Category Archives: PRP

PRP-platelet rich plasma is a new treatment based on the healing powers of platelets which are blood cells that contain many growth factors

What are my options for shoulder pain?

The shoulder has the honor of being is the largest, most complex, and most mobile joint in the body.  And it is this reason that makes it the most vulnerable to overuse.

The shoulder consists of three bones: the humerus (upper arm bone), clavicle (collarbone), and scapula (shoulder blade).

The rotator cuff muscles and tendons are responsible for movement and stabilization of the shoulder.

In addition, there are other muscles and a complex array of ligaments that also serve to ensure stability.

Another tendon, the biceps tendon, originates from the glenoid (the cup of the shoulder blade where the humerus sits) and extends down the humerus.  It is responsible for certain arm and shoulder movements.

The ironic fact is that a patient who complains of shoulder pain may have nothing wrong with the shoulder!shoulder-pain

For example, many medical conditions such as gall bladder disease, pneumonia, and ectopic pregnancies can present with shoulder pain.  Also, neck conditions often cause referred pain to the shoulder.  Patients with heart disease who are experiencing a heart attack may complain of pain in the left shoulder and arm.

Shoulder ailments fall into three major groups.  The first is trauma.  An example may be a skier who falls on an extended arm.  The impact can drive the head of the arm bone into the socket and cause damage to the cartilage, the bone, as well as the rotator cuff tendons. If the ligaments are stretched or torn, the shoulder can dislocate.  While the shoulder can be “relocated”, once dislocation occurs, the patient is at increased risk for another dislocation. Significant impact can cause damage to the cartilage that cushions the head of the femur as well as the “cup” of the scapula.  This cup is referred to as the glenoid.  The glenoid also has a lip of tougher cartilage that can be torn with impact injuries.

Trauma, if significant enough, can cause dislocation of the joint joining the collar bone to the shoulder blade. The common term for this is a “separated shoulder.”

A related but different type of ailment is wear and tear.  Because so many of the structures that permit shoulder movement and provide stability are made of connective tissue, it stands to reason that over time, they can begin to wear out.  And that is exactly what happens.  Tendons- the ropes that connect muscles to bone-, ligaments, and bursae (fluid filled sacks that cushion joint movement) all are prone to injury as a result of overuse.

When this occurs, conditions such as tendinopathy (previously known as tendonitis), bursitis, and ligament strain ensue.

While inflammation may be present, the overwhelming problem is tissue breakdown.

The last ailment that affects the shoulder is arthritis.  The three bones that make up the shoulder interact with each other at two specific points.  At these two points, there is a joint where two bones whose ends are covered with cartilage articulate.  The two joints are the glenohumeral joint- the joint that joins the shoulder blade and the humerus and the acromioclavicular joint that joins the collarbone to the shoulder blade.

Arthritis at these two areas can develop as a result of systemic disease such as rheumatoid arthritis or as a result of wear and tear- osteoarthritis.

The treatment of shoulder disorders depends upon both the underlying problem as well as the amount of patient discomfort and the impact on quality of life.

For traumatic disorder where there is obvious tissue disruption, surgery is usually required.  The type of surgery will be up to both the surgeon as well as to the individual who has the problem. The shoulder is a complex joint so it’s important to ensure whoever works on the shoulder is an expert.

For most wear and tear problems, non-steroidal anti-inflammatory medicines (NSAIDS) are sometimes, but not always, helpful. Ice and rest also can be useful.

Patients may require a steroid injection. For people who don’t respond to medicines, injections, and physical therapy, surgery may be an option. Ultrasound guidance is important.

Regenerative medicine techniques can be used for shoulder issues.  An example would be a procedure called percutaneous needle tenotomy which can be used to treat rotator cuff tendinopathy and tears.

In this procedure, a small needle is introduced using local anesthetic and ultrasound guidance. The needle is used to irritate the tendons of the rotator cuff and induce inflammation. Then, platelet-rich plasma, obtained from the patient’s whole blood is injected into the area where the tendons have been irritated. Ultrasound guidance here is mandatory. Platelets are cells in the blood that contain many growth and healing factors. This stimulates the production of new strong tendon tissue.

Another example of a regenerative medicine technique is the use of autologous stem cells (a patient’s own stem cells) for glenohumeral arthritis.

