Regenerative Injections in Sports Medicine: An Evidenced Based Approach

145 Pages·2020·6.159 MB·English

by  Suad Trebinjac, Manoj Kumar Nair

Regenerative
Injections in Sports
Medicine
An Evidenced Based Approach
Suad Trebinjac
Manoj Kumar Nair
123
Regenerative Injections in Sports Medicine
Suad Trebinjac • Manoj Kumar Nair
Regenerative Injections
in Sports Medicine
An Evidenced Based Approach
Suad Trebinjac Manoj Kumar Nair
CZECH Rehabilitation Hospital Dubai Health Authority
Al Ain; FIFA Medical Center of Excellence Dubai
Dubai United Arab Emirates
United Arab Emirates
ISBN 978-981-15-6782-7 ISBN 978-981-15-6783-4 (eBook)
https://doi.org/10.1007/978-981-15-6783-4
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Foreword
As a professor neurosurgeon and the chairman of the Development Committee of
the American Academy and Board of Regenerative Medicine, the Middle East and
North Africa Chapter, I am honored and privileged to write a foreword for this
important book in the field of regenerative medicine.
I consider Prof. Dr. Suad Trebinjac as one of the most active members in the
MENA Chapter of the AABRM. He worked hard to finish all the requirements of
the Diploma of the AABRM and deserved well to obtain it. He is a colleague and a
friend from whom I get a lot of inspiration. We work together on many regenerative
projects. He has recently been appointed as the Medical Director in one of the out-
standing rehabilitation hospitals where he is working actively to establish an
evidence-b ased regenerative therapy center. Dr. Manoj Kumar is another member of
the MENA Chapter of the AABRM. We were part of the first group of doctors to
prepare for the AABRM diploma. Since then, we have been close colleagues shar-
ing the values of evidence-based regenerative practice. He is a known physician in
his field, and his scientific approach is well appreciated by his patients and peers.
I am pleased that these important figures of regenerative medicine in the Middle
East have written the book that will serve as a reference for biological therapy in the
field of sports medicine. They have managed to cover all the important applications
of regenerative medicine including prolotherapy. The latter is a subject that is often
forgotten or missed in the arsenal of available therapies in regenerative medicine. It
offers excellent results in a proper indication at a very moderate price. As we all
know, the price of the treatment is an essential factor to decide on the availability
and affordability of any treatment in every part of the world.
I feel that this book has contributed a great deal in filling the gap of evidence-
based practice in the regenerative world. It is an important contribution made by
these enthusiastic authors that will be an asset to doctors of the field not only in the
Middle East but also all over the world.
As an expert in the field of regenerative medicine with particular interest in spi-
nal pathologies, I have the pleasure of presenting this masterpiece to the medical
and scientific community.
This book presents in a very well-illustrated method the wide indications of
regenerative therapy in sports medicine. The book starts by defining regenerative
medicine and the different types of regenerative treatment available. This paves the
way for the reader to understand and digest the valuable content of the book. This is
v
vi Foreword
followed by another important chapter that discusses the mechanisms of injuries in
sports. A presentation of the different regenerative therapies is then detailed in the
following chapters. The rehabilitation part of this book stresses the importance of
rehabilitation subsequent to regenerative treatment. So as a matter of fact, these two
types of treatment go together and are complementary to each other. This solid clini-
cal and scientific work is topped by the section on the future tendencies in biological
therapies in sports medicine. In essence, this important work could be a guide for
newly joining members to the community of biological therapy as well as for sea-
soned specialists to achieve perfection in their skills.
Both authors are highly experienced physical medicine and rehabilitation spe-
cialists with long and deep wealth of experience in the field of regenerative medi-
cine. This makes them well capable of sharing this very interesting experience and
knowledge with the sports medicine and the regenerative community.
In conclusion, I had a great joy in writing the foreword to this book as I believe
that it is a valuable addition to the regenerative medicine library. It will be the com-
panion and guide for orthopedics, sports medicine, rheumatologists, rehabilitation
specialists, physiotherapists, and all regenerative practitioners in general in their
daily practice. As the chairman of the Development Committee of the AABRM, I
endorse strongly this masterpiece to my fellow readers written by these brilliant
physicians. I would like to thank them sincerely for their tremendous efforts in com-
pleting this manuscript.
Liverpool, UK Mohammed Al-Jumaily
London, UK
Dubai, UAE
Contents
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 Definition of Regenerative Medicine . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Different Types of Regenerative Treatments . . . . . . . . . . . . . . . . . . . 2
1.3 Importance of Regenerative Medicine in Sport . . . . . . . . . . . . . . . . . 2
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
2 Injury Mechanisms in Sports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.1 Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.2 Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.3 Wrist and Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.4 Hip and Groin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.5 Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.6 Ankle and Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
3 Current Practices in Sports Injury Rehabilitation . . . . . . . . . . . . . . . . 17
3.1 Goal-Oriented Rehabilitation Pathway . . . . . . . . . . . . . . . . . . . . . . . 19
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
