Sports medicine has come a long way since the 1960s, when Runner’s World was first published over in the US. Back then, runners with a muscular or joint injury were given a little RICE (rest, ice, compression, elevation) – and that’s about it. X-rays detected fractures, which usually landed a runner in a hard cast and immobile for weeks. Today there are many more diagnostic and treatment options available. From bone scans to MRIs, from biomechanical video analysis to gait retraining, and from muscle stimulation to Kinesio tape, sports medicine practitioners have more tools than ever at their disposal to heal runners and keep them healthy.
And that’s just the beginning. Researchers continue striving to develop advanced therapies that are more effective and that give a non-surgical option to athletes with persistent injuries.
‘The field is really at a fascinating juncture,’ says sports medicine specialist Dr Joseph McGinley. ‘We are starting to treat conditions that once required surgery and significant downtime with minimally invasive therapies.’
While the development of cutting-edge treatments is exciting, the research on some of them is relatively new and the results thus far are mixed, says chiropractic sports physician Dr John Ball. ‘This doesn’t mean some of these treatments can’t be effective, but they should be used as a last resort, for injuries that haven’t responded to traditional therapies,’ he says.
Of course, it’s every runner’s dream to stay pain-free so there’s never need for any advanced interventions. But in case you aren’t so lucky, there’s value in knowing what might be available to you down the road – to ensure you get back on the road.
1/ PRP (Platelet-Rich Plasma)
What is it? PRP therapy uses a runner’s own blood to stimulate the healing process in a tendon or joint. Doctors draw a small amount of blood from a patient’s arm and spin it in a centrifuge, which isolates platelets and plasma containing healing proteins, says Dr Jonathan Drezner of the University of Washington Sports Medicine Center in the US. The PRP is then injected into the injured area to spur cartilage, tendon and muscle regeneration.
What does it treat? It is generally used to treat chronic injuries, including hamstring and Achilles tendon problems. ‘The worse the tendon degeneration is, the better PRP tends to work,’ says Drezner. He suggests trying the traditional protocols first: ice, rest, biomechanical adjustments and physiotherapy. But if those fail, ‘PRP can be life-changing’, he says.
How effective? The studies on PRP show mixed results, though a review in the journal Current Pharmaceutical Biotechnology evaluated the effectiveness of PRP in sports medicine cases and concluded that it may help connective tissue heal when other treatments have failed.
Who’s had it? Three-time US Olympic Marathon Trials qualifier Michelle Lilienthal reportedly used PRP to treat chronic hamstring pain.
Does it hurt? Drezner says that the injection may be uncomfortable, ‘but no one has ever jumped off the table’.
Who offers it? Larger sports medicine clinics, such as the London Orthopaedic Clinic.
What’s the cost? Around £900 to £1,200 (London Orthopaedic Clinic). Less-expensive treatments may not use ultrasound to place the injection, which, Drezner notes is key for tendon issues. ‘This treatment is about precision, and ultrasound allows us to be precise.’
Treatment plan? Most runners benefit from a single injection, though some require a second treatment three to six months later.
2/ Stem cell therapy
What is it? Stem cells are immature cells that have the ability to grow into many different types of cell. In sports medicine, stem cells are harvested and then injected into an injured area, says Jonathan Finnoff, professor of physical medicine and rehabilitation at the Mayo Clinic and medical director of the Mayo Clinic Sports Medicine Center in Minneapolis, US. While PRP therapy stimulates the healing process of tissue that is already there, stem cells may create new tissue. This is why researchers think this therapy may help joint injuries caused by worn-out cartilage; in cell cultures, stem cells can grow new cartilage and if this can happen in a joint it may prevent the need for a joint replacement. Bone marrow is generally harvested from the hip using an incision and a specialised needle capable of penetrating bone. Then, in a similar fashion to PRP therapy, the bone marrow is centrifuged to separate the stem cells and platelets, which are injected, under ultrasound guidance, into the injured area.
What does it treat? Stem cell therapy is most commonly used for tendon, ligament, joint and muscle injuries that are not responding to other treatments, including PRP, says Finnoff. ‘I would almost always recommend PRP first – it is less invasive, less expensive and there is more evidence supporting it.’
