Introducing IOF’s Case Study Feature
The Interventional Orthopedics Foundation is committed to serving as a resource for physicians pioneering the medical subspecialty of Interventional Orthopedics. In order to best help our members expand their knowledge about orthobiologic injections and procedures, we are excited to launch a series of case studies highlighting a wide variety of treatments and methodologies.
To submit a case for consideration to be shared on the IOF blog, please send us the following information:
- A 500 word (or more) article about the case including: patient sex, patient age, patient case details, treatment details, products used, dosage, follow up, outcome, etc.
- Any photos you can provide of imaging
- Information about yourself including name, biography, practice name, location, website, area of speciality, etc.
Rotator Cuff Tear Case Study
Submitting Doctor: Richard D. Striano D.C., RMSK
OptimumJoint Integrated Joint & Spine
Certified in Diagnostic Musculoskeletal Ultrasound
Certified Diagnostic Orthopedic Ultrasound Alliance for Certification and Physician Advancement
Interventional Orthopedic Ultrasound Guidance
Faculty, OrthoSono Diagnostic and Interventional Ultrasound Physician Training
Member, Board of Directors, Interventional Orthopedic Foundation
Diagnostic & Interventional Ultrasound Guidance, Ambrose Cell Therapy, Plano Texas
Diagnostic & Interventional Ultrasound Guidance, RMI-International, San Jose, Costa Rica
Principal Investigator IRB Orthopedic Studies Optimum Joint
Orthopedic Research, Ambrose Cell Therapy
Orthopedic Research, RMI-International
This case is an example of elastography of a rotator cuff, supraspinatus tendon having been treated for a partial thickness articular surface tear. Elastography provides a color image of the mechanocharacteristics of a tissue.
This case is a 59 YO Fe. The elastography images shown are 3 ½ months post treatment. The patient was treated with “amber” platelet rich plasma (PRP) void of red and white blood cells. 60cc of blood was drawn and 4cc final PRP. Precision ultrasound guided injection of 1cc into the Supraspinatus, 1cc into the Acromioclavicular joint, 2cc into the Glenohumeral joint.
MRI revealed tendinosis with partial thickness tear 7x4mm with bursal side fraying.
Ultrasound elastography is technology that has experienced major developments in the past two decades, however, rarely reported as an outcome measure in musculoskeletal treatment. We have begun developing elastography as an additional outcome measure following PRP or Lipogems adipose cell-based treatment of the rotator cuff and knee. The post treatment imaging is impressive.
The assessment of the main mechanical properties of tissues can be made with this technology by characterization of their response to stress.
Tendinopathy is characterized by the proliferation of tenocytes (why pathological tendons on US appear enlarged), collagen fiber disorganization (why pathological tendons on US appear heterogeneous), intrasubstance defects (why pathological tendon tears appear anechoic (black voids), increase of non-collagen matrix, fluid accumulation, ground substance between fibers (why pathological tendons appear on US hypoechoic (dark), capillary proliferation and calcification (why pathological tendons on US may show increases color flow), which can all induce modifications of the viscoelastic properties of the tendon and, consequently, be noticeable on ultrasound imaging.
The supraspinatus tendon in the imaging is viewed on the right as the ultrasound image and on the left the same image as an elastogram. The central structure coming to a point in a “bird beak” appearance is the supraspinatus tendon.
In grading tendons the pathological tendons become soft, filling with ground substance and fibrillar defects. The scale from blue to red, blue is hard and red soft. The percentage green/red reveals the degree of pathology. Using this initial image as a baseline, the post biological imaging reveals nearly all green and red within the supraspinatus tendon has been resolved. The elastography image now shows a nearly all blue supraspinatus tendon. Not simply the 7mm tear site but the entire tendon has changed.
This demonstrates objectively that the anatomical and physiological characteristics of the tendon having taken on a more native and less pathological characteristic and of course less pain and increase in function. NPS (numeric pain scale) 0-10 was 8/10 now 4/10 and ASES 0-100 was 48/100 now 86/100.