PRP: The Simple and Not So Simple
/Many of you are either very familiar or somewhat familiar with platelet-rich plasma injections commonly known as PRP. These are great options for osteoarthritis of a joint, a chronic tendon problem as well as some ligament and fascia problems. Our top conditions treated with PRP include knee osteoarthritis, tennis & golfers’ elbow, plantar fasciitis, rotator cuff tears and Achilles tendon conditions.
When it comes to PRP, here are the simple and not so simple :
Simple
-This is an office procedure, that from start to finish, only takes 45 minutes or less
-A simple blood draw from an arm vein is typically painless
-For a joint injection, pain afterwards is typically very mild
-Risks are exceedingly low as abnormal bleeding, infection, a blood clot or nerve damage are basically nonexistent.
Not So Simple
-We have been performing PRP injections for nearly 15 years. Literally hundreds of hours have been poured into training and fine-tuning the knowledge and skill set it takes to be highly competent to perform this procedure
-Some of our patients have very small veins. Fortunately, we have developed a skill set of ultrasound-guided venipuncture, making blood draws much more successful and less painful on those more challenging patients
-Ultrasound guidance, in our opinion, is a must when giving PRP injections. If you want these growth factor rich platelets to make it to the intended location with great accuracy, then ultrasound guidance is necessary. This is a skill set we have developed over the past 16 years
-With some soft tissue PRP injections, such as partial tears of tendons, we have to prepare our patients that there will be a spike in pain after the procedure, often for one to two weeks. Fortunately, the pain is typically not as significant as it would be if you had a surgery
-Finally, patients have to be patient! PRP exerts its positive effects very gradually. Most patients are seeing a benefit within one to two months, and the maximum benefit often is seen between 6 and 12 months. Thus, we have to advise our patients that with many orthopedic conditions, there is no “quick fix”
Ultimately, PRP can be simple and not so simple, depending on your perspective. Generally speaking, we leave the simple part up to the patient, and we will handle the not so simple aspects of the procedure.
As always, let us know if we can be of assistance to you!
F. Clarke Holmes, M.D.
I Have Knee Arthritis. Can I Still Run?
/The answer is, “yes,” “maybe” or “no.” Thus, it really depends on your situation, and fortunately, a period of relative rest may only need to be temporary.
Here’s the really good news: several recent studies have indicated that running a reasonable number of miles does not cause knee osteoarthritis and may actually have a protective effect.
If you are a runner and your knee is symptomatic, then our role is to help you reduce or eliminate your symptoms and safely return to running. We know that running has numerous health benefits, not only including protection of the joints, but also calorie burning, weight control, improvement of cardiovascular health and many mental health benefits.
As a patient though, it’s sometimes difficult to know when you need to stop running for a while, what’s a reasonable amount of running for your body and what treatment options may be available to not only reduce your symptoms, but also to protect your knees on a long-term basis.
That’s where we come in! We love treating runners and understand how you think. We typically focus on a nonsurgical and minimally-invasive approach to your care.
Physical therapy, bracing, footwear changes, custom orthotics, medications, supplements, and various injections can all play a role in the treatment of knee osteoarthritis. One of the best long-term treatment options, especially for those with mild to moderate osteoarthritis, would be platelet plasma (PRP) injections. These can have a very protective effect for the knee, and not only by reducing symptoms, but also by slowing or stopping the deterioration of the cartilage within the joint. Only a couple weeks of rest are typically required after these PRP injections.
Check out a few blogs on PRP as well as running as it relates to knee osteoarthritis:
https://www.impactsportsnashville.com/blog/2023/8/5/our-top-5-treatments-for-knee-oa
https://www.impactsportsnashville.com/blog/2023/5/12/five-keys-to-successful-outcomes-with-prp-injections
https://pubmed.ncbi.nlm.nih.gov/36875337/
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.
You Turned 50 and Now Have Pain. You Are Not Alone!
/Yes, so many of our patients reach the harsh reality that their body doesn’t feel “normal” when they reach those glorious middle ages. For many, this can be a lonely feeling, as they feel like they are unique with their aches and pains. Well, we are here to tell you, you’re not unique, and you’re not alone. And that’s a good thing.
