Orthopaedic & Sports Medicine





A new Innovative therapy for muscle
injuries: Platelet-Rich Plasma






Muscle injuries are the terror for elite athletes. Once injured, the athlete can expect a relatively long period of absence and a 20-25% chance of re-injury. Current research is focusing on developing new treatment options for these muscle injuries. Injections of growth factors, in the form of Platelet-Rich Plasma (PRP) have become a novel and innovative therapy for high level athletes. J.L. Tol MD, PhD, sports medicine physician, Aspetar, Orthopaedic and Sports Medicine Hospital, Doha, Qatar, investigates the effect of this new promising therapy for hamstring injuries.


Introduction

Muscle injuries account for up to 30% of injuries sustained in sports, especially during high-velocity sprinting. Despite numerous prevention programmes, the hamstring is still the most frequently reported muscle injury in sports. It has been estimated that in a professional football squad of 25 players, five of them will sustain a hamstring injury with an average time to return to play of approximately 4 weeks.

Traditionally, the RICE principal (rest, ice, compression, elevation) is practiced for all these muscle injuries. However, no high quality studies have clearly shown any benefit from compression and elevation. Anti-inflammatory medication, which is commonly used in muscle injuries, seems to show no effect on muscle strains and may even have a slight negative impact. Up to now there is only limited evidence to support the use of stretching, agility and trunk stability exercises.

Despite the frequency of muscle injury and high recurrence rate, there is still no consensus on the best management due to a lack of scientific evidence.

Innovative therapy

There is increasing interest in the sports medicine and athletic community about providing growth factors directly to the injury site to potentially facilitate healing and earlier return to sport after musculoskeletal injury.

Probably the most popular and innovative therapy that has been recently introduced is the injection of Platelet-Rich Plasma (PRP). PRP is derived from centrifuging whole blood leading to the separation of the platelets. The platelet concentration in PRP is dependent on the separation technique but may be up to 6 times higher than that of the whole blood. PRP contains numerous growth factors.

Basic research studies have shown that muscle cell growth can be improved with specific growth factors like b-FBG, IGF-1 and NGF. These growth factors have been shown to be essential for optimising healing in injured muscle. Growth factors are stored in α-granules within platelets, and are released in a selective manner upon when placed in different tissues.

It is the release of growth factors from the -granules of platelets that is assumed to techprovide the regenerative benefits of PRP. However, despite the promising results from basic research, and increasing clinical use, there is a lack of high-level evidence regarding randomised clinical trials assessing the efficacy of PRP in treating muscle injuries.

PRP is not doping

The intramuscular injection of the endogenous growth factors was first added to the World Anti Doping Authority (WADA) list of prohibited substances in 2010. This prohibition was exclusively reserved for intramuscular injections. Other forms of application as intra-articular and intratendinous were, however, permitted. The major concern of the WADA was the potential stimulation of excessive muscle hypertrophy and increased muscular performance.

However, new insights into the therapy have occurred since 2011. Since then it is no longer recognised as a prohibited drug or therapeutic substance, which means that it can be used without conflict with the WADA Prohibited List. Importantly however, the use of individual “man made” growth factors are still prohibited by the WADA and contraindicated for use in athletes. This change has lead to an exponential increase of the use of PRP for muscle injuries in elite athletes.

Scientific study

Anecdotal and low-level evidence suggests that PRP has the potentiality to facilitate healing and allow a 50% earlier return to sport after muscles injuries. Although it is questionable if the time to return to sports can be halved, even a slight reduction in recovery time will have an enormous effect for professional players and huge financial benefits for professional clubs. It may, for example, allow an individual player to return to play two or three games earlier; might potentially be the difference between winning and losing the game; and might allow for the winning of the championship. Aspetar’s goal is to assist athletes in achieving their full potential and in order to know if we are doing this, the sports hospital is currently carrying out an indepth randomised, controlled study on the benefits of PRP in muscle injuries.

PRP in the hamstring

All athletes who sustain an acute hamstring injury are potentially eligible to receive the PRP injections. The diagnosis is based on clinical findings and confirmed by Magnetic Resonance Imaging (MRI). MRI is the ultimate diagnostic tool to detect the degree of muscle injury and Aspetar has the capacity to perform this.

Based on the MRI findings and under ultrasound guidance, using a sterile technique, PRP is injected by specialised sports medicine physicians in the area of muscular pathology. It is known that within 20 minutes after injection there is release of the platelets-derived growth factors. It remains unknown if these growth factors significantly increase the healing response and decrease the desired recovery period.

