Proactive Versus Reactive: Which One Are You Choosing?

We strongly encourage our patients to be proactive with their musculoskeletal health over just being reactive.

Let’s list some examples of the two different approaches:

Proactive

1. You’re trying to remain in great shape, yet your knee is starting to ache due to mild osteoarthritis. No surgery is necessary, but you want to do something that not only reduces symptoms, but also protects the knee in the long term that is likely disease-modifying. Thus, a series of platelet rich plasma (PRP) injections will meet those goals. PRP injections are one of the best treatment options for the management of osteoarthritis.

2. You’re starting to have heel pain when you first get out of bed. You suspect plantar fasciitis. Instead of ignoring the symptoms or simply relying on Dr. Google, you decide to consult with a sports medicine physician, so a comprehensive diagnostic and treatment plan can be constructed and customize for you. You realize an inexpensive ultrasound in the office can confirm this diagnosis, determine severity and help with prognosis. At that visit, you’ll be given numerous treatment options and successfully guided on your ability to continue exercising to maintain good health.

3. You have daily aches and pains, early arthritis and stiffness, but really don’t want to go on daily medications to manage the symptoms. However, you need some help making lifestyle choices as a pertains to diet, supplements and exercise choices. You understand that friends, family, and the Internet are not the optimal resources. Therefore, you decide to move forward with a physician consult so you may receive advice in great detail regarding the best supplements to choose for your particular situation, how to approach exercise and dietary choices. You understand that it is your physician’s to help you decide between what is fact and what is myth.

Reactive

1. Your heel starts to hurt after some longer walks, especially when you first get out of bed. You talk to friends who recommend rolling the heel, stretching the toes and obtaining non-customized orthotics. You continue to walk, but three months later your heel pain is worse and you limp into the doctor’s office wondering what happened. Bottom line, you now have advanced plantar fasciitis. Unfortunately, the advice you’ve received from well-intentioned others has not been the best for you. Presenting to the doctor when the symptoms first developed would’ve given you a much better outcome, as an entirely different set of treatment options would have been suggested.

2. Your arthritic knee starts to hurt and you see a bit of swelling, but you decide to keep going to the gym, rubbing Biofreeze on it and you add in some heavy yardwork over several weekends, Ultimately, you can barely bend your very swollen knee, and you’re thinking about canceling that trip to see grandkids. Of course, we are here to help you, but we could’ve avoided this major flare if we would have proactively started some treatment as soon as your knee started to ache.

So we ask the question: are you going to be proactive or reactive? Not every little ache or pain that last hours to a few days should prompt a visit to the doctor. However, do not ignore symptoms and instead, do realize that early treatment usually provides better outcomes than waiting until symptoms rise to a moderate or severe level.

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

F. Clarke Holmes, M.D.

Our 5 Best Pieces of Advice for You

Some specialty medical practices see you as a “knee,” an “ankle,” a “hip replacement,” or “that person with too many aches and pains.” At Impact, we see you as a whole person. We see you from head to toe and do our best to advise you on long-term lifestyle choices to keep you, your joints and soft tissues as healthy as possible.

Here are our current 5 best pieces of advice for you:

1) Use food to your advantage, not as a detriment: many think only of food as calories, but instead, let food be nutrition…something that can nourish your body. Choose wisely with lean meats, some plant-based protein sources, numerous fruits and vegetables and healthy fats. Really limit fried foods, fast foods, processed foods, foods high in sugars and artificial sweeteners. Don’t forget about healthy beverage choices: more water than anything, adding green tea or black coffee but keep soda and alcohol very much in moderation. Why is this important? Proper nutrition allows for healing and recovery. Poor food and beverage choices lead to more inflammation and pain.

2) Being at a healthy weight is very important for your joints and soft tissues: every 1 pound someone is overweight equals 4 pounds of extra force going through his/her lower body joints. On the positive side, you lose 10 pounds, you have 40 fewer pounds of force on your knees and other joints. Osteoarthritis of the hips and knees, plantar fasciitis and insertional Achilles tendonitis are the most common conditions we see in overweight individuals.