Although there is a reality check that has to occur with an understanding that those aches and pains will often be there, that doesn’t mean that you have to “give in” to these. Some of these conditions can be effectively cured while others can be managed to the point where symptoms are mild, tolerable and do not significantly inhibit you. The good news is that the large majority of these conditions do not need surgery. More than ever, we have a large number of tools in the toolbox to manage chronic tendon problems, arthritis as well as ongoing strains and sprains.
Don’t just rely on “Dr. Google” for your health care. We can provide cost-effective, but very sound advice and treatment interventions to help you feel better, function better and have a greater quality of life.
Typically, when a patient presents with a pain or injury, we will cover all of these aspects of care:
what forms of exercise can still be utilized
what “relative rest” looks like for you
appropriate use of medication
supplements that may benefit you
the potential for physical therapy or a rehab program
various types of injections that may help manage or overcome your condition
lifestyle modifications including weight loss, improvement in ergonomics & sleep habits and stress reduction
only surgery if we feel it is absolutely necessary
An older physician once told me, “pain is inevitable, suffering is optional.” So, don’t suffer and know that we are here to help you!
F. Clarke Holmes, M.D.
Our Top 5 Treatments for Knee OA
/Whether it be mild, moderate or severe knee osteoarthritis, here are our top 5 treatments. If you can incorporate these into your regimen, then you undoubtedly will see the benefits of less pain, better function and greater longevity for your knees.
1) Weight Loss: for every 1 pound a person is overweight, an extra 4 pounds of force are going through the knees. So, lose 10 pounds, and you have 40 pounds of less force on those knees. Lose 25 lbs, and 100 fewer lbs. of force! A recent study indicated that when those with knee OA lost 10% of their weight, their pain decreased by 50%
2) Healthy Eating with an Anti-Inflammatory Diet: healthy eating doesn’t always result in weight loss, but choosing the right foods often results in less inflammation in our body. This means less pain and a better environment for the joints. Choose fresh foods over processed ones. Reach for the fresh foods in the refrigerator more than packaged food in the pantry. Eat at home more and go out to restaurants infrequently. Fruits, vegetables, whole grains and lean meats should be the staples of your diet. Alcohol in moderation. Red meat, fried foods and processed food only on occasion and when necessary. Sodas rarely and watch out for artificial sweeteners.
3) Injections: these are often a faster path to relief for most patients. Platelet-rich plasma (PRP) injections utilizing your own blood and concentrated growth factors are the star of this category. Long-term benefits are most common with PRP. Hyaluronic acid injections (brand names: Orthovisc, Trivisc, Gelsyn, Euflexxa, etc.) are good options for many. At times, we combine the PRP and hyaluronic acid injections to boost the benefits. Steroid injections are the final option and can have great utility when a patient needs to feel better quickly such as during a flare or before a big trip.
4) Exercise/Physical Therapy: choose exercise you like, you will stick to, a variety and types that do not cause pain in your knee, both during and afterwards. Sometimes, it’s not just the type of exercise, but the intensity and duration. Find your “sweet spot,” meaning your knee might feel great if you walk a one mile but hurts if you go further. You can bike for 30 minutes, but beyond that causes swelling. So, stay below your pain threshold. Lower-impact options like biking, elliptical, rowing and swimming/aquatic exercises are often the best choices for most with knee OA. Physical therapy is often a good starting point to strengthen the muscles around the joints and to improve biomechanics, functional movement patterns and flexibility.
5) Supplements: our favorites are collagen, curcumin (the active ingredient of turmeric) and for more advanced knee OA, glucosamine and chondroitin. Others like fish oil may have benefits for the joints as well. The key here is choosing a high-quality brand and taking these on daily basis. Admittedly, they don’t help everyone, and you need to make sure that your physician knows you are taking these, especially if you are taking other medications and/or will soon have a medical procedure.
As always, let us know if we can be of assistance to you!
F. Clarke Holmes, M.D.
Knee Replacement Soon? Hit the Pause Button...
/So many patients with knee osteoarthritis ask me the question “well, if I’m eventually going to require knee replacement, shouldn’t I go ahead and have it done now?”
