Question 1

A 35-year-old man presents with bilateral shoulder pain of six months' duration, worse over the past month, with limited range of movement. He has no diabetes or other inflammatory condition. His rheumatoid factor is positive, ANA negative and uric acid normal, and MRI shows likely chronic partial-thickness tears of both supraspinatus tendons at the footprint with subacromial bursitis. How would you approach this case?

Dr. Rakesh Mahajan · Accepted Answer

With bilateral shoulder pain, I first ask about diabetes and thyroid disease, in which this problem is very common; in my practice around 30% of such patients have it. If not, I ask whether the patient does manual work or heavy lifting that loads the shoulders. If not, I get plain X-rays to rule out joint space narrowing and calcium deposits in the tendons (calcific tendinitis). If those are normal, I start physiotherapy (ultrasonic therapy, TENS, cold packs and shoulder exercises) with an anti-inflammatory for three weeks. If there is no response within three weeks, an ultrasound of the shoulders shows whether the subacromial bursa is inflamed and impinging, which is very common, and rules out partial tears or tendinitis of the supraspinatus or infraspinatus. In this patient, with positive rheumatoid factor and inflammation of the joints and bursa, the treatment is anti-inflammatory drugs, anti-rheumatoid drugs, a steroid (triamcinolone) injection into the subacromial bursa and physiotherapy. If the injection needs repeating, do not repeat it before three months. If the patient still does not respond, proceed to shoulder arthroscopy to debride the bursa completely, assess the AC joint and look for any tear of the supraspinatus or infraspinatus.

Question 2

Must all cases start with medical treatment before progressing to regenerative therapies?

Dr. Rakesh Mahajan · Accepted Answer

It depends on the duration of the problem. I label it chronic at three months; 6 to 12 weeks is the boundary of chronicity. Most patients who reach me have already seen several consultants, come after more than six weeks and have taken all types of treatment, which means the problem is chronic. If tests rule out acute inflammation, you go for regenerative therapy. If the patient comes early, you start with NSAIDs, not regenerative therapy. Consider regenerative therapy only in the 6 to 12 week window, and only if steroid has also failed to reduce the inflammation. The ideal point is three months.

Question 3

How is PRP prepared?

Dr. Rakesh Mahajan · Accepted Answer

We use a kit and a centrifuge machine. We draw about 10 to 14 ml of the patient's blood into a vial supplied by the kit company, which contains an anticoagulant, usually citrate, and centrifuge it to separate the platelet-rich plasma. From 12 to 14 ml of blood we obtain about 4 to 5 ml of PRP solution. It is injected all around the tendon or ligament in multiple pricks, not at one point, to achieve the maximum result.

Question 4

How does PRP promote healing at the cellular level?

Dr. Rakesh Mahajan · Accepted Answer

Platelets promote healing at the cellular level through the growth factors they carry. Different growth factors help in the healing of the ligament or the tendon.

Question 5

What growth factors are involved in PRP, such as PDGF and TGF-beta, and what are their roles?

Dr. Rakesh Mahajan · Accepted Answer

There are many growth factors. My focus is the technique and how to apply PRP to achieve the maximum result rather than the underlying biology. Some factors help vascularisation and others help regeneration of cells: one increases vascularity and the other increases cellular activity. That is the principle.

Question 6

What nutraceuticals do you recommend for joint pain treatment?

Dr. Rakesh Mahajan · Accepted Answer

If the articular cartilage is involved, I prefer collagen type 2, which is available combined with Boswellia and other agents marketed to support the articular cartilage. It has to be given for a long time, and the evidence that these supplements regenerate cartilage is limited; guidelines do not recommend them as a treatment. Collagen types 1 and 3 are available separately and are used in partial tears of ligaments and tendons, because ligaments and tendons are rich in collagen 1 and 3.

Question 7

What are the alternatives for a patient who has been on analgesics for joint pain, given the problems with long-term use of most of these drugs?