3) Make cost-effective medical decisions: did you know that seeing a physician employed by a hospital or one associated with a larger group practice is more expensive than seeing a physician in a smaller private practice? Why is this? It is because insurance companies and these larger organizations have negotiated higher reimbursement rates. Is this based on a higher quality care? Absolutely not! It’s just the behind-the-scenes business of medical economics, and not many patients are aware of this. An office visit at “Hospital/Large Practice X” may cost you $300. A similar and possibly even more comprehensive visit at our practice may cost you $200.

4) Stay moving, as “motion is lotion”: whether your knee or low back hurts, or you are just stiff quite often, staying mobile will help your musculoskeletal system. Don’t sit for too long. Don’t keep your hips, knees or spine in one position for too long. Set a goal for a certain number of steps each day, even if you are not classifying this as formal exercise. Walk while you talk on the phone. Choose an adjustable or standing desk if possible.

5) Find your sweet spot when it comes to exercise and activity: perhaps 2 miles of walking is too much for your arthritic knee, but 1.5 miles feels good, both during and after the walk. 25 minutes of the bike is great, 30 minutes creates pain. 2 sets of bench press with 30 pound dumbbells feels right, but 3 sets with 40 pounds causes shoulder pain. “Sweet spot” exercise is essential, especially for us middle-agers and older.

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

F. Clarke Holmes, M.D.

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 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.

Five Keys to Successful Outcomes with PRP Injections

1. 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.

2. 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.

3. 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.

4. 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.

5. 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.

Tiger Woods and You...

You or someone you know may have something in common with Tiger: plantar fasciitis. Tiger dropped out of the Masters golf tournament last weekend due to severe heel pain caused by plantar fasciitis. This all-too-common orthopedic condition afflicts a huge number of middle-aged Americans every year. The most common symptoms are heel pain when first getting out of bed, when barefoot or with prolonged walking, running or sports. Here are some key “Dos” and “Don’ts” when it comes to plantar fasciitis:

What To Do When You Have Plantar Fasciitis:

1) Seek medical attention early: We have many tools in the toolbox to treat this condition, but we first need to need to confirm the diagnosis, set-up a multi-faceted treatment plan, and guide you on your prognosis. Ultrasound, which can be done in our office, is by far the best imaging study to see the plantar fascia. This factors into our concept of PIO- Proactive Interventional Orthopedics.

2) Wear good footwear at ALL times: when in the house, in the yard, at the gym, at the pool, while shopping, going to that concert, socializing with friends and at church. Good footwear means very supportive, not too flexible, and not too cheap. Cheap unfortunately often means lower quality.

3) Consider inserts/orthotics for your shoes: over-the-counter can get the job done, but you’ll need some advice on how to choose these. A high-quality athletic shoe store or a visit to your sports medicine doctor can supply that information. However, custom orthotics prescribed by your physician may really be what you need. We are fortunate to have custom orthotic specialists that work directly with our practice.

4) Consider physical therapy as it’s beneficial for most patients: many cases of PF are related to biomechanical problems, meaning that your calves are too tight, your foot pronates or supinates, your foot muscles are weak or you are overweight. Physical therapy along with weight loss in some individuals can help correct these biomechanical problems.

5) Realize that 10-20% of cases of PF will need an advanced treatment: in our practice, our first-line innovative and advanced treatment for stubborn PF is a platelet-rich plasma injection. PRP uses your own blood and the concentrated growth factors we have produced to reduce inflammation and pain while stimulating a healing response. If this fails, then we move on to a minimally-invasive surgery called a percutaneous fasciotomy using the Tenex system.

What Not To Do When You Have Plantar Fasciitis:

1) Stretch the bottom of the foot: many cases of PF involve tears in the plantar fascia. Although stretching the calf can help, stretching the bottom of the foot often irritates the fascia and can inhibit the healing process.

