Shoulder Recovery Miracle

One of hardest things for patients to accept and believe is the extremely long time it takes for proper healing and rehabilitation after shoulder surgery.

The Importance of Time in Healing After Surgery

When we emphasize the importance of allowing stress free healing of repaired tissue for at least the first 12 weeks after surgery, most patients either openly or silently say something like “I AM A FAST HEALER,” believing that the biologic principles of healing DO NOT APPLY to them. Unfortunately, the widely varying rehabilitation protocols and anecdotal reports on the internet, the news, and from their social networks aren’t helpful, because everywhere one turns it is easy to find a story that seemingly supports the notion that A MIRACLE RECOVERY FROM SHOULDER SURGERY is possible.

Shoulder Surgery Research

Some excellent research from the Hospital for Special Surgery helps us answer whether concierge shoulder surgeryearly aggressive motion is beneficial with real science. “The rats that were immobilized and didn’t have any load through that period of healing did the best. This study suggests that we might want to consider immobilizing human patients for a little bit longer to let some of the post operative inflammation calm down, because excess inflammation might be having a harmful effect.”
The investigators suggest that the best path to recovery for patients undergoing rotator cuff surgery might be to keep individuals in slings for six weeks and then start with passive motion therapy. This and other studies are why we recommend all shoulder repairs be protected for 12 weeks after surgery and avoid resistance and upright motion during this critical phase.

Improving Healing After Shoulder Surgery

So once we get to the point of acceptance the next most common inquiry is ARE THERE ANY STEM CELLS OR OTHER INJECTIONS OR DRUGS I CAN TAKE TO IMPROVE MY HEALING AND RECOVERY?
Again, this question is often driven by the FANTASTIC claims often made in the media and the internet about a MIRACLE injection an athlete was able to obtain by flying to a secretive location. For example, Bartolo Colon’s return from the abyss is illustrative and was covered on the NPR show Science Friday with Ira Flatow noting in part:
“…his amazing comeback is being attributed, at least in part, to a controversial medical treatment, a treatment involving injecting cells taken from his own body back into spots where he has injuries. The cells then repair the damage…”
The NPR article does raise some additional questions regarding the full extent of the cocktail that was injected noting that often many other FACTORS (legal and illegal) may have been included further making the recovery claims problematic.

Problems With Recovery Claims

An article in Scientific American also examining this issue noted: …worries that high-profile sports testimonials by Colón, Nitkowski and others will encourage joggers with blown-out knees and the parents of sore-armed Little Leaguers to demand the procedure before it has been thoroughly tested. “When celebrities take to a new treatment, many other people follow suit,” he says. Such premature enthusiasm—or an unforeseen tragedy that results from proceeding too fast too soon—could also prevent serious researchers from getting funding to do the kinds of careful experiments that might eventually lead to safe and reliable treatments.

The siren song of these treatments is compelling as outlined beautifully in Scientific American:
“Healing is slow in part because tendons, ligaments and cartilage lack the interlaced blood vessels that other organs rely on for quick delivery of cells involved in repair and growth factors that encourage cells to thrive and divide. Under these circumstances, the rationale for stem cell therapy seems straightforward: bathe the injury in a healing, concentrated wave of tissue-mending cells, and the body will repair itself that much more quickly…
As so often happens in biology, however, applying a simple idea can quickly become more complicated once you start dealing with the details. For starters, the term “stem cell” describes several different types of cells with different capabilities… 

Studies in animals suggest that mesenchymal stem cells play important roles in the body’s ability to heal after an injury, although researchers are still working out the signals and steps required to steer their differentiation into one type of tissue or another…
It turns out, for example, that mesenchymal stem cells do not regenerate tissue in isolation. They depend on other cells and growth factors that may or may not be present in a particular region of inflamed tissue, says Rocky Tuan, who directs the Center for Cellular and Molecular Engineering at the University of Pittsburgh School of Medicine. “You can inject all the best cells,” Tuan says, “but if you don’t have the right combination of healing goodies around them, it’s useless.”
Lab studies are also finding that mesenchymal stem cells extracted from different parts of the body can have different attributes. Those found in fat, for example, though relatively plentiful and easy to extract, do not seem to form cartilage as readily as those that come from bone marrow, Tuan says. Other studies suggest that mesenchymal stem cells also modulate the immune system and may have some part in the spread of tumors. Gathering much more basic information about how these cells behave is a vital first step before any safe and broadly reliable treatment can be developed for people, Tuan and other leading stem cell scientists argue.
Undeterred, advocates for the immediate use of stem cell therapy in human athletes point to successes with racehorses as the best evidence that the treatment works. Yet some experts say that the same hype that makes human testimonials unreliable has enveloped company-sponsored studies of competitive horses, too.
In the July 2012 issue of Equine Disease Quarterly, Wesley Sutter of Lexington Equine Surgery and Sports Medicine in Kentucky cautioned: “To date, no published controlled clinical studies show efficacy in use of stem cell treatment for any of the conditions being treated.”
Carol Gillis, a longtime veterinarian and researcher who specializes in soft-tissue injuries in racehorses, says that the more than 22,000 ultrasound images she has captured in her studies and clinical practice have convinced her that with a tightly regimented exercise program, tendons and ligaments will heal, producing strong, well-organized fibers—all without the use of stem cells. The reason that many soft-tissue injuries end a horse’s racing career, Gillis explains, is because most owners allow the animal to run free too soon, when the pain from the initial injury has faded but the tissue is still fragile.
Meanwhile the professional story of Colón, now an Oakland Athletic, entered a darker chapter on August 22, 2012, rendering his experiment with stem cells moot. The 39-year-old’s season ended that day when Major League Baseball officials suspended him for 50 games—because he tested positive for the performance-enhancing drug synthetic testosterone.
As of today in 2016, for shoulder surgery, we have seen a wave of enthusiasm for several factors come and go and the next potential star on the horizon appears to be stem cells derived from fat.”

For those interested here are more articles:
http://www.hindawi.com/journals/bmri/2014/129515/
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3646373/
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4617212/
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3325631/

The recent finding of a significant percentage of athletes testing positive for Meldonium also provides greater insight:

“The high number of positive tests for meldonium has been a reminder of athletes’ continual search for a pharmaceutical edge and has raised questions about the ethics of using a prescription drug for performance enhancement even when it is legal.”

Athletes like Colon, Nitkowski, and more recently Maria Sharapova will always pursue all means necessary to preserve and hopefully extend lucrative careers without regard for the consequences. The question of whether the rest of us should pursue these treatments is a complex one that involves considering more than just the expense involved.

Until we ARE able to isolate the SHOULDER RECOVERY MIRACLE, I find that like horses, humans start to feel good and run free too soon. 

Author
Vivek Agrawal, MD

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