How effective? The scientific literature on stem cell therapy is relatively scant. The most encouraging studies are in sheep, where stem cells have been shown to regenerate cartilage, in essence reversing the process of osteoarthritis. ‘This is still very experimental,’ says Finnoff. ‘That said, I’m having runners respond to stem cells, runners who might otherwise need major surgery.’
Who’s had it? Outside the world of running, American football star Peyton Manning reportedly had stem cell therapy in 2011 as a last-ditch effort to treat a bulging disc in his neck. While Manning appeared to recover eventually, he also had at least one surgery after his stem cell treatment. Finnoff says he’s treated a handful of runners with stem cells, some of whom had great success.
Does it hurt? The bone-marrow extraction process is typically performed under a local anesthetic, so you won’t feel this part. Similar to PRP, the injection of stem cells shouldn’t be very painful.
Who offers it? This is really one for the future, but stem cell therapy is already available in a research-related context at some major academic medical centres in the UK, while Basildon Hospital in Essex has pioneered stem cell therapy to treat damaged cartilage. You should be aware that outside of this, many orthopaedic stem cell treatments are largely unproven and unregulated; however, there is hope for fully approved stem cell treatments. The UK Stem Cell Foundation (UKSTF) has funded a range of research projects that aim to speed up the process of making stem cell therapy safer and more widely available.
What’s the cost? Around £3,000 to £8,000 for stem cell therapy to treat damaged cartilage at Basildon Hospital.
Treatment plan? Stem cell therapy is usually a one-off treatment. ‘The only time I’ll administer a second injection is if someone had a good, but partial, response,’ says Finnoff. ‘If a runner with osteoarthritis is starting to regrow cartilage, but they haven’t grown enough to run without pain, I’d consider a second treatment.’
3/ LIPUS (Low-Intensity Pulsed Ultrasonic Bone Stimulation)
What is it? Ultrasonic waves activate cells near a fracture in order to stimulate the healing process, says sports podiatrist Stephen Pribut, a clinical assistant professor of surgery at George Washington University School of Medicine and Health Sciences in the US. Patients are given a small ultrasound kit to use at home. It straps onto the fracture site, so patients can sit while undergoing treatment.
What does it treat? Bone stimulation is generally used if a shin or foot bone fails to heal after four to six months of traditional treatment. It’s sometimes used as an immediate treatment of fifth-metatarsal fractures, since this bone tends not to heal without stimulation or surgery. ‘If you’ve reached the point where you need to use a bone stimulator, this probably means that you’ll also be in a soft cast or on crutches,’ says Pribut.
How effective? A number of studies support it as an effective treatment. Reviewing 17 clinical studies, The National Institute for Health and Care Clinical Excellence concluded that low-intensity pulsed ultrasound treatment showed high rates of fracture healing, judging results sufficient to support the efficacy of treatment. Pribut has found this to be true in his clinic, too.
Who’s had it? Former 800m Olympian Rich Kenah used a bone stimulator to help heal a navicular (a bone on the top of the foot) stress fracture. ‘The fracture healed, I returned to make the US Olympic team and I run pain-free today,’ says Kenah.
Does it hurt? Some people report a slight warmth, but most patients feel nothing. ‘All the vibration is deep and internal,’ says Pribut.
Who offers it? Treatment via the Exogen ultrasound bone-healing system is available on prescription, while a device that’s produced by Osteotron can be purchased directly and is widely available. Most sports medicine physicians should be aware of – and have access to – the technology, adds Pribut.
What’s the cost? The Osteotron IV LIPUS Ultrasound Bone Growth Stimulator costs £1,700 from EMS Physio.
Treatment plan? Pribut suggests runners use the stimulator for 20 minutes per day over three to four months. Since the process takes so long, Pribut says, ‘many elites elect to have surgery instead’.
