I Don't Want Surgery But What Else Can I Do?

Fortunately, 90% of problems that come into an orthopedic clinic do not require surgery.

Approximately 80% of those conditions treated nonsurgically can be treated with traditional treatment measures: rest, activity modification, physical therapy, medications, supplements, lifestyle changes, brace, splint, a boot walker, steroid injection, etc. This is “bread and butter“ treatment administered by an orthopedic/sports medicine physician.

Now, what about that last 20% of non-surgical treatment? That’s often where we have to think “outside the box.” Let’s say in the case of osteoarthritis and tendon problems, that’s where treatment like platelet-rich plasma (PRP) injections can be very helpful. For example, in the case of knee osteoarthritis, how would you like to have less pain, less stiffness, less swelling and better function? What if we could accomplish that with a treatment that is minimally-invasive, safe, proven and natural? As a bonus, this treatment has preventative benefits, meaning we likely are slowing down the cartilage breakdown in your knee. These are the benefits seen with PRP injections.

In the case of tendon or fascia problem like a rotator cuff partial tear, tennis or golfer’s elbow or plantar fasciitis, PRP is designed to be a healing agent. We are using these growth-factor rich injections to accomplish healing, not just make you feel better like a steroid injection might.

Check out a few of our previous blogs, and let us know if we can help you!

https://www.impactsportsnashville.com/blog/2023/12/8/prp-the-gift-of-health

https://www.impactsportsnashville.com/blog/2023/9/23/5-things-you-have-to-know-if-you-have-knee-pain

https://www.impactsportsnashville.com/blog/2023/8/5/our-top-5-treatments-for-knee-oa

F. Clarke Holmes, M.D.

Why Me? Why So Many Tendon Problems?

If you are 40 years old or above, it’s probably not “if” but “when” you are going to have a tendon problem. Tendons connect our muscles to bones, but as we age, they become problematic. Common tendon problems include/involve the rotator cuff, tennis and golfer’s elbow, Achilles tendon, posterior tibialis tendon and then the plantar fascia, which behaves like a tendon but technically is a ligament.

Thus, these conditions are usually a disease of the middle-aged and older. What are the causative factors for what we call tendonopathy?

-acute injury to the tendon

-overuse activities

-genetics

-inflammation

-diet

-biomechanics

-weight

So, to treat tendonopathy, we have to address these factors with genetics being an exception, as this can’t be changed.

Thus. we have to modify activities, either temporarily or permanently, especially avoiding overuse situations.

We want to reduce inflammation, and this can be achieved multiple ways: medications, steroid injections, supplements and an improved diet can all play a role. Medications and steroids can be very helpful in the short term but are not always a long-term solution. Platelet-rich plasma injections can be a great option to promote long-term management of inflammation and the actual healing of a tendon.

Biomechanics are often improved through changes in movement patterns, improved flexibility and strengthening. At times, footwear changes and orthotics can play a role as well.

As we often preach, early treatment of a tendon problem usually produces better outcomes than late treatment, but either way, we’ve got you covered. Don’t be discouraged if you have one or more tendon problems, knock on our door and we’ll be more than happy to share our expertise!

F. Clarke Holmes, M.D.

PRP: The Gift of Health

As we near the major holiday gift-giving season of the year, consider one the best gifts you can give to yourself: the gift of health! Platelet-Rich Plasma (PRP) injections are a great option for you in 2024 if you are looking to boost your orthopedic health and longevity. Here are 5 great adjectives that apply to PRP injections:

1) Safe: adverse effects and complications associated with PRP injections are exceedingly rare.

2) Effective: 80-90% of our patients that receive PRP injections have very good outcomes and are satisfied with their results.

3) Natural: these injections use your blood, specifically your platelets and your growth factors to exert their positive effects.

4) Proven: once considered experimental, there are now hundreds of studies that demonstrate clinical benefit with PRP injections.

5) Preventative: PRP injections are touted in their ability to prevent many degenerative joint and soft conditions from further deterioration.