Well, there’s not just one answer to that question, but here are some of my replies:
-Most knee replacements only last 15 to 25 years. After that, the implants start to loosen, creating pain, swelling or a sense of instability.
-Most patients are at higher risk for surgical complications at the time of a second surgery, known as a “revision,” simply due to their age and likelihood of having more significant medical conditions.
-Surgical techniques are improving with breakthroughs every two or three years. Robotically-assisted replacements and having replacements as an outpatient surgery are two recent examples. More advancements are sure to come.
-One should never base the need to have knee replacement on the appearance of the x-rays. Some patients with “bone-on-bone” arthritis have minimal pain and excellent function. These patients don’t need a replacement.
-What often produces the most pain is an unhealthy environment within the knee joint, some of which may be controlled with injections like platelet-rich plasma (PRP).
-We also believe that PRP may put a stop sign or at least a yellow light on cartilage deterioration. We do not make guarantees about cartilage regrowth, but if we can stabilize a patient’s current cartilage and slow or stop the deterioration, then we are slowing the process of osteoarthritis and perhaps delaying the need for knee replacement.
-For a joint condition like arthritis, we often think of PRP as a maintenance treatment, not just a one-time application. Much like the maintenance for your car, you don’t just take it to the mechanic once or twice and then get a new car. This is an ongoing process.
-Assuming a patient is in that 80% success group with PRP treatments, one should plan on likely having repeat PRP injections every 1 to 2 years. This is a great long-term investment in the health of your knee.
-Want to know more about PRP? Check out this blog:
Five Simple Reasons You Should Consider Platelet-Rich Plasma — Impact Sports Medicine & Orthopedics (impactsportsnashville.com)
In summary, for some individuals, knee replacement is inevitable, but there can be great value in delaying this surgery to increase the odds that it is required just once in a patient’s lifetime. For others, treatments like PRP can eliminate the need to have a replacement.
As always, let us know if we can be of assistance to you!
F. Clarke Holmes, M.D.
Insurance Companies Say PRP Is Experimental…We Sigh
/Platelet-rich plasma (PRP) injections first presented in the orthopedic medical literature in 2004, nearly 20 years ago. Now, new PRP studies hit the orthopedic journals monthly. The overwhelming majority of the evidence suggests that PRP injections are safe, beneficial and have positive effects on soft tissue and joints. Somehow though, insurance companies continue to classify these as “experimental” and will not pay for PRP injections. Thus, these remain cash-pay procedures. PRP injections are not alone, as some of the best procedures now in medicine are not covered by insurance.
PRP is not just used in orthopedics, but also in dentistry, ENT, neurosurgery, ophthalmology, urology, wound healing, cosmetic, hair restoration, cardiothoracic, and maxillofacial surgery. Could all of these specialties be wrong about PRP? I really doubt it.
So, we ask the question: what does it take for something to no longer be classified as experimental? In my opinion, as a physician of 25 years, treatments should no longer be considered experimental if they meet the following basic criteria:
1) They have been used consistently in medicine for 10 years or longer by a reasonably high percentage of specialists in a particular field.
2) Quality studies published in the reputable medical journals demonstrate a clinically significant benefit.
3) Use of a particular treatment steadily grows because of positive results with a low likelihood of adverse events.
If you evaluate PRP with this criteria, then it’s a no-brainer…it is no longer an experimental treatment.
Insurance companies do serve a valuable role in our medical system. Without them, health care would be unaffordable for many Americans. However, the criteria they sometimes use to classify whether a particular treatment or test is covered or not is often very flawed and/or “behind the times.” Here’s a classic example: we could choose to give 10 steroid/cortisone injections into a patient’s knee in just one year, and almost all insurance companies would pay us for each injection. This could be very damaging to the joint, but it would be a “covered” procedure. In contrast, PRP injections, which have been shown to be superior to steroid injections for knee osteoarthritis in dozens of studies, would not be covered by insurance.
So, as a patient, you have to be discerning and partner with a physician who understands what treatment options are best for you. Basing these decisions on what insurance covers can be a short-sighted approach.