2) Buy expensive orthotics that are rigid or produced by an “orthotics store”: in our experience, these tend to be very uncomfortable for patients and unsuccessful in treating patients’ symptoms. Stick with an orthotics specialist recommended by an orthopedic/sports medicine physician.

3) Have multiple steroid/cortisone injections: although offered by some orthopedic doctors and podiatrists, we rarely offer these injections for PF and essentially never do more than one. Steoid injections can contribute to further tearing and often impede healing. Some patients feel better in the short term with steroid injections, but are worse in the long term.

4) Run/Walk through the pain: unfortunately, PF will just not get better if you keep doing the things that are causing the problem. So, a period of complete rest or relative rest will be necessary for PF to improve. Relative rest can mean dialing down your walking/running frequency or distance to the point that you stay below your pain threshold.

5) Become impatient: recovery from PF is often in the range of months, not days or weeks. So, once a treatment plan is in place, you’ll have to be patient. We often construct a Plan A, Plan B and Plan C. Each plan has 2-4 treatment entities within it and we insitute these for 1-2 months, judge their success and then move on to the next plan if we are not seeing the expected results.

In summary, plantar fasciitis is a condition that requires methodical treatment under the care of an experienced physician. Don’t just trust the advice from your non-medical friend, Dr. Google or YouTube. We are always here to help!

F. Clarke Holmes, M.D.

PRP And The Three "Es"

This sounds like the name of a band, right? Well, we’re referring to platelet-rich plasma (PRP) injections and three important words that start with an “E” when discussing these procedures.

First, a quick reminder that we use your own blood obtained from an arm vein, a special kit, a centrifuge and a precise separation process to create the PRP. PRP is then a great treatment choice for osteoarthritis of the knee, hip, shoulder and other joints. It’s also an effective treatment for tennis and golfer’s elbow, plantar fasciitis, Achilles and rotator cuff tendon problems, just to name a few. When considering who will perform your PRP injection, you absolutely need to consider the three Es:

Experience: At Impact, Dr. Holmes has been performing PRP injections since 2009. Very few physicians in the Nashville area can claim that level of experience. In addition, we are giving more PRP injections than ever as more and more patients are realizing the benefits of this procedure. Thus, in 2009, we may have given 1-2 PRP injections a month, and now, we give 12-15 a month on average.

Expertise: With experience comes expertise, yet expertise also comes with putting in the work. This means attending conferences, reading and interpreting studies, participating in webinars and interacting with peers who are also experts in the field. Hardly a week goes by that we don’t spend some time fine tuning our expertise in this field. Next, we’ve been pioneers in the sports medicine industry through our ultrasound-guided injections. 14 years of experience with ultrasound and over 10,000 injections later, we consider this to be an area of expertise.

Equipment: PRP is not just PRP, meaning some kits, equipment and the preparation process are better than others. Novices in the field tend to choose lower cost and lower quality PRP systems which often produce fewer numbers and a lower concentration of platelets. At Impact, we are on our 5th PRP system over the past decade. These systems continue to improve, and you deserve a high-quality option. Finally, ultrasound-guidance is paramount when having a PRP injection. Don’t you want this high-powered solution to be injected into the precise location? Without ultrasound guidance, you are proceeding “blindly” and can only hope the injection makes it to the intended location.

Considering a PRP injection for your orthopedic condition? Remember the 3 Es and let us know if we can be of any assistance to you!

F. Clarke Holmes, M.D.

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.

Five Simple Reasons You Should Consider Platelet-Rich Plasma Injections For Your Tendon Or Joint Pain

Let’s make this one quick and easy. Some blogs, we may hit with you great details, information rich in scientific data and opinions full of medical jargon. Today, let’s share some simple information regarding why platelet-rich plasma (PRP) injections should be on your radar if you have OSTEOARTHRITIS, TENNIS OR GOLFER’S ELBOW, ACHILLES TENDONOSIS, PLANTAR FASCIITIS, LATERAL HIP, PATELLAR AND ROTATOR CUFF TENDONOSIS, just to name a few.