Want to know more? Check out some of our blogs:

Insurance Companies Say PRP Is Experimental…We Sigh — Impact Sports Medicine & Orthopedics (impactsportsnashville.com)

Five Keys to Successful Outcomes with PRP Injections — Impact Sports Medicine & Orthopedics (impactsportsnashville.com)

PRP And The Three "Es" — Impact Sports Medicine & Orthopedics (impactsportsnashville.com)

As always, let us know if we can be of assistance to you!

F. Clarke Holmes, M.D.

Three Roadblocks to Your Health: Time, Fear and Money

Time: we’re all so busy, at least we think we are. Let’s be real, going to see the doctor does take time. Driving, parking, filling out forms, waiting, talking, testing and deciding. The average visit from start to finish. meaning door-to-door is in the range of 2 to 3 hours. Yet, that 2 to 3 hours could be the difference in you getting a diagnosis, relieving anxiety, feeling better, promoting better function and doing something that can help your body long-term. Are you willing to binge watch a show for 2 to 3 hours? Are you willing to go to dinner for 2 to 3 hours? Are you willing to surf social media and watch videos for 2 to 3 hours? Are you willing to go to the mall for 2 to 3 hours? Are you willing to go to the gym for 2 to 3 hours? If the answer to these questions is “yes,” then you definitely have time for a doctor’s visit.

Fear: so many patients skip that doctor’s visit because of fear of a frightening diagnosis, a recommendation that surgery is necessary or because of potential expenses that come with that visit and subsequent treatment. Here’s the good news: often that fear fades away once you get into the doctor’s office and actually are able to learn why you have certain symptoms and then are able to develop a plan of action. I’ve seen it for decades, as many patients, even when given news that they did not want to hear, find a sense of relief. Frequently though, we are able to provide good news and reassurance, calming the patient’s fears. In a nutshell, fear of the unknown is often much greater than the fear of the known. More good news here… 95% of patients that present to our office do not require surgery!

Money: sometimes the most expensive course of medical treatment is the one that was developed late in the game. Meaning, if a patient would have sought treatment earlier, a much less expensive plan of action could have been developed. There is no greater investment than the one in your health. We are all willing to spend money on trips, hobbies, clothes, restaurants, cars, etc. While all these can have value, they don’t hold a candle when compared to your health. So, make sure that you are budgeting enough money to pay for your necessary healthcare. Finally, when making financial decisions about your health, attempt to think long-term, not just short-term.

As always, let us know if we can be of assistance to you!

F. Clarke Holmes, M.D.

Five Financial "Must Knows" Relating To Your Healthcare

Not too long ago, it was considered taboo for physicians to discuss money issues with patients. Now, it’s irresponsible not to do so. Therefore, let me share 5 quick considerations pertaining to the blending of your finances and your healthcare:

1. You must save additional money for your healthcare. Deductibles are rising, fewer procedures are being covered and overall, all costs in healthcare are rising. You can’t just save enough money to pay your insurance premium each month. You must plan with an additional reserve.

2. A Health Savings Account (HSA) is a great tool to have. Either you can contribute to this periodically and use it for your out-of-pocket medical expenses as they arise, or you can choose to invest this money in your HSA account and allow it grow to tax free while saving it for later. Either way, your contributions are tax deductible.

3. Insurance companies’ mantra: “Deny, Deny, Deny.” We are seeing more procedures and valuable interventions such as MRIs, physical therapy visits and certain injections get denied by insurance. Now, some of these can eventually get approved, but not without a lot of extra work put in by the physician and his/her office staff. Insurance denials are a cost-containment measure for these for-profit companies. There’s nothing wrong with being a for-profit business, but you have to realize this as you approach your relationship with your insurance company.

4. Some of the best procedures in orthopedics are not covered by insurance. This includes innovative procedures such as PRP injections and certain surgeries. Insurance companies are often slow to catch-up with the latest and most effective treatments in medicine.

5. Except for those with Medicare and Medicaid, we really need to consider insurance coverage as “catastrophic” medical coverage. Meaning, we have insurance to help cover the majority of the expenses in the event of a major surgery, a hospitalization or cancer treatment as examples.

In summary, we have to shift our thinking regarding how we budget for our current and future healthcare. I want all of us to receive the best medical care possible. To do that, we have to be prepared financially.

As always, let us know if we can be of assistance to you!

