John J. Wilson

Musculoskeletal Applications of Platelet-Rich Plasma: Fad or Future?

OBJECTIVE The purpose of this article is to detail the biology of platelet-rich plasma (PRP), critically review the existing literature, and discuss future research applications needed to adopt PRP as a mainstay treatment method for common musculoskeletal injuries. CONCLUSION Any promising minimally invasive therapy such as PRP deserves further investigation to avoid surgery. Diagnostic imaging outcome assessments, including ultrasound-guided needle precision, should be included in future investigations.

Effectiveness of Platelet-rich Plasma Injection for Rotator Cuff Tendinopathy: A Prospective Open-label Study

Objective: Assess platelet rich plasma (PRP) injection for rotator cuff tendinopathy (RCT). Design: Prospective open label study with 1-year follow-up. Methods: Participants recruited from an outpatient sports medicine clinic had clinically and magnetic resonance image (MRI)—demonstrated RCT refractory to physical therapy and corticosteroid injection. They received one ultrasound-guided injection of 3.0 mL of 1% xylocaine followed by 3.5 mL of PRP at the lesion and surrounding tendon. Primary outcome: 0—10 visual analog scale (VAS; baseline, 8, 12, and 52 weeks). Secondary outcomes: functional shoulder tests assessing rotator cuff strength and endurance (at baseline and 8 and 12 weeks), MRI severity (1—5 points [at baseline and 4 and 8 weeks]), and patient satisfaction (52 weeks). Results: Eighteen participants with 19 assessed shoulders reported VAS pain score improvement from 7.5 ± 0.3 points to 0.5 ± 0.3 points by week 12 and 0.4 ± 0.2 (P = .0001) points at week 52. Functional outcomes significantly improved; the largest effect was seen in the external rotation test: 33.5 ± 5.7 seconds to 62.6 ± 7.2 seconds at week 12 (P = .0001). MRI appearance improved by 1 to 3 points in 16 of 18 assessed shoulders. Seventeen participants were “completely satisfied” (12) or “satisfied” (5). One participant was “unsatisfied.” Conclusions: A single ultrasound-guided, intralesional injection of PRP resulted in safe, significant, sustained improvement of pain, function, and MRI outcomes in participants with refractory RCT. Randomized multidisciplinary effectiveness trials that add ultrasound and validated clinical outcome measures are needed to further assess PRP for RCT.

Practical management: vocal cord dysfunction in athletes.

Vocal cord dysfunction (VCD) is characterized by paradoxical adduction of the vocal folds during inhalation, and occasionally upon exhalation, resulting in extrathoracic airflow obstruction. Sports medicine professionals must have a high index of suspicion for VCD when acute respiratory symptoms occur so that prompt evaluation and use of appropriate specialists results in an accurate and timely diagnosis. Many factors have been implicated in the pathophysiology of VCD, including laryngeal irritants, psychogenic and neurogenic causes. The diagnosis and management of VCD involves a variety of specialties including pulmonology, otolaryngology, speech-language pathology, allergy and immunology, and psychologic management as appropriate. The mainstay of treatment remains behavioral management guided by a medical speech-language pathologist, as well as pharmacologic management for VCD triggers.

Evaluation and management of vocal cord dysfunction in the athlete.

Vocal cord dysfunction (VCD) is defined by paradoxical vocal fold closure during inhalation, and rarely upon exhalation. The precise etiology of VCD is unknown; however, a variety of potential causes may include laryngeal hyperresponsiveness, laryngeal irritants, psychogenic causes, and rarely neurologic diseases. VCD can occur in athletes, particularly females, and the sports medicine professional likely is to care for patients with acute respiratory difficulties caused by this condition. Given its complex nature, a multidisciplinary approach to VCD evaluation and management is necessary and results in optimal outcomes.