1) Most of the time, it works: let’s be real, nothing in medicine works all of the time. If we see a significant benefit in 75% of patients or more, then we are all pretty happy with a treatment. In our patient population, PRP meets this criteria.

2) Most medical studies suggest a clinically significant benefit: do a “pub med” search for PRP as it relates to orthopedic conditions. Although some studies always will be too small or of lower quality, once you start to pool the data, you find that PRP is not really “experimental” any more. There are now hundreds of studies looking at patients receiving PRP for arthritis and chronic tendon problems, and the majority of these studies demonstrate a clinically significant benefit with PRP.

3) It’s both natural and safe: PRP is derived from your own blood. It’s designed to concentrate your platelets that contain your growth factors. These growth factors have many positive effects, ranging from inflammation reduction to slowing down the deterioration process within a tendon or joint. Major side effects are extremely rare, and when compared to steroid injections, prescription medications and surgical intervention, PRP is a safer treatment option with fewer adverse effects.

4) It’s a relatively quick office procedure: 5 minutes to set-up and draw the blood, 5 minutes to transfer the blood to the centrifuge system, 10 minutes to spin the blood, 3 minutes to further separate the blood components and capture the PRP, 2 minutes to prep the patient, and 1 minute to give the injection. In some instances, we may first inject a numbing medication (anesthetic) and then give that 10 minutes to work. So, in total, 36 minutes for this procedure done in the office, all in one sitting.

5) Although typically not covered by insurance, it’s likely a wise investment in your health and may save you money in the long run: the days of insurance always covering the best and most innovative procedures for orthopedic conditions are over. If PRP works for you like we expect it to, then you will potentially save money on doctor’s visits, medications, physical therapy, surgical interventions and other treatments. Not to mention that if you have not yet met your deductible, you will pay out-of-pocket for all of the other treatments “covered by insurance” that may be less effective than PRP.

In an nutshell, PRP is not for everyone and every orthopedic condition. We carefully select those patients who we think can “win the battle” with their orthopedic condition with one or more PRP injections. 20+ years of experience in sports medicine and orthopedics and 10+ years utilizing PRP have given us the knowledge to determine what patients may truly benefit from PRP injections. Come see us if you are curious!

F. Clarke Holmes, M.D.

Impact Sports Medicine and Orthopedics

5 Reasons to Either Have or Avoid a Steroid/Cortisone Injection

Steroid, often called “cortisone,” injections have been used in orthopedics and other specialties for several decades as potent anti-inflammatories. In recent years, they’ve become more controversial, as medical studies have validated that they likely have negative effects on our bodies and actually worsen certain conditions in the long-term. However, steroid injections still have some positive utility, and careful discussion with each patient must be undertaken to determine whether a steroid injection may be more beneficial or more harmful in each unique situation. Let’s explore those situations:

A Steroid Injection Can Be Particularly Beneficial in These Situations:

1)      Adhesive Capsulitis- most commonly seen in middle-age women, this highly-inflammatory condition causing shoulder pain and stiffness often responds beautifully to an ultrasound-guided injection into the glenohumeral joint.

2)      Early Phase of Tendonitis- if we catch tendonitis very early and when it’s primarily in the inflammatory stage (like tennis elbow or calcific rotator cuff tendonitis), a steroid injection can be very helpful in reducing pain and restoring function.

3)      Diagnostic and Therapeutic- many times, we see a patient that has pain in an area, yet we can’t determine the exact source. Thus, we use a precisely-placed injection with ultrasound to see if the pain is relieved. If so, then we feel that we’ve located the source and can then customize a more effective treatment plan. We use this strategy often for hip pain.

4)      A Patient Needs Rapid Relief- your knee is swollen and that bucket-list vacation that will require a lot of walking is fast-approaching. Your arthritic knee is in a flare, and we need to reduce pain and swelling within days, so that you can better enjoy that trip or upcoming event.

