The MRI of Craig Gray’s shoulders read like a rap sheet of shoulder ailments: multiple small rotator cuff tears, of full-thickness and partial-thickness, in both shoulders, along with tendinosis and osteoarthritis. Four decades of active living as a T11 para had taken their toll. “My shoulders were constantly hurting, any kind of transfer caused sharp pain, and I couldn’t sleep on either side because they hurt so much,” says Gray, 68.

Gray had tried cortisone injections over the years, which “provided relief, but only for a few months.” Fearing he was facing shoulder surgery, he went to see Drs. Joanne Borg-Stein and Adam Tenforde, physiatrists at Spaulding Rehabilitation Hospital in Boston. “They recommended orthobiologic therapy to provide relief from inflammation, pain, and [to] create optimum conditions for my body to heal without being dependent on caregivers for six months per shoulder with surgery,” says Gray.

Orthobiologics are regenerative orthopedic therapies developed from natural substances, often injected to facilitate healing or relieve pain. Common biologics include stem cell treatments and blood products, like PRP, where a vial of blood is drawn from the arm and spun in a centrifuge to concentrate platelets.

Dr. Borg-Stein prescribed three treatments of shockwave therapy, followed by a session of PRP and MFAT (AutologousMicrofragmented Adipose Tissue, or fat drawn from the body and processed into concentrated fat-derived cells) into three areas of each shoulder.

The shockwave therapy sent soundwaves through Gray’s tissues for about a minute per area, in order to promote healing. “The doctor also did my elbows, wrists and one finger — areas that had been hurting for a long time,” says Gray. “It relieved the pain right away.”

After shockwave sessions, he underwent injections of PRP, then MFAT. “My shoulders were really sore after the … injections. I was able to still do my daily routine, including transfers, but I had to take it easy for a few days after each session,” he says.

Within three months of the treatments, his shoulders were pain-free and he was able to do a mile or two of pushing on his wheels or using cross-country ski poles. By spring his shoulders felt strong and he was pushing along dirt trails. “It’s a year later and my shoulders feel great, except for a very mild strain in my left shoulder,” he says. “It’s nothing anywhere near what it was before. If the shoulder strain continues, I plan on going in for a booster PRP injection.”

Since insurance does not cover the procedures, Gray was left with the bill: $1,075 for shockwave therapy, $1,890 for PRP and $5,700 for MFAT — a total of $8,665. PRP generally ranges from $700-$1,500, and MFAT from $3,000-$10,000.

How Orthobiologics Work

Drs. Borg-Stein and Tenforde are proponents of orthobiologics’ benefits for wheelchair users with shoulder damage, as long as it’s understood what they can and cannot deliver.

“Our goal is to optimize function and reduce pain,” says Tenforde. Borg-Stein makes clear there is no clinical evidence that orthobiologics can fix rotator cuff tears, but wonders whether MFAT could potentially help repair small tears. She emphasizes that good PT is essential for achieving and sustaining improvement.

“It appears [PRP and MFAT] help turn up the volume, signaling the body to focus on reducing inflammation and focus on healing the area where they are injected,” says Borg-Stein. “With PRP we are injecting blood platelets that have growth factors in them that fight nerve pain.” She adds that although not clinically proven, it appears PRP contains elements good for nerves and vascular growth, as well as molecules of serotonin that fight pain. She says at this point it isn’t 100% clear whether it’s reduction of inflammation alone or if there is some other aspect about platelets that may have an influence on pain.

“Our experience — one that has not yet been proven in trials — is that [MFAT] works better [than other biologic injectables] in the shoulders of wheelchair users,” says Borg-Stein. The hypothesis is that the fat cells have chemicals that “talk with” the rest of your tissues to promote a healing response as a scaffold to hold the healing cells in place.

Shockwave therapy complements biologic injections by stimulating tissue-healing and disrupting pain pathways. One way it does so is by helping heal tendinosis — chronic inflammation of the tendon — by breaking up calcium deposits, disrupting incorrect/disjointed healing, restarting the healing response of the tendon, and reducing inflammation. This last effect is key because when a tendon grows inflamed, it is more likely to become damaged or further injured: So, reducing inflammation reduces likelihood of injury. Lastly, although shockwave therapy will help heal an intact part of tendon, it will not heal a tear.