Muscle & Tendon Tears

A muscle tear can also be referred as a muscle strain, or pulled muscle (depending on the severity of the tear). This occurs when your muscle is overstretched or torn. This usually occurs as a result of fatigue, overuse, or improper use of a muscle. Strains can happen in any muscle, but they’re most common in your lower back, neck, shoulder, and hamstring. (Epainassist, 2017)

A tendon tear is very similar to a muscle tear, however tendon’s will take a very long time to repair & often their symptoms can be significantly more debilitating when compared to a muscle tear.

Strong muscle can pull on tendons, during this process it can either cause the tendon to rupture or become inflamed.
The stage of inflammation within the tendon is called “Tendonitis” or “Tendinosis”

Despite the great advances in the surgical procedures used to treat rotator cuff tears, the frequency of re-rupture is still unacceptable for large injuries. Chronic degenerative lesions are most common in the elderly. (Tornero-Esteban et al., 2015)

Ligament & Cartilage Tears

A ligament is a short band of tough, flexible tissue, made up of lots of individual fibres, which connect the bones of the body together. Ligaments can be found connecting most of the bones in the body.

The cartilage is the firm, flexible connective tissue found in between the bones, the purpose of the cartilage is to protect and cushion your joint movements. (Physioworks, 2017)

How your body addresses Ligament tears:

The ligaments can be difficult to repair; this is typically due to the poor blood supply to the ligament. There are sections in the distal part of ligaments which are vascularized by branches of the surrounding arteries. In other sections of the ligament there are avascular zones. These are areas which have no blood supply.
(Petersen and Tillmann, 1999)
When the tear is located within an avascular area, it is difficult for your immune response alone to induce healing. In many cases these areas may require surgical intervention.
(Kamimura and Kimura, 2014)

How your body addresses Cartilage tears:

Cartilage tears are in their own category since they are completely avascular. There is no blood flow or nerve connection to the actual cartilage.    For this reason alone, cartilage does not possess the regenerative capacity of bone or the other connective tissue types.
(Solomon et al., 2005)

A tear of cartilage will require surgical intervention if the symptoms are unbearable.

HOW DO STEM CELLS WORK TO TREAT THESE TEARS?

When it comes to treating patients with a tear of any kind, the symptoms are the initial target which show improvements. This specifically relates to the level of pain, stiffness and strength you have lost in your joint  which is causing you to struggle with your daily activities.

The stem cells have the potential to;       

  1. Target and fight off inflammation (reduce the pain you have)
  2. Repair damaged tissue
  3. Differentiate to the matching tissue type (eg: muscle, tendon, ligament & cartilage)
  4. Increase the productivity of synovial fluid (increase lubrication of your joints)
  5. Soften existing scar tissue (increase range of movement)

(Condé-Green et al., 2016) (Wu et al., 2013) (Gibbs et al., 2015) (Jo et al., 2014)  (Michalek, 2015)

Inflammation is a key feature of the early period following tendon repair, but excessive inflammation has been associated with poor clinical outcomes. Modulation of the inflammatory environment using cellular treatments can provide a means to enhanced healing. (Manning et al., 2015)

When it comes to the treatment of tears, there are 2 categories of patients

1. Patients with minor, & partial tears or tears which are still intact

The cells will home to inflammation surrounding the site of the tear, within the short term these cells will resolve the inflammation thus allowing your pain levels to decrease. Over time the cells will start their repairs to the tear.

 

a. Pre-existing or old tears which have been partially repaired.

If the tear is pre-existing, your body would have attempted to repair the area. This will be repaired with scar tissue.
Scar tissue is able to hold the tissue together but it is inflexible and weak. This means the area can either easily re-tear or the surrounding tissue adjacent to the existing tear can sustain a new tear.

The cells can soften existing scar tissue which in-turn means better elasticity, improved range of motion and this area will be less likely to re-tear.
This will allow the patient to be able to take on physiotherapy to increase the range of motion and strength surrounding the tear.
NOTE: This does not apply to cartilage tears since they can’t form scar tissue.

 

b. New or current Tears

If the tear is fresh (within the first 1 to 3 months) the cells will be able resolve the inflammation as mentioned above, from this point they will continue to differentiate into the existing tissue type.
This means your body’s attempt to repair the damage with scar tissue will be over ridden with the ability of these cells to repair the damage with the original of tissue.
For example, stem cells will differentiate into tendon cells; these tendons cells will repair the torn tendon as opposed to forming scar tissue. Therefore the treatment has the ability to restore the tear back to full function and original form.