5)      Gout and Pseudogout- these are highly-inflammatory conditions due to excessive urate or calcium deposits in a joint, respectively. A steroid injection can provide rapid relief from these conditions.

A Steroid Injection Should be Avoided in These Situations:

1)      Chronic Tendonitis and Partial Tears- if you’ve had tennis or golfer’s elbow, rotator cuff issues or gluteal tendonitis for 3 months or greater, then your tendon likely has more degeneration and tearing than just inflammation. Steroid injections are far less likely to provide a long-term benefit in these situations.

2)      Repetitively- unfortunately, many patients make it to our office after having had 3-5 steroid injections over the past 1-2 years for their chronic condition such as tennis elbow or plantar fasciitis. We know that steroid injections have a catabolic (causing further deterioration) effect on joints and soft tissues if used excessively.

3)      Around Tendons at Risk for Rupture- the patellar tendon and Achilles tendon are two areas where we always avoid steroid injections. These tendons are prone to major tears, especially if exposed to injectable steroids.

4)      Risk of Infection- if there is any suspicion for an infection in a joint or bursa, then steroid injections are a “no-go.” It’s better to aspirate the fluid and send for analysis first before considering a steroid.

5)      Surgery in the Near Future- if a patient is considering having a joint replacement in the next 3 months, then steroid injections should be avoided due to the risk of infection during and shortly after the surgery.

We hope you find this information helpful when it comes to one of the most commonly proposed non-surgical treatment in orthopedics. As always, let us know if we can be of help to you!

-F. Clarke Holmes, M.D.

Impact Sports Medicine and Orthopedics

Will My Heel Pain Ever Go Away? I Need Help!

In middle-age individuals, 90% of the time, heel pain is caused by plantar fasciitis. The plantar fascia is a soft-tissue band, technically a ligament, that supports the hindfoot and midfoot. It is quite prone to inflammation, degeneration and tearing. It is a stubborn problem to both endure and to treat, and commonly becomes a condition that last months to occasionally years. However, do not fear, we have solutions for you!

How Does it Present?

·       Heel pain, often sharp, with the first few steps out of bed and after a long day on your feet

·       Pain when rising from a seated position after prolonged sitting, such as in a car

·       In endurance athletes, pain during and after exercise

·       Tenderness on the bottom of the foot, specifically at the heel where the plantar fascia originates

Why Did I Get This?

·       Age- middle-agers are prone to this, as they are very active, but their rate of tissue breakdown exceeds their body’s repair rate. This is why younger individuals do not typically get this problem. They have a faster healing rate.

·       Poor footwear- shoes that are flimsy, too old or generally unsupportive contribute

·       Weight- gaining weight or being overweight overloads the tissue at the lowest point of our body

·       Too much activity/overuse- runners, walkers, and athletes repetitively load the plantar fascia, and at times, are in a situation of overuse or too much, too soon

·       Poor biomechanics- tight or weak calf muscles, a high arch or flat foot or a foot that excessively pronates or supinates can all contribute

How Do I Treat It?

Patience is the key. Let’s repeat that….patience is the key. This condition often requires months of treatment. Recovery can be slow. The underlying risk factors listed above must be corrected. What works for one patient may not be the best treatment for another. Care must be individualized.

·       Rest- yes, this is a dirty, four-letter word for many patients. Plantar fasciitis will NOT improve as long as one continues to run, walk or exercise to the same degree. Sometimes, activity modification will work- fewer miles, less frequent high-impact exercise and/or trying something lower impact such as biking or swimming

·       Improve the footwear and minimize going barefoot- remember with shoes, you often get what you pay for. Don’t go cheap!

·       Physical Therapy- helps most patients, can be curative for those with mild cases. Will not get the job done by itself for moderate to severe cases.

·       Orthotics/Inserts- over-the-counter or custom. OTC ones are less expensive and worth a try for mild cases. Custom are more expensive but are more successful for most patients. Orthotics alone usually will not cure plantar fasciitis. Other treatments must be combined.

