Possible Insight

Looking Forward to the Sports Injury Revolution

with 8 comments

When I was 16, I dislocated my elbow.  The ensuing re-injuries and calcification of the ligaments ended my competitive wrestling career.  Last year, I separated my shoulder and while it’s pretty well healed, it’s going to have some annoying weaknesses the rest of my life.

I’m not the only one.  Most of the people I know who have been reasonably active through age 40 have some sort of permanent impairment from a ligament, cartilage, or tendon injury.  Today, I was wondering if extracellular matrix (ECM) might be the answer.

ECM has been used to promote wound and burn healing.  I figured a little Googling was worthwhile. Imagine my surprise when I found out that verterinarians have off-the-shelf ECM products to heal horse ligament and tendon injuries.

Moreover, I was flabbergasted to find a book on the subject of ECM based scaffolds for repairing orthopedic soft tissues. Unfortunately, all the relevant journal articles are behind paywalls.  But this seems to be a rapidly advancing area.

Together with stem cell advances, this could change the game for us 40-year olds.  We could be assured of fully functioning joints for a long time.

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Written by Kevin

April 17, 2009 at 2:11 pm

8 Responses

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  1. Maybe. But ball and socket joints, ligaments, and shoulders require a delicate balance. When the ligaments are too loose, your shoulder is more likely to come out of the socket. When the ligaments are too tight, you lose range of motion.

    Daniel

    April 17, 2009 at 2:21 pm

  2. Daniel, I’m not sure how this is relevant. I had a grade 2 A-C separation, which means I completely tore through my A-C ligaments. They don’t naturally heal. You can’t even repair them surgically very well.

    All I want is to grow them back which is what ECM may be able to help with. So it’s hard to see how this could provide too little stability.

    You could say that there’s the potential for too much. However, in this case, the A-C ligaments are very short and shouldn’t move very much.

    Moreover, the great thing about ligaments and tendons is that you can stretch them. It’s common practice for orthopedic surgeons to repair them so they are initially too tight. Then they rely on therapy to stretch them to the appropriate length.

    kevindick

    April 17, 2009 at 2:35 pm

  3. Kev, not sure if you caught this talk but this stuff is advancing even faster than most imagined. Around minute 11:30 or so, you see a heart was re-grown from just the cartilage and started beating(!)

    Kevin’s looking to grow a new joint, I’m looking to grow a new heart, who wants a brain? Anyone? Dorothy? Bueller?

    rafefurst

    April 19, 2009 at 11:10 am

  4. Looks like we might be closest with macular degeneration and eyes. Human trials likely to start within two years.

    http://www.timesonline.co.uk/tol/news/uk/health/article6122757.ece

    Daniel

    April 19, 2009 at 2:59 pm

  5. @Kevin

    Sorry for getting off topic. I am talking specifically about shoulders.

    I believe that surgery is rather effective if you can find a specialist who has performed several hundred similar operations. The consensus opinion against surgery seems to be based on the inability to predict how serious the initial injury is, and thus surgery is only prescribed for serious chronic problems and professional athletes. Additionally, most surgeons don’t want to perform the surgery because a “perfect” outcome is unlikely. This is due partly to practitioner error, the joint will either be somewhat too lose or too tight, as well as the reliance on the patient for strict adherence to physical therapy regimen. It’s unclear exactly how early and how hard initial physical therapy should be, and this compounds practitioner error and can lead to excessive scar tissue (which restricts mobility and can warrant an additional surgery.)

    I am proposing that growing these ligaments back will also yield a less than perfect outcome. I am aware that ligaments stretch, but once they become stretched out or “too loose” they can only be tightened by surgery. (Although after the age of 35-40, shoulder joints do tend to become more stable due a tightening of the subscapularis muscle)

    I am (perhaps naively) more interested in the possibility of an additional ligament in my shoulder, as opposed to simply replacing and regrowing existing ones (how do we control their growth? one size does not fit all, How is this better than surgery?) I do not find advances in knees or horses to be particularly applicable to the shoulder, but I’m not going to pretend to be a doctor anymore.

    Daniel

    April 19, 2009 at 5:14 pm

  6. Yes, I realize you’re talking about the shoulder. But the shoulder is perhaps the most complex joint in the human body so I think you’ve made a fundamental mistake in generalizing to all possible shoulder repairs.

    I’m talking specifically about the A-C ligaments. The particular problem with these ligaments is that they are very short and friable. I contend they are therefore a good candidate for using something like ECM as a scaffold like I described.

    Moreover, I don’t think your arguments even hold for the shoulder in general. There is a set of failure modes in surgical repair of the other ligaments (and tendons) where the problem is lack of healthy tissue due to scarring and friability. ECM scaffolds have the potential to address these issues.

    Ligament length is one that can be addressed and I highly doubt it will be the limiting factor. The fact that you can only loosen ligaments in the shoulder (note that the elbow is different BTW) is not a very convincing argument against ECM scaffolds. It’s also a property of the original tissue.

    So once you’re original shoulder gets too loose due to over stretching or breakage, you get ECM scaffold surgery to tighten it up. If it loosens more over time, you’re still better off.

    kevindick

    April 19, 2009 at 6:23 pm

    • Kevin,
      I came off my bike onto my shoulder, generating a Type-3 AC separation Aug 4.  I’m tring to assess whether the stem-cell therapies I see online are worth trying, or am I just grasping at expensive straws.  Nearly everyone suggests I avoid intervention, but it seems plausible they’re predisposed to that conclusion.  Suggestions???

      William

      August 20, 2011 at 4:31 pm

      • Insist on seeing the evidence.  Orthopedics is notorious for doing procedures that aren’t supported by single-blind trials.  And in fact, when single-blind trials are conducted, they often demonstrate a total lack of effectiveness compared to a sham procedure.  So ask for real studies, not just case studies.

        In general, my recommendation would always be to see how a moderate shoulder injury heals on its own.

        Anonymous

        August 23, 2011 at 8:01 pm


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