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Another excellent study showing PRP works for tennis elbow!

Tara Haelle writing in Rheumatology News reported on a 24 week randomized controlled and double blind study looked at the effectiveness of platelet-rich plasma –PRP in treating tennis elbow. prp

The study  involved 230 patients who had failed physical therapy, non-steroidal anti-inflammatory drugs, and/or cortisone shots and was conducted at the Rothman Institute of Thomas Jefferson University.  The PRP group showed a 71.5% improvement in pain scores while the control group showed a 56.1% improvement.

tennis-elbow-on-fire

Comment: The differences weren’t huge but this still indicates PRP is the treatment of choice for this extremely painful disorder.

Cortisone shots should be avoided since they actually damage soft tissue and lead to more recurrence of tennis elbow and other forms of tendinopathy.

PRP should be administered using ultrasound guided needle tenotomy technique.

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Steroid injections for tennis elbow make it worse

Genevra Pittman writing in Reuters reported that in an Australian study published in the Journal of the American Medical Association, researchers evaluated 165 adults with tennis elbow.

tennis-elbowThe participants were divided into four treatment groups: cortisone shots without physical therapy, cortisone shots with physical therapy, placebo shots without physical therapy, and placebo shots with physical therapy. After one year, 83% of the participants who received a cortisone shot reported that they had completely recovered, compared to 96% of those who received a placebo shot.

Steroid shots weaken tendons over the long haul.  A much more physiologic approach is to use ultrasound guided needle tenotomy and platelet-rich plasma (PRP).

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Radiation Therapy Provides Relief For Plantar Fasciitis

Helen Albert writing in Medwire reported on a study of 62 patients, published in the International Journal of Radiation Oncology, which showed that “external beam radiation therapy, similar to that used in treating cancer, provided effective pain relief for patients with plantar fasciitis.” plantar-fasciitis

For the study, “researchers found that 80% of those who received standard-dose therapy experienced complete pain relief, 64% of whom maintained this relief for up to 48 weeks.”

Comment: I would be concerned that radiation would bring along its own potential risks.  There are better and safer options for this condition. It’s like using a bazooka to kill a mouse.

One option we’ve used is ultrasound-guided injections of platelet-rich plasma (PRP). Another is ultrasound-guided injection of Botox.  Both of these are far safer than radiation.  Another treatment that seems to work and is safe is shock wave therapy.

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Why is PRP being used by athletes?

The use of regenerative treatments such as PRP and autologous stem cells have revolutionized our approach to athletic injuries and also to tendinopathies involving Boomer athletes.

PRP is an ultraconcentrate of blood that contains a large number of platelets, prpcells packed with growth and healing factors.

PRP ideally is administered using an ultrasound guided needle tenotomy injectingprptoankle-mmiller-13technique.  What this entails is using a small gauge needle to “pepper” the area of tendon damage to induce an acute inflammatory response.  Inflammation is the first step in healing. Inflammation causes the platelets to release their growth factors and initiate the healing of the damaged tendon.  The inflammatory phase lasts roughly about a week.  The healing phase lasts about 3-04 weeks.  The final stage is the reorganization phase where the tendon fibers are organized into a normal fiber pattern.  This can take up to a year.

Nonetheless, the ability to heal tendon damage withour having to resort to surgery is exciting.  In those patients who don’t respond to two PRP treatments, autologous stem cells are indicated.

 

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Iliopsoas bursitis… an underdiagnosed cause of hip pain

Bursitis is a term that describes inflammation of a bursa- the small sacks that surround joints.

One of the more common conditions that causes pain in the front of the hip is iliopsoas bursitis. This is particularly common in active people who exercise regularly.

The iliopsoas muscle originates from the inside of the pelvis as well as the lumbar spine. This muscle inserts onto a small bony ridge on the upper femur (upper leg bone).

The iliopsoas bursa is a small fluid filled sac that lies just behind the iliopsoas muscle and in front of the hip joint. Its purpose is to provide cushioning for the hip joint as well as to ensure proper gliding of the tendons adjacent to it.