F. Clarke Holmes, M.D.

5 Things You Have to Know If You Have Knee Pain

1. Three factors play a role in knee pain: structural, biomechanical and environmental. Structural means damage, biomechanical means abnormal tracking or loading within a joint or tendon because of misalignment, weakness, and/or inflexibility. Environmental typically means inflammation within the joint or tendon. When formulating a treatment plan for you, we typically want to address one or two of these factors initially. Unless you have major damage, we’re normally not treating structure initially, as that results in a surgery.

2. Age often plays a role in these different factors: in the absence of injury, in patients under 20 years of age, the problem tends to be biomechanical. In patients ages 20 to 40, the problem tends to be biomechanical and inflammatory. In patients older than 40, structural, biomechanical and inflammatory are typically all playing a role.

3. Being proactive in the care of your knee problem usually produces better outcomes than being reactive. This means integrating treatments early on and not waiting until you have major pain or disability to see a physician. We term this “PIO,” Proactive Interventional Orthopedics.

4. Meniscus tears are commonly found on MRIs and may or may not be a source of pain. For decades, the trend was to treat these surgically, typically arthroscopically, removing the torn piece of meniscus. There’s now a trend towards repairing the meniscus tear when possible, but only about 10% can be successfully repaired. Thus, surgery for meniscus tears, especially those age 40 and above, is falling out of favor. On occasion, surgery is the better choice, but treating these initially nonsurgically is usually the best way to start. We often tell patients “a little torn meniscus is better than less meniscus,” especially long term. Less meniscus often equals greater arthritis.

5. Three types of injections can be used for most knee problems: steroid, hyaluronic acid, and orthobiologics. Orthobiologics include platelet-rich plasma (PRP) and stem cell injections. Each of these injections can be reasonably good choices, but for long-term success, PRP is likely your best option in terms of producing favorable outcomes, modifying the disease process, and these are often the most cost-effective option. Stay away from “stem cell” injections that are ordered by physician’s or chiropractic offices and do not come from you own bone marrow or fat. These are often being used inappropriately, and patients are charged exorbitant amounts of money to have these injections.

As always, let us know if we can be of assistance to you!

F. Clarke Holmes, M.D.

TENex for TENnis Elbow

At times, tennis elbow, also known as lateral epicondylitis, can be so stubborn that an advanced procedure is needed to overcome this condition. There are two basic types of surgeries used to treat this condition. The first and by far our favorite is a percutaneous tenotomy under ultrasound guidance, commonly referred to as the Tenex procedure. The other is an open release of the tendon which involves cutting the tendon off the bone.  Let’s briefly highlight the differences between the two:

Anesthesia      

Tenex: Local-lidocaine injection only            

Open: General- patient is put to sleep

Incision Size      

Tenex: 1/4 inch                                  

Open: 1-2 inches

Trauma To Tissue

Tenex: Minimal                                  

Open: Moderate

Infection Risk  

Tenex: Minimal                                  

Open: Mild

Sutures/Stitches

Tenex: None                                        

Open: 1-2 layers required

Recovery Time    

Tenex: 2-6 months                            

Open: 4-12 months

Success Rate

Tenex: 90-95%                                    

Open: 75-90%

Are we biased towards the Tenex? You better believe it! Look at those comparisons above. In our mind, it’s an obvious choice: the Tenex procedure is the better overall option. Why do more physicians not perform the Tenex procedure? Because you are required to have proficiency in musculoskeletal ultrasound to perform this procedure. Not many physicians have taken the time and made the investment in ultrasound-guided procedures, so they tend to revert to the more traditional, sometimes higher-risk and less successful options.

We’ve performed more Tenex procedures in Middle Tennessee than any other physician. So, if you, a loved one or friend has tennis elbow, then come see us!

F. Clarke Holmes, M.D.

Hamstring Strains- The All Too Common Injury

Picture this….an explosive movement that involves hip flexion and knee extension. What could go wrong? Well, this is the mechanism of a hamstring strain or tear. The classic actions are jumping, kicking, or running. Occasionally, a pop will be felt. We see hamstring strains and tears in our practice often, and frequently, the patient is mistreating their hamstring pathology by the time they get to us. Because of this, we hope this blog will provide education on appropriate first-line treatment before and when you seek medical attention.

