previous blog, laser therapy has the ability to assist cellular regeneration and reproduction which reduces pain in arthritic joints. To address the functional or biomechanical changes associated with arthritis, exercise is vital.

Physiotherapy for Osteoarthritis

There have been numerous studies published to support the theory of strengthening the knee in order to decrease the incidence of osteoarthritis. An example is a recent study published in the journal Medicine & Science in Sports and Exercise (see reference below). This study found that strengthening of the quadriceps muscle combined with proprioceptive exercises helped to decrease the incidence of osteoarthritis. The mechanism for this effect was through an improved ability to stabilize the joint dynamically.

Strengthening for Arthritis

Strengthening an arthritic joint is difficult for many patients and is why we recommend consulting a professional who can assist you (like a physiotherapist). Although an individualized plan is ideal, we often recommend trying a standing closed kinetic knee extension using theraband or a pulley system. Although seated open kinetic knee extension can be unhelpful for many knee conditions, it is another option. This exercise may allow a patient with degenerative arthritis to strengthen their quadriceps without compressing the main compartment of the joint. Swimming is also a good option for some patients since it also doesn’t require significant joint compression.

Physiotherapy in Burlington – info@burlingtonsportstherapy.com

Segal NA, Glass NA, Felson DT et al. Effect of quadriceps strength and proprioception on risk for knee osteoarthritis. Medicine & Science in Sports and Exercise 2010; 42(11): 2081-2088.
Bjordal JM, Couppe C, Chow RT et al. A systematic review of low-level laser therapy with location-specific doses for pain from chronic joint disorders. Aust J Physiotherapy 2003; (4).
Brosseau L, Gam A, Harman K et al. Low level laser therapy (classes I, II and III) for treating osteoarthritis (Cochrane Review). The Cochrane Collaboration 2004; 3.
Jamtvedt G, Dahm KT, Christie A et al. Physical therapy interventions for patients with osteoarthritis of the knee: an overview of systematic reviews. Physical Therapy 2008; 88(1): 123-136.
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Many patients present to our clinic with hip pain. In the past, muscle strain or osteoarthritis may have been on the top of the diagnostic likelihood, but this is changing as our knowledge of the hip is improving. One condition that we have a relatively new understanding about is femoroacetabular impingement.

Hip Impingement

More and more literature is being published on femoroacetabular impingement syndrome. Since we are still learning about it, we really don’t know how common it is. We do know that it is painful and is a cause of early degenerative arthritis in young adults. The pathomechanics of the condition is relatively simple since the name almost says it all; the femur abuts against the cartilage in the hip “socket” (acetabulum) and causes an impingement of the tissue. This usually occurs when the hip is placed at the end of its movement range. For those people at risk, the repeated movement in this manner damages the cartilage, causing advanced degeneration of the cartilage and potential tearing of the labrum. (The labrum is a round, bowl like structure of cartilage that the femoral head sits in).

Symptoms of Hip Impingement

Symptoms of femoroacetabular impingement include hip pain (in the groin area or on the lateral aspect of the hip) and stiffness, usually after prolonged sitting or prolonged activity. Progressive degeneration of the cartilage occurs with repeated aggravating activity; this increases the pain. When there is tearing of the labrum, patients may report catching or locking sensations.

Treatment for Hip Pain

The treatment for femoroacetabular impingement is variable. As with most musculoskeletal conditions, conservative treatment is a good starting point. If there is a certain activity that aggravates your hip it would be advisable to stop doing it for a while. Your family doctor may be able to offer you temporary medication to help control your pain and inflammation. Corticosteroid can also be considered as an option for temporary relief. From the perspective of physiotherapy or chiropractic, treatment geared at the tight muscles of the hip may be helpful. Therapeutic modalities like interferential current and low intensity laser may also be helpful for reducing pain and inflammation, and the regeneration of healthier cells in the area of the joint (as in the case of low intensity laser).

Surgery for Hip Impingement

Keep in mind that conservative treatment does not alter the structural changes occurring in the hip joint itself. To address these changes, referral to an orthopedic surgeon who is knowledgeable about this relatively new condition is paramount. Early, effective treatment can help reduce the progression of femoroacetabular impingement and preserve the joint structures for the future.

Diagnosing Hip Impingement

According to the literature, there are some subtle radiographic signs that can help determine whether femoroacetabular impingement is present. Our Chiropractors are able to assist you with this. We can refer you for the appropriate imaging and perform the appropriate clinical tests to see if this may be the cause of your persistent hip pain.

For further information about treatment for this condition at our Burlington clinic, feel free to email us at info@burlingtonsportstherapy.com

References
Emary P. Femoroacetabular impingement syndrome: a narrative review for the chiropractor. Journal of the Canadian Chiropractic Association 2010; 54(3): 164-175.
Martin RL et al. Acetabular labral tears of the hip: examination and diagnostic challenges. Journal of Orthopaedic & Sports Physical Therapy 2006; 36(7): 503-515.
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