As with many types of bursae, inflammation can affect the iliopsoas bursa. When this occurs, the patient will experience pain in the groin as well as the front of the thigh. The pain is aggravated by flexing (bending)  the hip. Activities such as walking, running, and climbing stairs can be painful.hip-flexor

Sometimes patients may hold their leg with the hip slightly bent and the foot turned out in order to minimize discomfort. Patients may also have a limp.

On examination, there is tenderness when pressure is placed directly over the front of the hip. In severe cases, the bursa may be swollen.

While overactivity or trauma may be the most common cause of this type of bursitis, arthritis can also lead to iliopsoas bursitis.

Between 15 to 20% of the time, the bursa communicates with the hip joint. In situations like this, it is sometimes difficult to differentiate whether the discomfort is coming from the bursa versus the joint.

The diagnosis is suspected by taking a careful history and doing a careful physical examination. The clinical impression can be confirmed by either magnetic resonance imaging or diagnostic ultrasound.

The treatment for this condition is usually conservative to start with. Non-steroidal anti-inflammatory drugs and physical therapy may be helpful.

Ice may also be palliative.

Aspiration of fluid from the bursa and simultaneous injection of  glucocorticoid using ultrasound guidance can be curative. On rare occasion, the bursitis may return. If the bursitis does recur, aspiration followed by needle fenestration and injection with platelet rich plasma (PRP) may be effective.

If the bursitis recurs repeatedly, surgery may be required.

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PRP Treatment For Tendinitis And Arthritis

To help heal damaged tissue, both athletes and non-athletes alike – particularly those in the Baby Boomer generation- have been attracted to the use of platelet-rich plasma (PRP) therapy. PRP is made by obtaining a specimen of a patient’s blood (usually 60 cc’s) and centrifuging it to isolate the platelets, (cells responsible for clotting), in a small volume of plasma.

prp_0This concentration of platelets is then injected, using ultrasound guidance, into the site of the patient’s injury. The theory surrounding PRP is that growth and healing factors, stored in small packets located inside platelets, accelerate tissue recovery.

Tendonitis, or more accurately, tendinopathy, is a universal soft tissue injury problem and is a common affliction of both athletes as well as Baby Boomers.

These tendon injuries tend to become chronic, and are due to microscopic tearing of the tendon with formation of scar tissue. These tendinopathies heal poorly because they are usually located in “watershed” areas, regions where there is as relatively poor blood supply. An example would be the Achilles tendon. Since poor blood supply restricts the ability of nutrients as well as  healing or growth factors to get to the area, the application of PRP fixes that problem.

So theory aside, what has the data shown?

A number of studies conducted on the effectiveness of PRP have come up with mixed results.  Some studies have shown benefit while others have not.

So why the discrepancy and does PRP really work?

Some investigators have argued that the placebo effect accounts for the success of PRP since it is a dramatic procedure involving a needle.

Another explanation is that the process of needling a tendon cause irritation and bleeding and this is known to help healing by attracting growth factors in the blood.

Another factor that might suggest a discrepancy in the results of studies is the difference in the rehabilitation program.  For optimal results following a PRP procedure, a patient requires rest, modification of activity level and a specifically designed rehabilitation program with stretching and strengthening. The rest is important for the first few days since a significant amount of pain is experienced by many patients following PRP.

A patient is considered a candidate for PRP if they have either failed at least two to three months of other therapies or have a significant tendon or ligament issue that needs immediate attention.

Usually patients respond to one treatment but may require at least one more.  Patients rarely require three.

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Arthritis Pain Treatment

Before arthritis can be treated, an accurate diagnosis is needed. This is done with a careful history, physical exam, laboratory tests, and imaging procedures.

In the history, we ask questions such as:

o How long have you had the symptoms?

o What joints are involved?

o Is it symmetrical? One side like the other

o Is there a family history?

o Are there other symptoms?

On physical exam, we examine a patient from the top of the head to the bottoms of the feet! We look at the skin, eyes, ears, nose, throat, internal organs, and finally the joints

The goals of treatment are straightforward. They are:

o Relieve pain/inflammation

o Enhance quality of life

o Slow disease progression

o Control co-morbidity (associated diseases such as high blood pressure, diabetes, etc.)

o Minimize risks of therapy

We first start with non-medicine treatment:

o Social support: make sure the patient’s family and friends understand the problem

o Education: make sure the patient understands all the things they must do themselves to get better

o Weight-loss: many patients with low back pain, knee pain, and hip pain are overweight. All the medicines in the world aren’t going to help until weight is corrected.

o Assistive devices: splints, braces, walkers, canes, etc. all may help.

o Thermal modalities: ice or moist heat depending on the situation

o Exercise: non impact as well as stretching and strengthening play a role.

o Modification of lifestyle: sometimes habits need to change and routines need to be altered.