First, can anyone name the three hamstring muscles? The answer is: Biceps femoris, semitendinosus, and semimembranosus. What’s the common injury in Major League Baseball: you’re thinking a shoulder or elbow problem, right? Not so fast…a hamstring strain is the most common injury in baseball, and likely the NFL and Major League Soccer as well.

Hamstring strain/tear prevention: proper warm-up, dynamic stretching, adequate rest and recovery, and strengthening. Specifically, the quadriceps muscles tend to get a lot more attention than our hamstrings because they are “look good” muscles. However, neglecting the hamstrings and creating a muscle imbalance definitely increases one’s risks of a hamstring injury. Also in regards to prevention, when a hamstring starts to feel tight or crampy, then that’s a warning sign. It’s then wise to minimize those explosive activities that often lead to a major strain.

In terms of radiographic diagnosis, x-rays are primarily only helpful to evaluate a patient for an avulsion fracture when the pain and strain is near the ischial tuberosity. These fractures are most common in skeletally immature patients such as younger teenagers with open growth plates. Musculoskeletal ultrasound, one of our areas of expertise, is a great and inexpensive way to visualize and grade hamstring strains in our office. Finally, an MRI is the most complete test to visualize a hamstring injury, but is not necessary in most patients and certainly the most expensive and time-consuming test.

Complete tears: If a complete tear is found, particularly proximally (at the origin at the “sit bone”), then surgical reconstruction is the typical treatment. I once knew someone who had liquid courage, (a.k.a., too much alcohol) on board and attempted to do the splits. He made it down into the splits but the explosiveness of the movement caused his hamstring to avulse off of the ischial tuberosity. He had to undergo surgery to reattach it. Needless to say, don’t try to do the splits, folks! Fortunately, complete tears are rare.

Strain/partial tear: This is most commonly the hamstring pathology we see. Hamstring injuries take a long time to heal. With proper treatment, this can be accelerated. The BIGGEST piece of advice I can give initially after the strain is DO NOT STRETCH the hamstring. It will commonly feel tight and feel like you need to stretch, but this will only strain the tendon and muscle belly further. Rest and activity modification are important steps in recovery. This even means to not lead up the stairs with the affected leg or bending at the waist, but instead with at your knees. Any activity that can tug on the hamstring, you should avoid. Other treatment options include thigh sleeve, steroid injection, physical therapy, and platelet-rich plasma (PRP) injections under the guidance of musculoskeletal ultrasound. PRP becomes a great option for proximal hamstring tendon problems that persist beyond a few months. We most commonly see this problem in long distance runners.

Recurrence: hamstring injuries are highly prone to recurrence. This is often due to a return to activity or sport too quickly and/or inadequate rehabilitation. This is why having an expert guide you in your recovery often decreases your risk of re-injury.

In a nutshell, if you have an acute or chronic hamstring injury, it’s best to seek medical attention as opposed to managing this yourself. Proper diagnosis, grading of the strain, discussion of treatment and prevention strategies along with a return-to-play/exercise plan is what we offer our patients.

As always, let us know if we can be of assistance to you!

Taylor Moore, NP and F. Clarke Holmes, M.D.

What is a Sports Medicine Provider, and Can I See One?

You may be asking yourself what is a Sports Medicine provider? To be honest with you, I only found out the difference between sports medicine and general orthopedics in my last semester of Nurse Practitioner school. Because of this, I want to provide more insight into the differences so that you can be educated and empowered in choosing an orthopedic specialist that best fits your needs.

Sports Medicine is a specialty underneath the orthopedics umbrella. Just like you can see specialists who see only hips, shoulders and knees, foot and ankle, or the spine, you can see a sports medicine specialist. Dr. Clarke Holmes and I are Orthopedic Sports Medicine Providers. What might differentiate a sports medicine provider from a general or specialty orthopedist? Here are few key points:

1.      One stop shop: Sports Medicine Providers see orthopedic conditions from the top of your head (concussions) to the tip of your toes, and everything in between

2.      Conservative treatment options versus jumping right into surgery: Dr. Holmes and I will always be transparent with our patients if surgery is the best option, but why not try utilizing all the nonsurgical options first if surgery is not necessary?