In conclusion, both physicians and insurance companies play vital roles in the care of the patient, but these roles are different. I say, “let doctors doctor and administrators administer.” For now, don’t count on a PRP injection to covered by insurance companies any time soon, but that should not deter you from choosing these valuable treatments. Want even more info? Check out one of our recent blogs on the topic:
As always, let us know if we can be of assistance to you.
F. Clarke Holmes, M.D.
Here Comes Volleyball Season: We Are Ready in the Ortho World!
/Volleyball season is fast-approaching. Today, let’s discuss the four most common areas of injury, treatment and prevention.
Volleyball was my sport as a youth. I played all year-round, and if I wasn’t in practice or a tournament, I was working out. But is the constant wear and tear on our bodies without rest hurting us even at a young age? In parts, yes. We commonly see athletes whose injuries could have been prevented with a short period of rest or prevention methods. Let’s talk about that:
1. Ankle
Most common: ankle sprain. It comes as no surprise that ankle injuries are one of the most common injuries seen in volleyball. Initial treatment includes RICE (rest, ice, compression, and elevation). However, it is always wise to see an orthopedic provider who can help guide you in treatment, prevention, and return to play. What many people do not know is younger children and teenagers’ growth plates are still open and are also at risk of injury with a twist of the ankle. When growth plates are still open, they are the most vulnerable and at risk for a Salter-Harris fracture which involves the growth plate. After growth plates close, the ligaments become the most vulnerable. I like to tell my patients that ligaments are like the candy Laffy Taffy. Once they are stretched out, they don’t necessarily return to their original state. Thus, prevention and strengthening are imperative.
Prevention: ankle range of motion, strengthening, and balance exercises; keeping footwear up to date; purchasing well-fitting and high-quality footwear; and ankle braces during practice and games.
2. Knee
Most common: patellar tendonitis (chronic) and ACL tears (acute)
Patellar tendonitis, also known as jumper’s knee, is very common due to the amount of jumping volleyball requires. Many times, the athlete will localize the pain right under the kneecap at the proximal aspect of the patellar tendon. Our office utilizes diagnostic ultrasound to look at the characteristics of patellar tendon, identify if there is tearing, compare it to the unaffected size, and determine if there is any new blood vessel formation (neovascularization). Prevention and treatment include stretching and strengthening exercises, a period of rest from jumping, and a patellar tendon strap. Short-term anti-inflammatories can helpful. In difficult cases, we can turn to platelet-rich plasma injections (PRP). Those with an open growth plate at the tibial tuberosity are at risk of developing Osgood-Schlatter’s.
Anterior Cruciate Ligament (ACL) tears: Volleyball is relatively high risk for ACL tears due to potentially landing awkwardly after a jump or during pivoting maneuvers frequently required. The ACL is under the most load when the knee is under sudden valgus (knock-kneed) stress. The best preventative options are to strengthen the outer hip, upper thigh, and gluteal muscles along with jump-training techniques to help protect the knee. If diagnosed with an ACL tear, treatment can be conservative or surgical. Those who wish to continue participating in high-risk sports generally opt for surgical intervention.
3. Shoulder
Most Common: Impingement, Labral Tears, Instability, and Rotator Cuff Tendinitis
Those who are hitters in volleyball are at risk for all of these shoulder conditions. Once again, relative rest, recovery, and strengthening are imperative in preventing these conditions. Improvement in form and hitting techniques are often helpful. Injections (occasional steroid, but more commonly PRP) can play a role in more difficult cases.
4. Low Back
Most Common: Lower Back Strain/Sprain (acute) or Spondylolysis
Volleyball requires repetitive bending, twisting, and hyperextension movements which put the low back in vulnerable positions. The biggest takeaway is if you or your child is experiencing low back pain that is not relieved after a couple weeks, please see an orthopedic provider. This could indicate a spondylolysis (a stress fracture) or stress reaction in the bones of the lumbar spine. Low back strains/sprain can be muscular or ligamentous and tend to improve within 2 weeks. If that’s not the case, then we often look for spondylolysis or even disc problems.
As mentioned, strengthening and adequate rest while allowing our bodies to recover are the best ways to prevent these common injuries. However, if these injuries occur and you or your child’s symptoms are unresolved beyond a week or two, please give us a call!