2. Patients with complete tears or full detachment

This is a different area where there is not enough evidence to suggest stem cells alone will completely repair the tear. We have observed anecodotal cases in both our own practice as well as international seminars where complete detached ligaments and cartilage tears have been restored back to full-function. However current medicine suggests a surgical intervention to re-join the tear back to 1 piece.
Stem cell treatment has the potential to improve recovery rate post surgery and have a significantly higher chance to restore full-function.Your body naturally looks to repair any form of damage, however in certain cases it may only be able to do so with scar tissue.

RESULTS POST TREATMENT

Once the cells have homed to the damaged areas of your body, they are able to repair the damaged tissue and potentially differentiate into the surrounding cell types.

EG: your body is now able to use the stem cells to repair the torn tendon with actual tendon tissue as opposed to scar tissue.

The implantation of mesenchymal stem cells (MSC) into tendon defects is safe and effective. MSCs improved the tendon’s maximum load over time, indicating that MSCs could help facilitate the dynamic process of tendon repair. (Tornero-Esteban et al., 2015)

Clinical Published Examples

Achilles tendinopathy

In 2016, de Girolamo et al. reported a result of randomized prospective clinical trial involving 56 patients with Achilles tendinopathy. Of the 56 patients, 28 patients were randomly assigned to a single autologous PRP injection and the other 28 patients were assigned to a single autologous adipose SVF injection. All patients were assessed clinically using VAS, Victorian Institute of Sport Assessment for Achilles tendinopathy (VISA-A), the American Orthopaedic Foot & Ankle Society (AOFAS) and Short Form-36 (SF-36) forms. Before the treatments, all patients also underwent ultrasound imaging studies and MRIs; these were then repeated at 4 and 6 month follow-ups. At the final follow-up, both patients group showed significant improvements in all scores compared to baseline. In the adipose SVF injection patients, these improvements were faster and more pronounced. After 6 months, the MRI and ultrasound studies showed no significant difference. No side effects were observed in either group. The study concluded that both PRP and SVF are safe and effective treatments for Achilles tendinopathy, although adipose SVF may allow faster clinical results than PRP. (De Girolamo et al, 2016)

Lateral epicondylosis

Lee et al. published an article in 2015 involving 12 patients with lateral epicondylosis treated with allogeneic adipose-derived MSCs. Although the scope of this article is limited to autologous adipose SVF, the study by Lee et al. is significant in light of the fact that an insufficient number of human studies are available with regards to tendon and ligament repair. The study is a pilot study assessing the safety and efficacy of culture expanded ASCs in treating human patients with lateral epicondylosis. The ASCs were injected with fibrin glue under ultrasound guidance into the hypoechoic tendon lesions of chronic lateral epicondylosis. Then, patients’ VAS score, modified Mayo clinic performance index, and longitudinal and transverse ultrasound images of the tendon defect areas were evaluated at 6, 12, 26, and 52 weeks. Through 52 weeks of follow-up, VAS scores progressively decreased and elbow performance scores improved. Tendon defects, assessed by ultrasound images, also significantly decreased throughout the follow-up period. No significant adverse effects were observed (Lee SY et al, 2015)

Meniscus tear

The meniscus is a fibrocartilaginous disk that functions to transfer weight, absolve shock to the knee, and to protect the hyaline cartilage at the knee joint. With knee injuries, the meniscus may be damaged causing it to be torn. Such meniscus tears are initially treated conservatively with NSAIDs and physical therapy . If conservative treatment fails, an arthroscopic meniscectomy is traditionally performed. However, arthroscopic meniscectomy, either full or partial, is associated with early onset of OA of the knees. Thus, potential cartilage regeneration with MSCs, or autologous adipose SVF, may offer a major therapeutic breakthrough.

In 2014, Pak et al. reported that autologous adipose SVF may be effective in treating meniscus tears. This case report involved one patient treated with autologous adipose SVF obtained from digesting approximately 40 g of packed adipose tissue with collagenase. Afterward, the autologous adipose SVF was injected with PRP and HA. After 3 months of treatment, the patient’s symptoms, measured with VAS scores for pain, FRI, and physical therapy ROM, had improved. In addition, probable regeneration of the meniscus cartilage was documented by pre- and post-treatment MRIs.  (REFs: 47,48,49,50 – in the references page)

 

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