3.      We are experts in minimally-invasive procedures that can either prevent surgery or be an alternative to surgery: For example, Platelet Rich Plasma (PRP) injections are very successfully used for partial tendon tears and osteoarthritis of numerous joints. See our PRP blogs or check out our social media posts to learn more about PRP.

4.      Improved accuracy of our injections by utilizing musculoskeletal (MSK) ultrasound guidance. Ultrasound is becoming a mainstay in the sports medicine world, and we’ve used MSK ultrasound for over a decade. We also use this daily to diagnose tendon tears, bursitis, joint swelling and ganglion cysts.

5.      Holistic treatment: We care about the patient as a whole person and do not see them as just a body part, a diagnosis or a potential surgery.  We develop a plan of action with the  patient that considers what activities they like to do, their occupation, weight, nutrition, mental health and any other contributors to formulate an individualized treatment plan.

6.      YOU DO NOT HAVE TO BE AN ATHLETE TO SEE A SPORTS MEDICINE PROVIDER. Yes, we experts in treating athletes ranging from the youth to the professional ranks, but we also treat those who do not consider themselves an athlete. In addition, we see patients of all ages and all activity levels. One of my favorite things to treat is arthritis, even in those who do not exercise and just want their pain to decrease and daily function/activities to improve.

Hopefully this has provided clarification on the differences between a sports medicine orthopedic specialist and a other types of orthopedists. As always, let us know if we can be a resource to you!

Taylor Moore, NP

TENex Gets a 10!

Are you looking for permanent relief from tennis or golfer’s elbow? Are you tired of having elbow and forearm pain with lifting, gripping and grabbing, even with items like your phone or coffee mug? Are your workouts in the gym or tennis or golf severely hampered by these symptoms? Well, then look no further than the Tenex procedure. This is an innovative minimally invasive procedure developed 13 years ago in conjunction with the renowned Mayo Clinic. Dr. Holmes has performed more Tenex procedures than any other physician in middle Tennessee over the past 10 years.

The Tenex procedure, also termed a percutaneous tenotomy, is a great option for tennis or golfer’s elbow (also known as lateral or medial epicondylitis, respectively) that has not healed with rest and other possible treatments such as medications, physical therapy, injections, or bracing.

We go to the operating room, give the patient an injection of lidocaine only, a numbing agent. We get to avoid the sedation, cost and side effects of general anesthesia (getting put to sleep).

A tiny incision of about 1/4 inch is made. A small hand piece with a needle tip is inserted through the incision. Under ultrasound-guidance, this tip is inserted to the damaged part of the tendon and ultrasonic energy allows the tip to debride and remove the unhealthy portion of the tendon while leaving the healthy portion alone. Two minutes of treatment time or less and you are on the road to recovery.

No stitches required, just a few small steri-strips, followed by a small dressing and you are out the door, headed towards tendon healing, and eventually becoming pain-free.

Post-operatively, you wear a wrist splint for at least 2 weeks, and we restrict lifting for about 6 weeks. Our golfers, tennis players and weightlifters can usually gradually resume these activities at the 3-month mark. There is no “quick fix” for these conditions, yet Tenex offers a permanent solution to an often-stubborn problem.

We’ve done in the range of 500 of these procedures over the past 11 years with excellent results.

This procedure really beats the option of steroid injections, which often make the condition worse in the long term. The alternative to Tenex is a larger surgery requiring a 2-inch incision and a much longer recovery.

In our book, the Tenex procedure gets a rating of 10!

What Does "Being Proactive Over Reactive" Mean?

Proactive Interventional Orthopedics (PIO)…a concept we will continue to promote. What does it mean in orthopedics to be proactive over reactive? Here are some examples and brief explanations:

Choose maintenance and more long-term injections over short-term steroid/cortisone injections: platelet-rich plasma (PRP) and hyaluronic acid injections often produce a more clinically significant and longer duration of benefit than steroid injections. For your knee and hip arthritis, tennis and golfer’s elbow and plantar fasciitis, just to name a few, choose these injections.

A course of physical therapy over exercises you simply found online: patient outcomes are generally better when you work with a physical therapist over Dr. Google or YouTube. We have fantastic relationships with physical therapists across Middle Tennessee and can work with you to find the best fit.