Platelet-Rich Plasma for the Treatment of Chronic Plantar Fasciopathy in Adults A Case Series

Plantar fasciopathy (PF) is a common source of pain and disability that is often refractory to conservative management. There are no uniformly effective standard-of-care treatments for chronic recalcitrant PF. Corticosteroid injection is considered a viable treatment option when traditional therapies fail, but is limited by suboptimal long-term efficacy and potential adverse effects. Platelet-rich plasma (PRP) is an emerging injection-based treatment for various chronic degenerative soft-tissue diseases. It is postulated to promote native tissue regeneration; however, consistent scientific evidence remains lacking. A prospective case series, including 24 consecutive PF cases, was conducted to report patient-rated pain and disability following PRP injection. Foot and Ankle Ability Measure (FAAM) scores were the primary clinical outcome measure. Foot–Single Assessment Numeric Evaluation (Foot-SANE) scores, Short Form-12 Health Survey version 2 (SF-12v2) questionnaires, and PRP treatment satisfaction surveys were secondary outcome measures. Statistical analysis compared baseline and 32 weeks post-injection time points. Patients receiving PRP injection reported clinically and statistically significant improvement in all outcome measures during this interval. There were no serious adverse events associated with treatment. PRP is considered a safe therapeutic option with the ability to decrease heel pain in patients with chronic PF refractory to appropriate conservative management. Levels of Evidence: Therapeutic, Level IV, prospective case series

Arthroscopic Partial Meniscectomy: MR Imaging for Prediction of Outcome in Middle-Aged and Elderly Patients

PURPOSE To determine whether preoperative magnetic resonance (MR) imaging could help identify factors associated with poor clinical outcome after arthroscopic partial meniscectomy (APM) in middle-aged and elderly patients with meniscal tears. MATERIALS AND METHODS The prospective, institutional review board-approved, HIPAA-compliant study was performed with informed consent in 53 men and 47 women (average ages, 54.5 and 56.6 years, respectively). Patients underwent knee MR imaging before APM; clinical symptoms were evaluated preoperatively and 1 year postoperatively with International Knee Documentation Committee (IKDC) questionnaire. Overall severity of knee joint degeneration and severity of each feature of joint degeneration were assessed with Boston Leads Osteoarthritis Knee (BLOK) scoring system. Tear length was measured, and type of meniscal tear was classified. Spearman correlation coefficients and relative risks showed the relationship between clinical outcome after APM (difference between preoperative and postoperative IKDC scores) and severity of joint degeneration. RESULTS Seventy-four patients with isolated medial APM had a significant (P < .05) inverse correlation between clinical outcome and severity of cartilage loss and bone marrow edema in the medial femoral condyle and medial tibial plateau. Fifteen patients with isolated lateral APM had a significant (P < .05) inverse correlation between clinical outcome and severity of cartilage loss in the lateral femoral condyle and lateral tibial plateau and bone marrow edema in the lateral femoral condyle. One hundred patients with APM had a significant (P < .05) inverse correlation between clinical outcome and severity of meniscal extrusion, total BLOK score, and meniscal tear length. A significantly (P < .05) increased relative risk that a patient would not definitely improve after APM was observed if a meniscal root tear was present. CONCLUSION Poorer clinical outcome after APM was associated with greater severity of cartilage loss and bone marrow edema in the same compartment as the meniscal tear, greater severity of meniscal extrusion, greater overall severity of joint degeneration, a meniscal root tear, and a longer meniscal tear at preoperative MR imaging.

Articular Cartilage of the Human Knee Joint: In Vivo Multicomponent T2 Analysis at 3.0 T

PURPOSE To compare multicomponent T2 parameters of the articular cartilage of the knee joint measured by using multicomponent driven equilibrium single-shot observation of T1 and T2 (mcDESPOT) in asymptomatic volunteers and patients with osteoarthritis. MATERIALS AND METHODS This prospective study was performed with institutional review board approval and with written informed consent from all subjects. The mcDESPOT sequence was performed in the knee joint of 13 asymptomatic volunteers and 14 patients with osteoarthritis of the knee. Single-component T2 (T2(Single)), T2 of the fast-relaxing water component (T2F) and of the slow-relaxing water component (T2S), and the fraction of the fast-relaxing water component (F(F)) of cartilage were measured. Wilcoxon rank-sum tests and multivariate linear regression models were used to compare mcDESPOT parameters between volunteers and patients with osteoarthritis. Receiver operating characteristic analysis was used to assess diagnostic performance with mcDESPOT parameters for distinguishing morphologically normal cartilage from morphologically degenerative cartilage identified at magnetic resonance imaging in eight cartilage subsections of the knee joint. RESULTS Higher cartilage T2(Single) (P < .001), lower cartilage F(F) (P < .001), and similar cartilage T2F (P = .079) and T2S (P = .124) values were seen in patients with osteoarthritis compared with those in asymptomatic volunteers. Differences in T2(Single) and F(F) remained significant (P < .05) after consideration of age differences between groups of subjects. Diagnostic performance was higher with F(F) than with T2(Single) for distinguishing between normal and degenerative cartilage (P < .05), with greater areas under the curve at receiver operating characteristic analysis. CONCLUSION Patients with osteoarthritis of the knee had significantly higher cartilage T2(Single) and significantly lower cartilage F(F) than did asymptomatic volunteers, and receiver operating characteristic analysis results suggested that F(F) may allow greater diagnostic performance than that with T2(Single) for distinguishing between normal and degenerative cartilage.