Accelerated rehabilitation

Comparable to the accelerated rehabilitation after knee ligament (ACL) surgery, the post-injection rehabilitation will have a great influence on the recovery period and potentially enable a quicker return to sports.

Aspetar’s rehabilitation programme starts with a range of motion exercises, regular ice therapy and rapidly progresses through a programme of isometric, concentric and eccentric exercises, as much as pain free motion allows. Core stability training is included in the overall rehabilitation programme. Based on clinical progress the athlete is required to effectively finish the final phase of the rehabilitation programme before returning to sports. This final phase implies a gradual transition to sport-specific exercise, supervised by a physical therapist and physical performance coach. At the end of the rehabilitation, the athlete is tested in our rehabilitation isokinetic testing laboratory to quantify the muscle performance and compare it with the uninjured site.

The future will show us if this new innovative therapy and accelerated physical therapy programme will enable elite athletes to achieve a significantly quicker recovery, earlier return to sports and the ability to achieve their full potential. That might be the difference between finishing second or being the champion.

Further reading

1. de Vos R, Weir A, van Schie H, Bierma- Zeinstra S, Verhaar J, Weinans H,Tol J. Platelet-Rich Plasma Injection for Chronic Achilles Tendinopathy; A Randomized Controlled Trial. JAMA. 2010; 303: 144-149.

2. Hamilton B,Best TM. Platelet-Enriched Plasma and Muscle Strain Injuries: Challenges Imposed by the Burden of Proof. Clinical Journal of Sport Medicine. 2011; 21: 31-36.

3. Hamilton B, Knez W, Eirale C, Chalabi H. Platelet Enriched Plasma for Acute Muscle Injury. Acta Orthop Belg. 2010; 76: 443-448.
 

BioPoly partial knee resurfacing – a world first

On 9 January this year, The London Clinic consultant Dinesh Nathwani successfully performed the world’s first BioPoly partial knee resurfacing procedure. The new procedure, for patients presenting with cartilage lesions of the femoral condyle, enables immediate weight bearing and stronger qualities for the prostheses. Middle East Health reports.

The world’s first BioPoly partial knee resurfacing procedure was conducted through The Advanced Therapies Centre, a newly launched clinical trials facility at The London Clinic in London, United Kingdom. The aim of the centre is to provide innovative treatment options for patients through access to trials and novel therapies.

BioPoly knee surgery, which enables the patient to immediately weight bear (with the aid of anti-inflammatories), uses a new type of material combining hyaluronic acid and ultra-high molecular weight polyethylene. When combined, these two materials improve the wear qualities of the prosthesis, whilst also providing a biologically lubricated surface that effectively interacts with the body’s natural tissues. The material is strong enough to take the weight of the body, but also has a degree of flexibility not matched by standard metal replacements.

Commenting on the prosthesis, Mary Keal, the first person to receive the BioPoly prosthesis, said: “My experience of BioPoly so far has been excellent. I was in pain when crossing my legs or walking up stairs; anything where my knee was at an angle. Since my operation, this pain has completely disappeared. I was able to weight bear straight away with the aid of crutches, after 4 weeks I was cycling again, and at 7 weeks I started to increase resistance.”

Dinesh Nathwani, the surgeon who performed the operation said he was exceptionally pleased with Mary’s progress. “The bone conserving nature of the procedure, along with the new BioPoly material used, means that recovery has been relatively quick and the original pain experienced has disappeared.”

The procedure is bone conserving, meaning that only the damaged cartilage is removed. The prosthesis is then attached to the end of the bone via a metal stud anchoring it into place. By preserving the healthy bone and cartilage, younger patients experiencing knee problems and who are likely to need further reconstructive work, will have as much healthy bone in-tact as possible, making future operations not only viable, but less complicated.

Patients who will benefit from the BioPoly procedure are those presenting with painful cartilage lesions of the femoral condyle, who might not be suitable candidates for other procedures including biological treatments or joint replacement.

The London Clinic is one of the four UK centres that are involved in this multi- centre registry trial which has been fully approved by the UK multi regional ethics committee and data collection and analysis of this study is on-going.

In a statement, The London Clinic – the UK’s largest independently-owned non-profit hospital with more than 250 beds and 12 operating theatres – said it is committed to utilising its state of the art facilities and world leading expertise, in order to provide patients with access to novel therapies, procedures and the best possible care options.



 Date of upload: 26th Sep 2012

 

                                  
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