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.

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:

Why Insurance Does Not Pay For Platelet-Rich Plasma Injections, But Why That Should Not Deter You — Impact Sports Medicine & Orthopedics (impactsportsnashville.com)

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

F. Clarke Holmes, M.D.