4/ McGinley Vascular Pressure Treatment
What is it? Botox – the neurotoxin that has been popularised by the cosmetic surgery industry – is injected under ultrasound and computed tomography (CT) guidance into the problem spot of a muscle that’s compressing blood flow, in effect freezing it for three to four months. ‘The goal of this patented procedure is to isolate the part of the muscle that is causing an issue and use botulinum toxin to turn it off,’ says sports medicine physician Joseph McGinley, who pioneered the treatment. McGinley, a keen athlete, has completed the 300-mile adventure race the Cowboy Tough, so his interest is more than just professional.
What does it treat? Botulinum injections are used to treat two lower-leg injuries: chronic exertional compartment syndrome (CECS) and functional popliteal artery entrapment syndrome (FPAES). In afflicted athletes, a small part of the calf muscle compresses veins or arteries, which can cause a buildup of pressure in the lower leg (CECS) or a lack of blood flow to the lower leg (FPAES). The result is intense pain, swelling and numbness in the calf, ankle and foot. Surgery has traditionally been the only option for runners with CECS or FPAES. Now, another option is to inject botulinum toxin into the area of muscle that is impinging blood flow. ‘The invasiveness and risks are minimal, especially when compared with surgery,’ says McGinley, Although runners lose some muscle function in the ‘frozen’ area, it is generally a small loss and, over time, the body compensates.
How effective? Using botulinum toxin in this manner is new; only one study has been published. But that research, published in The American Journal of Sports Medicine, found it eliminated pain in 94 per cent of CECS subjects. Although 69 per cent of subjects experienced some loss of strength, the authors reported this had ‘no functional consequence’.
Who’s had it? US runner Laura Stamp was the first patient to be treated with botulinum toxin for CECS. She had already undergone surgery three times to treat her injury. The Vascular Pressure Treatment worked and Stamp went on to enjoy a successful college career in cross country skiing and running.
Does it hurt? The injection hurts no more than a flu jab, says McGinley.
Who offers it? McGinley is currently the only provider of botulinum toxin therapy. So, if you want the treatment, you will need to travel to Casper, Wyoming, in the US, where McGinley treats athletes from all over the world.
What’s the cost? Depending on the amount of botulinum toxin needed for the procedure, the treatment costs between $5,000 and $8,000 (£4,000 and £6,400).
Treatment plan? Most athletes need a second treatment six to seven months after the first, adding $3,000 (£2,400) to the cost. Then, the portion of muscle that’s impinging blood flow should atrophy, says McGinley, becoming so small it no longer causes a problem.
5/ Dry needling
What is it? It’s used by physios who want to reach problem areas of tissue deep in a muscle. They insert thin (acupuncture-like) needles into tense bands of muscle. ‘Needles can solve a problem that standard soft-tissue work hasn’t been successful with, as it can reach the areas other techniques can’t reach,’ says sports physiotherapist David Wells. ‘It causes muscles to relax, blood flow to increase and the body’s healing process to begin,’ says physio Scott Epsley.
What does it treat? ‘It’s great for releasing stubborn muscles and fascia – most successfully in athletes with ITB syndrome, troublesome calves and glutes that don’t want to release,’ says Wells.
How effective? There is a growing body of evidence showing the benefits of dry needling.
Who’s had it? Three-time Ironman world champion Mirinda Carfrae uses the therapy when she is deep in training. While Carfrae says deep-tissue massage work alleviates most of her problems, sometimes she’ll have a ‘super tight muscle’ that just won’t loosen up. For these cases, she turns to dry needling, which ‘can go deeper and only takes a session or two to help the muscle relax.’
Does it hurt? The needles are very fine, so there is minimal discomfort upon entry. Once the needles penetrate the trigger point, expect a dull pain, similar to someone pressing on a bruise. The needles remain in the trigger point for five to 15 minutes, or are inserted and withdrawn from the area several times. ‘In the majority of applications dry needling is less painful than standard manual therapy,’ says Wells.
Who offers it? Dry needling is now offered by many physiotherapists and clinics across the UK.
What’s the cost? From around £40 per session.
Treatment plan? Epsley says runners require from two to seven sessions over a few weeks. If the issue doesn’t improve after multiple treatments, he says, ‘something other than a soft-tissue issue, like a stress fracture, may be causing the problem’.