Medicines:

o Analgesics: These help reduce pain. They don’t block inflammation. Analgesics may be habit-forming or addictive. They offer the potential for side effects as well. Examples: Tylenol, Ultram, Darvocet, Percodan.

o Anti-inflammatory medicines: These block inflammation and help with pain. There is the potential for side-effects including the liver, kidneys, and cardiovascular system. Examples: Naprosyn, Motrin, Celebrex.

o Disease-modifying drugs: these drugs slow down the progression of arthritis. They are used in conjunction with analgesics and anti-inflammatory medicines. Examples: hydroxychloroquine (Plaquenil), methotrexate, azathioprine (Imuran).

o Biologic therapies: these are lasers that target the immune abnormalities found in many forms of arthritis. Examples: Enbrel, Humira, Remicade, Cimzia, Simponi, Actemra, Rituxan, Orencia, and other newer therapies.

Also, for some arthritis related pain we also use medicines such as GABA stimulators.  Examples are medicines like gabapentin (neurontin) and pregabalin (Lyrica).

Lidoderm patches also help as do topical agents such as Blue Relief.

Sometimes injections of different types will be needed. These injections may be combinations of local anesthetics and glucocorticoid.

Other therapies we have used include Botox and platelet-rich plasma (PRP).

Every patient’s problem is different which is why it’s important to individualize treatment. or they may consist of materials such as Botox. We have used the latter quite successfully in patients with neck and low back problems.

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Pain in the top of the foot

Foot pain is ubiquitous in society since most people get around by walking.

top-of-the-footThe foot consists of 26 bones which are held together with a complex arrangement of ligaments, muscles, and tendons.

In addition, multiple nerves and blood vessels traverse the foot.

While much attention is placed on disorders of the arch of the foot and the heel, the top of the foot is often the site of discomfort.

The reason this area is susceptible to pain is because of the anatomy.  In addition to being an area where many of the small bones of the foot interact, it is also a location where many of the critical nerves and blood vessels traverse.

The most common cause of pain in the top of the foot is osteoarthritis.  Osteoarthritis is a disorder due to derangement in cartilage metabolism.

Cartilage is the gristle that provides the cushioning between bones.  It consists of cartilagea matrix made up of collagen and proteoglycans.  Proteoglycans are complexes of proteins and sugars.  Within this matrix are cells called chondrocytes which help manufacture and nourish the matrix.  When a trigger such as trauma occurs, there is a change in the complexion of cartilage.  The chondrocytes begin to make destructive enzymes and the cartilage begins to wear away.  The underlying bone starts to react by forming bony spurs.  These spurs, particularly in the top of the foot, impinge upon nerves and blood vessels.  The spurs also rub against each other leading to pain.

Anything that magnifies this problem will also magnify the pain.  For example, tight-shoewearing shoes that compress the top of the foot can make pain in the top of the foot worse. The treatment here is, at least early on, to reduce the amount of pressure, use anti-inflammatory medicines either by mouth or topically, and possibly injections of glucocorticoid.  Since this is an area where the joints are narrow and many blood vessels and nerves are located, it is best to use ultrasound guidance for injections.

Since some spurs will continue to irritate nerves, sometimes the best treatment is to remove the spurs using a technique called tenotomy where a sharpened needle bevel is used to “chisel” the spurs, and then platelet-rich plasma (PRP) is prpused to heal the area.  In our hands, this technique, again using ultrasound guidance, has been very successful.

gout-footAnother cause of pain in the top of the foot is gout.  Gout is a metabolic disease due to the excessive accumulation of monosodium urate crystals. The treatment is to reduce the uric acid load in the body.  This is best accomplished with a combination of dietary as medicine therapies.

Tendonitis can also occur in the top of the foot.  This is sometimes seen in people who have walked or run a long distance wearing tight shoes or other footwear that irritates the top of the foot.

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