Dr. Rakesh Mahajan · Accepted Answer

You cannot keep giving analgesics indefinitely; you have to identify when to tell the patient to go for surgery. NSAIDs have their own side effects: cardiovascular, kidney and gastrointestinal problems. Ibuprofen and similar drugs have caused many GI and kidney problems. I give them for a maximum of three weeks, and tell patients they can reduce from the full dose after two weeks if they are more than 50% better. After that, the most I allow is paracetamol or a tramadol and paracetamol combination, which is safe for the kidney, heart and GI tract. I do not give other groups beyond three weeks. If the patient is not responding and would benefit from surgery, recommend it.

Question 8

Fitness influencers, and sometimes doctors, advise weight training because muscle supports bone density in the long term, yet bad form or training beyond capacity can cause injury. How does one strike that balance?

Dr. Rakesh Mahajan · Accepted Answer

Train in a graded way and know your own limits. I see many young patients who have damaged their elbows and shoulders lifting heavy weights because a gym instructor told them they were capable. Training classes for gym instructors would help prevent much of this damage, and young people should be taught to progress gradually and not overload. The principle is the elastic limit: tissue can stretch and recover only up to a point, and if the stress is too great, the muscle or tendon will fail.

Question 9

Is it correct that strength training to build muscle also benefits bone strength with age?

Dr. Rakesh Mahajan · Accepted Answer

Yes. With proper instruction, emphasis on muscle development at a younger age directly helps maintain bone strength into old age. Staying physically active, through sport or a proper gym routine, keeps the joints, muscles and mind young in the long run.

Question 10

Doctors generally advise 0.8 to 1.2 g of protein per kilogram of body weight, or 1.2 to 1.5 g/kg for athletes in training, while fitness influencers sometimes push 2 g/kg. What is your view, given that excess protein can cause complications?

Dr. Rakesh Mahajan · Accepted Answer

In people with kidney disease, excess protein can worsen kidney function, and in healthy people intake beyond what the body can use brings no extra benefit; around 1.4 to 2 g/kg is considered safe for people training hard. You also have to be careful that these products do not have anabolic steroids added. Gym users should be guided by a nutritionist or dietitian on how much protein to take, based on body weight and exercise routine, and on the source: whey, wheat, barley or milk protein. Amino acids, the building blocks of protein, are now available directly, and they too should be taken under proper guidance. Because young people listen to social media influencers, young doctors should also be active on social media and guide them properly.

Question 11

Is there an age limit for using PRP injections for joint pain?

Dr. Rakesh Mahajan · Accepted Answer

There is no age limit. It can be given up to the age of 60 or 70 without a problem. The only consideration is the blood draw: about 14 to 15 ml of blood for PRP and 10 ml for GFC, from which about 5 ml of plasma is obtained for injection.

Question 12

Competitive athletes, such as Kenyan and Ethiopian marathon runners or cricket fast bowlers, have to push their limits. How should doctors who treat athletes approach that?

Dr. Rakesh Mahajan · Accepted Answer

Competitive athletes have to perform. Orthopaedic surgeons are not the right people to guide them on technique to minimise injuries, sprains or strains; sports physiotherapists can do that better. Certain precautions are essential: well-padded shoes for marathon runners, hydration, and adequate protein, vitamin D and calcium. It is a team of physiotherapists, nutritionists and sports doctors, and everyone has a role. We come into play when there is an injury, and then we work with our physiotherapists to help them recover and return to sport as early as possible.

Question 13

Can PRP and steroid injections be used concurrently?

Dr. Rakesh Mahajan · Accepted Answer

No, not together. Steroid is given early, when there is pain, because its role is to reduce inflammation, like other anti-inflammatories. PRP is for regeneration and is given once the problem has been labelled chronic and inflammation has cleared, that is, once it is clear the condition will not heal within its normal healing period. Only then do you shift to PRP.

Live Discussion with Dr. Rakesh Mahajan