4 Prolotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
4.1 Definition of Prolotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
4.2 History of Prolotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
4.3 Prolotherapy: Mechanism of Action . . . . . . . . . . . . . . . . . . . . . . . . . 22
4.4 Indications and Contraindications for Dextrose Prolotherapy . . . . . . 24
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
5 Dextrose Prolotherapy: Preparation Methods and
Protocols of Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
5.1 Animals Study on Dextrose Prolotherapy . . . . . . . . . . . . . . . . . . . . . 32
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
6 Clinical Applications of Dextrose Prolotherapy in Sports . . . . . . . . . . . 35
6.1 Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
6.2 Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
6.3 Wrist and Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
6.4 Hip and Groin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
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6.5 Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
6.6 Ankle and Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
7 Platelet Rich Plasma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
7.1 Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
7.2 History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
7.3 Mechanism of Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
7.4 Assessment of Platelet Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
8 Platelet Rich Plasma: Preparation Methods . . . . . . . . . . . . . . . . . . . . . 61
8.1 Activation of Platelets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
8.2 Classifications of PRP Preparations . . . . . . . . . . . . . . . . . . . . . . . . . . 65
8.3 Different Types of Platelet Preparations . . . . . . . . . . . . . . . . . . . . . . 68
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
9 Clinical Applications of Platelet Rich Plasma in Sports . . . . . . . . . . . . 71
9.1 PRP in Muscle Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
9.2 PRP in Tendon and Ligament Pathologies . . . . . . . . . . . . . . . . . . . . . 72
9.3 Anterior Cruciate Ligament Pathology . . . . . . . . . . . . . . . . . . . . . . . 75
9.4 Rotator Cuff Tendinopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
9.5 Patellar Tendinopathy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
9.6 Plantar Fasciitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
9.7 Lateral Epicondylitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
9.8 Ankle Ligaments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
9.9 Achilles Tendinopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
9.10 Greater Trochanteric Pain Syndrome (GTPS) . . . . . . . . . . . . . . . . . . 77
9.11 Knee Osteoarthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
9.12 Variables Affecting the Efficacy of PRP Preparations . . . . . . . . . . . . 79
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
10 Settings for PRP Injections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
10.1 Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
10.2 PRP Centrifuge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
10.3 PRP Kit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
10.4 Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
10.5 Steps in Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
11 Stem Cells . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
11.1 Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
11.2 History of Stem Cells . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
11.3 The Main Features of Stem Cells . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
11.4 Sources of Stem Cells . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
11.5 Mechanism of Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Contents ix
12 Stem Cells: Preparation Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
12.1 Collection of Stem Cells . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
12.2 BMAC Harvesting and Processing Technique . . . . . . . . . . . . . . . . . 107
12.3 Harvesting and Processing of Adipose Tissue . . . . . . . . . . . . . . . . . 110
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
13 Clinical Applications of Stem Cells in Sports . . . . . . . . . . . . . . . . . . . . . 115
13.1 Mesenchymal Stem Cell Treatment in Ligament and Tendon . . . . . 115
13.2 Mesenchymal Stem Cells in Patellar Tendinopathy . . . . . . . . . . . . . 118
13.3 Mesenchymal Stem Cells in Osteoarthritis . . . . . . . . . . . . . . . . . . . 118
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
14 Rehabilitation After Regenerative Injection procedures . . . . . . . . . . . . 121
14.1 Rehabilitation After Platelet Rich Plasma Injection for
Patellar Tendinopathy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
14.2 Return to Play Decisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
15 The Future of Regenerative Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
About the Authors
Suad Trebinjac, MD, PhD, graduated from the Faculty of Medicine, University

of Sarajevo, Bosnia and Herzegovina (former Yugoslavia). He is currently an
Associate Professor at Dubai Medical College for Girls and Consultant on Physical
Medicine and Rehabilitation to Al Garhoud Private Hospital/FIFA Medical Center
of Excellence, Dubai, and CZECH Rehabilitation Hospital, Al Ain. Dr. Suad has
more than 30 years of experience in the field of physiatry and 12 years of experience
in prolotherapy and regenerative medicine.
Manoj Kumar Nair, MD, DNB, is certified by the National Board of Examinations

India. Dr. Nair holds a Diploma in Sports Medicine from the International Olympic
Committee and is currently working as a Specialist in Physical Medicine and
Rehabilitation at the Dubai Health Authority. He has more than 15 years of experi-
ence as a specialist in Physical Medicine & Rehabilitation (Physiatry) and 5 years
of experience in prolotherapy and regenerative medicine.
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