Regular use of supplements over prescription or over-the-counter medications: there’s a time and place for prescription meds when managing orthopedic conditions. However, for long-term management, we prefer options like curcumin/turmeric, collagen, and glucosamine/chondroitin. That being said, it’s always wise to consult with a physician before starting new supplements.

Don’t wait for your pain or disability to reach high levels before you seek treatment: orthopedic conditions treated early after the onset of symptoms and when pain and dysfunction are at a low level typically respond better to less-invasive treatments, and this early treatment can lower the risk of further damage to the joint or tissue.

Choose a specialist over a primary care physician for your orthopedics needs: PCPs work really hard and a do a great job to care for your overall health, but they do not necessarily have the expertise, the tools such as on-site imaging and advanced equipment or the time to dedicate to your orthopedic conditions.

Healthy eating patterns over a fad diet: weight loss is a vital part of the treatment plan when it comes to weight-bearing joint problems like hip and knee osteoarthritis. Through a variety of options, we can help you a structure a plan to gradually lose weight in a manner that the weight will stay off and through means that can be maintained for the long-term.

As always, let us know if we can help you overcome an injury, treat an orthopedic condition or find the pathway to greater wellness with an improved quality of life!

F. Clarke Holmes, M.D.

Why Insurance Does Not Pay For Platelet-Rich Plasma Injections, But Why That Should Not Deter You

Platelet-rich plasma injections, commonly known as PRP, have been utilized in orthopedics for at least the past 15 years. The first studies in orthopedics looked at PRP being utilized for tennis elbow, and the results were promising.

Fast forward 15 years and now platelet rich plasma has become a mainstay in the treatment of many orthopedic conditions, ranging from osteoarthritis to tendon and ligament problems. An estimated 60% of orthopedic practices now offer PRP to their patients and while some physicians can claim true expertise in this type of treatment, other practices remain novices when it comes to the application of PRP.

Now, to answer the question in the title of this blog, “why do insurance companies not cover PRP….” We will provide an educated opinion with several bullet points.

-Many insurance companies claim that PRP injections are “experimental.” Experimental is a very broad term that can be applied in numerous ways. What classifies something as experimental? In my opinion, this is something that has been utilized for a very short period of time and has very few studies or anecdotal pieces of evidence to demonstrate a sustained rate of efficacy. Meaning, this treatment hasn’t been used for very long, has not been used on very many patients, and we really don’t know what the short-term or long-term results are.

When it comes to PRP, I would say we are light years beyond the experimental stage. For many years, PRP has been used not only in orthopedics, but also in plastic surgery, wound care, dermatology/aesthetics and hair-loss situations, to just name a few. PRP has demonstrated a long track record of safety, and the overwhelming majority of studies demonstrate that patients benefit from these procedures. So, in my mind as a physician of nearly 25 years who has studied medical data for his entire career, I would no longer classify PRP broadly as experimental. Are more studies regarding PRP necessary? Of course. Yet this is true for every treatment in medicine. Trust me when I tell you that there are numerous treatments in all fields of medicine being utilized right now that have been studied far less than PRP.

-Next, the truth is that insurance providers these days are looking to pay for fewer and fewer of your medical expenses. We have to get away from the mentality that “I have health insurance, and it should cover all of my medical needs.” In truth, we are probably getting back to a model where insurance should be used for major health expenses and catastrophic situations, not for most of your routine day-to-day medical care. Almost all of private insurance companies are for-profit organizations. There’s nothing wrong with that. However, you must realize that their first goal is making a profit to sustain their business. Their first priority is not providing the optimal care for the patient, as often is the case, the optimal care is not the least expensive. So, we are constantly preaching to our patients these days that the best treatments in orthopedics are not necessarily the ones you can expect your insurance to cover.

-Finally, to partially take the side of the insurance company, an argument against covering PRP would be that it cannot be “standardized.” We can standardize a medication or certain forms of medical equipment, but we cannot standardize a patient’s blood. Therefore, one person’s PRP may not look like another patient’s PRP, meaning the number of platelets, white cells, etc. may be fairly variable between patients. Also, there are probably 20 to 30 commercially available PRP systems on the market now. None of these produce PRP in exactly the same way, once again, making the argument that PRP injections cannot be completely standardized. For this reason, insurance companies often take a pass on something they don’t view as uniformly the same treatment for every patient.