Taylor Moore, NP
Five Keys to Successful Outcomes with PRP Injections
/Quality Equipment- we’ve chosen a PRP system created by one of the industry’s leaders in orthobiologic injections.. This is our 5th PRP system to use over the past 12 years. Thus, we are always searching for the best option to produce a high-quality PRP solution.
Appropriate Selection of Patients- we attempt to choose patients and conditions that are excellent candidates for PRP injections. Admittedly, not every patient is an ideal candidate, yet their options may be limited in terms of other forms of treatment, or they are willing to have PRP due to its excellent risk-benefit and cost-benefit ratio compared to more invasive treatments. Partial tendon tears, plantar fasciitis and osteoarthritis of the knee, hip and shoulder comprise 95% of our PRP injections.
Appropriate Pre-Procedure and Post-Procedure Instructions and Compliance-little things can be the difference between PRP succeeding or not succeeding or between a good outcome and a great outcome. For example, it’s important for a patient to be off any anti-inflammatories at least a week before and 2 weeks after a PRP injection. It’s also important to rest the treatment area, and this form of rest really varies depending on the patient and their area treated. A patient’s timetable for return to exercise and/or rehabilitation must be carefully outlined.
Quality Preparation of the PRP solution- not all PRP is the same. The platelet concentration and number of platelets can vary and are important aspects of the potential success of PRP. How much blood we take from the patient and the PRP system dictate these numbers. Also, we typically create a leukocyte-poor (low numbers of white blood cells) for joint injections and leukocyte-rich (higher white blood cells and the highest number of platelets) solution for tendon injections.
Accuracy of the Injection, Preferably with Ultrasound Guidance- using ultrasound for the injection often results in less pain, lower risk, and greater accuracy. We place the PRP exactly where it needs to be and avoid hitting other structures like bone, cartilage, nerves and blood vessels. We often say, “if you’re going to invest your time and money in this procedure, don’t you want it done as precisely as possible?”
More medical professionals are performing platelet-rich plasma injections than ever. This innovative treatment is not going away and will only evolve in the years to come. If you think you are a first-time or repeat candidate for a PRP injections, then come see us!
F. Clarke Holmes, M.D.
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!
Frozen Shoulder... More Than Just a Winter Occurrence
/We’ve talked a lot about PIO (Proactive Interventional Orthopedics) recently and this concept really applies when it comes to a frozen shoulder, also known as adhesive capsulitis. This is a condition most commonly seen in middle-aged women around the time of menopause with the average age of a frozen shoulder being 51.
It starts as shoulder pain, often unrelated to a particular injury or overuse situation, and is followed by a very stiff shoulder with loss of motion. Although a frozen shoulder can be a self-limiting condition, with our interventions, we can greatly expedite the recovery process while alleviating pain.
Other risk factors for adhesive capsulitis include thyroid disease, diabetes and recent shoulder surgery. In the early “pain” stage, it’s often difficult to determine whether a patient has a frozen shoulder, osteoarthritis, or rotator cuff and/or biceps tendon problem. An MRI can be helpful, especially to see tendon or joint pathology, but in the presence of isolated adhesive capsulitis, the MRI can be normal or near normal. The next stage is the “stiff” or “frozen” stage, highlighted by the loss of motion both actively (what the patient can do) and passively (how someone else can move the shoulder). The final stage is the “thawing” or “recovery” stage. Each stage typically last 2-6 months, and early treatment often shortens these stages.
Being proactive and interventional often means an ultrasound-guided steroid injection into the joint. Without ultrasound guidance, it is often very difficult to achieve accuracy. This tends to be a very inflammatory condition, and thus, the potent anti-inflammatory effects of the steroid can provide rapid relief of pain. Early treatment within the first few weeks or months of the onset of the shoulder pain is the optimal path to a faster and more complete recovery. After that steroid injection, a rehab program, often made much more effective by the steroid injection, is the mainstay of treatment. 20% of patients with a frozen shoulder develop the same condition on the opposite shoulder within 5 years, so if pain in the other shoulder develops, it’s wise to seek treatment early.
Check out this brief article:
Steroid injection may be the best medicine for frozen shoulder - Harvard Health
If you think you may have a frozen shoulder, let us use PIO to help you!
F. Clarke Holmes, M.D.