Repair of a complete anterior cruciate tear using prolotherapy: a case report.

Abstract Introduction: Surgical reconstruction is considered definitive treatment for anterior cruciate ligament (ACL) tears but precise surgical indications are debated. Some patients are reluctant or inappropriate surgical candidates. Prolotherapy is a non-surgical injection therapy for chronic musculoskeletal pain and instability. This case report documents the non-surgical repair of a torn ACL using prolotherapy and at-home exercise. Clinical presentation and intervention: An 18-year-old woman sustained a right knee injury during a downhill skiing accident. Magnetic resonance imaging (MRI) revealed a high-grade partial versus complete rupture; Lachman examination findings suggested a complete rupture. She deferred surgical treatment. At 21 weeks post-injury, with unstable gait, inability to climb stairs and more than 1-cm anterior drawer test, she consented to undergo prolotherapy injections. She received seven prolotherapy sessions over a 15-week period. At-home exercises were initiated at the third prolotherapy session. Results: The patient improved. Walking on flat ground improved 4 weeks after initiation of prolotherapy; she could ride a stationary bicycle for 30 min by 12 weeks. By 15 weeks, the patient had no instability climbing and descending stairs, the anterior drawer test was negative and MRI showed an intact ACL with fibrosis. Subsequently, she returned to full sport activity. Conclusions: We document the non-surgical repair of a high-grade partial or complete ACL tear using prolotherapy and at-home exercise. Prolotherapy may be an alternative to surgery in carefully selected patients. This report is consistent with findings of recent pilot-level studies and suggests the need for rigorous clinical trials assessing prolotherapy as treatment for ligament and tendon injury in selected patients.

Cross-relaxation imaging of human patellar cartilage in vivo at 3.0T

OBJECTIVE To compare quantitative magnetization transfer (qMT) parameters of patellar cartilage measured using cross-relaxation imaging (CRI) in asymptomatic volunteers and patients with osteoarthritis. DESIGN The study was performed with Institutional Review Board approval and with all subjects signing informed consent. CRI of the knee joint was performed at 3.0T on 20 asymptomatic volunteers and 11 patients with osteoarthritis. The fraction of macromolecular bound protons (f), the exchange rate constant between macromolecular bound protons and free water protons (k), and the T2 relaxation time of macromolecular bound protons (T2(B)) of patellar cartilage were measured. Mann-Whitney-Wilcoxon rank-sum tests were used to compare qMT parameters between asymptomatic volunteers and patients with osteoarthritis. RESULTS Average f, k, and T2(B) of patellar cartilage was 12.46%, 7.22 s(-1), and 6.49 μs respectively for asymptomatic volunteers and 12.80%, 6.13 s(-1), and 6.80 μs respectively for patients with osteoarthritis. There were statistically significant differences between groups of subjects for k (P < 0.01) and T2(B) (P < 0.0001) but not f (P = 0.38) of patellar cartilage. CONCLUSION Patients with osteoarthritis had significantly lower k and significantly higher T2(B) of patellar cartilage than asymptomatic volunteers which suggests that qMT parameters can detect changes in the macromolecular matrix of degenerative cartilage.

Rapid in vivo multicomponent T2 mapping of human knee menisci

To compare multicomponent T2 parameters of menisci measured using Multicomponent Driven Equilibrium Single Pulse Observation of T1 and T2 (mcDESPOT) in asymptomatic volunteers and osteoarthritis (OA) patients with intact and torn menisci.