Now, let’s turn attention to why it really may not matter whether insurance companies cover PRP or not and why you should not be deterred from seeking this treatment.

-First, let’s look at the financial piece. So many of our private insurances require that we first meet our deductible before insurance will pay a significant portion of our medical bill. These deductibles are rising. Until you meet your deductible, you are going to pay out-of-pocket for any office visit, diagnostic test, medical procedure, or medication. Therefore, let’s say you were choosing between a steroid injection versus a platelet-rich plasma injection. Technically, the steroid injection is “covered by your insurance,” but until you meet that deductible, you are going to pay for an office visit and the cost of that steroid injection. So, “covered by insurance” doesn’t mean it’s an expense-free treatment.

-Next, that steroid injection may not be the best treatment for your particular condition. Let’s say you have a partial rotator cuff tear. You either don’t want or don’t need surgery for it. The steroid injection may temporarily alleviate symptoms, but certainly will not heal the partially torn tendon, and in fact, some patients worsen within weeks to months after a steroid injection. Thus, assuming you then are still seeking care for your shoulder pain and torn tendon, you will require additional tests and treatments. This may mean an MRI, a long course of physical therapy, additional medication, or even surgery. Those options, especially when combined, can be very expensive. Although platelet-rich plasma injections are not covered by insurance, they could be the long-term solution to your problem, saving you hundreds to thousands of dollars on other necessary potential treatments. Therefore, why not choose the treatment that will be most successful, not just the one that your insurance states that it covers?

-Finally, gone are the days that you can depend on insurance companies decide what is best for you and your health. I tell patients all the time that I literally could give them 10 steroid injections over the course of the year and cause bodily harm to them and their particular joint or tissue. Insurance companies would reimburse me to do this, often without question. Nevertheless, that is just not the right thing to do. I took an oath as a physician to “first do no harm” which I have continued to practice to the best of my ability. In addition, not only do I want to not do harm, but I also truly desire to help my patient. Therefore, I will help you choose what I believe to be the best and most customized treatment option for your particular situation. This is not always in line with what insurance companies would prefer that I do. I have no desire to be a “rogue” physician, but I’ve dedicated my career to developing an expertise to help my patients. Part of our ability to help our patients lies in the fact that we get to know them personally and their particular situations, goals, desires, comorbidities, and even their financial situations. Therefore, we work as a team with our patients to decide what we believe is best for them. Although it’s very natural to want to pay as little as possible but still get the best outcome, you just can no longer rely on insurance companies to have the authority over these decisions for you.

I realize what is said above gives you a lot to consider. I have a passion for educating our patients on the best treatments for their particular situation, and I am dedicating to doing that for the remainder of my career.

As always, please let us know if we can be of assistance to you!

F. Clarke Holmes, M.D.

Impact Sports Medicine and Orthopedics

You Want To Run in the Turkey Trot, and You Haven’t Even Been Exercising: 5 Tips

Turkey Trot races can be a ton of fun, a great way to celebrate the holiday with the masses and can jump start the winter “get back into shape” mindset. Fortunately, many of these races attract a wide variety of competitors, many of which are not even currently exercising. So, these tips are directed towards those individuals.

1) Update your footwear: If your shoes are greater than a year in age or show wear on the tread, then it’s time to get new shoes ASAP. Choose a high-quality shoe store where an actual shoe-fitting can be done. Just remember, if you’re not paying at least $75, you’re probably getting a lower quality shoe.

2) Start with run-walk intervals, especially if you’ve not run in a good while: Start with intervals of three minutes of walking and then one minute of running. Consider training every other day for the first 2 weeks, then you can start to train daily. Each week, you can phase out some of the walking and add more running. Your ratio can go from 2:1, then 1:1 and eventually, to a majority of running. However, if you don’t consider yourself a big runner, there’s nothing wrong with doing intervals during the race or simply just walking the race.

3) Set realistic goals: It’s less than four weeks to Thanksgiving, and you’re not even exercising. Thus, your goal is to simply to get to the finish line. Don’t put an emphasis on your time either. Enjoy the process of training, getting back into shape and accomplishing a goal on or around Thanksgiving day.

4) Get the race-day wardrobe ready: Pay attention to the weather report a few days before the race. Don’t forget about something to keep your head warm as well as high-quality socks and gloves, especially if the temperature is going to be in the 40s or lower.

5) If you want to do this race with company, then find some friends and family who have a similar pace to you: Don’t plan on competing in a race with a peer who is much faster or slower than you. This can certainly steal your joy and/or put you at risk for injury.

As always, let us know if we can be of any assistance to you!

Clarke Holmes, M.D.

Should My Son Play Tackle Football?

"Should my son play tackle football" is a question I receive on a very frequent basis. Parents are more concerned than ever about the risks that come with playing this collision sport. The first question I ask the parent in return is "Does your son really want to play tackle football?" Football is a rigorous, gladiator-style sport. It often pushes boys towards their limits with regards to commitment, fear, body contact and fitness level. These "pushes" can be a positive thing for your son, but if he is not enthusiastic about playing this sport, then your question has been answered. I strongly discourage participation in football if your son doesn't want to be on that field. 

Here are the reasons your son SHOULD play football:

• He becomes part of a team, something bigger than himself. Bonding is often very high among football teammates, as they adopt an "in the trenches together" mentality
• Courage, dedication, loyalty, sportsmanship and confidence are valuable character traits that often develop with a successful football experience
• Improved fitness levels- football is a sport requiring endurance, speed, quickness and power, with some positions emphasizing more of these traits than others
• Mentoring- many football coaches become like father-figures to young men, teaching them important life lessons while teaching them football as well

Here are the reasons your son should NOT play football:

• First and foremost, he doesn't want to play
• The risk of injury. Here are some important injury-risk considerations:

1. Size and strength deficits- if your son is physically less developed than many other peers competing in football, then his risk is increased. If the team or league is allowing 140 lb. boys block and tackle 225 lb. boys and vice-versa, then the smaller boy's risk is much greater. In the youth leagues, rules are often in place to reduce this effect. In the high school environment, it is up to the coaches to ensure the safety of the smaller athletes.
2. Concussions- we could create an entire blog on this subject, but in a nutshell, concussions are common at all levels of football. Contrary to most conditions in medicine, concussion symptoms in younger football players often last longer than those more mature. New evidence is suggesting that the earlier the age one starts having concussions, the greater the risk of long-term problems such as memory deficits and depression, just to name a few. Also, the multiple concussions likely create a cumulative effect, meaning several concussions in a relatively short period of time create more long-term damage than one concussion or a few concussions separated by many years. Simply put, someone playing tackle football for 10 years is much more likely to have more concussions, whether diagnosed or not, than one playing for only 3 years. Improved equipment such as helmets and better tackling techniques may reduce the severity and risk of concussions, but no equipment or rule adjustment can significantly reduce or eliminate concussions. 
3. Orthopedic Injuries- minor contusions and sprains are part of the game for nearly every player and heal without consequence. However, some fractures and ligament sprains, although appropriately treated, leave football players with long-term pain and dysfunction. For example, despite a successful ACL-reconstruction surgery after an ACL tear, 50% of athletes have knee arthritis within 12 years of the injury. In addition, repetitive microinjury to the back likely leads to an increased risk of disc problems in the cervical and lumbar spine. 

When weighing the risk of injury as it relates to football participation, consider not only the immediate impact of injury, but also the long-term implications of concussions and orthopedic injuries.

If there is an opportunity to play flag football, then I encourage one to play this version for as long as possible. In my opinion, tackle football is a sport that be re-joined or joined for the first time at a later age, perhaps 9th or 10th grade without a major roadblock to success. Years of tackle football does not necessarily guarantee success at higher levels such as high school or college. In fact, beginning tackle football at a young age can lead to burnout or injuries that derail one's ability and desire to continuing playing into middle and high school. 

In conclusion, the decision of whether your son plays tackle football or not must be one thoughtfully considered by and discussed among the athlete and his family members. Risks and benefits for your child should be carefully weighed.

F. Clarke Holmes, M.D.

Impact Sports Medicine and Orthopedics, PLLC