·       Anti-inflammatory medications- helpful in mild cases caught early. Not helpful in more severe cases or in patients that have had the problem for months or longer.

·       Cortisone injections- occasionally helpful, more often harmful. We rarely utilize these, as they don’t promote healing, only reduce inflammation and can increase the risk of further tearing of the fascia. NEVER get a series of 3 cortisone injections as recommended by some.

·       Orthobiologic injections- very helpful for most. These are meant to “heal the heel!” Platelet-rich plasma injections introduce numerous growth factors to the area to improve the tissue environment and thus, are typically successful in promoting healing of the fascia while reducing pain and improving function. These are game-changing injections and ones we have provided under ultrasound-guidance successfully now for many years.

·       Surgery- we favor a minimally-invasive procedure called the Tenex procedure. Tiny incision, local anesthesia only, no stitches required with minimal healthy tissue disruption. The “old-school” surgeries require larger incisions and involve “releasing”/cutting the fascia off the bone, are less successful, higher risk and have been abandoned by many orthopedic surgeons.

What to Avoid:

1)      Stretching the bottom of the foot. An example is when you pull the toes back towards you. Most cases of PF involve inflammation and/or tearing of the fascia. Stretching damaged or inflamed tissue is often counterproductive

2)      Pushing through the pain with exercise. If you have PF, you have to relatively rest, which may mean temporarily discontinuing running, walking, jumping, etc. or at least, reducing your distance or frequency of these activities.

3)      Skimping on shoes and/or orthotics. The old adage, “you get what you pay for…” applies here. Think of purchasing high-quality athletic and everyday shoes as well as orthotics (inserts) as an investment in your health and quality of life. At times, the more expensive orthotics are worth the extra cost.

In conclusion, heel pain affects a high percentage of middle-age individuals and can range from a nuisance problem to a disabling one. The key here is to seek care early and from someone who can customize a well-constructed treatment plan for you that has a variety of quality interventions. We are here to help!

Five Mistakes to Avoid with Plantar Fasciitis

Plantar Fasciitis is the most common cause of heel pain, most commonly seen in middle-age individuals. There are numerous treatment options, yet with our decades of experience in treating this problem, we’ve found many pitfalls, and thus, here’s a list of what NOT TO DO!

1)      Stretching the bottom of the foot. An example is when you pull the toes back towards you. Most cases of PF involve inflammation and/or tearing of the fascia. Stretching damaged or inflamed tissue is often counterproductive

2)      Pushing through the pain with exercise. If you have PF, you have to relatively rest, which may mean temporarily discontinuing running, walking, jumping, etc. or at least, reducing your distance or frequency of these activities.

3)      Skimping on shoes and/or orthotics. The old adage, “you get what you pay for…” applies here. Think of purchasing high-quality athletic and everyday shoes as well as orthotics (inserts) as an investment in your health and quality of life. At times, the more expensive orthotics are worth the extra cost.

4)      Having multiple cortisone/steroid injections. It’s probably best to avoid steroid injections altogether for PF, yet a one-time steroid injection can occasionally be indicated for the patient that is miserable due to severe heel pain. Repetitive steroid injections often result in long-term worsening of this condition.

5)       Not being patient. PF resolves in 95% of individuals with the proper customized treatment, yet it often is a 6 to 12-month process. Don’t give up on certain treatments too soon, as most interventions work gradually over weeks to months, including footwear changes, night splints, relative rest, physical therapy, orthotics and orthobiologic/regenerative injections.

If you are struggling with plantar fasciitis, then we are here to help!

Clarke Holmes, M.D.

I've Heard of Platelet-Rich Plasma (PRP) Injections. Am I a Candidate?

Platelet-Rich Plasma injections have taken the orthopedic world by storm. Why is this? They are safe. They are natural. They can be done in the office in a short period of time. They may prevent surgery in some cases. They can be disease-altering, not just symptom-reducing. Most importantly, in many cases of tendon, ligament and joint problems, they are EFFECTIVE.

PRP injections involve drawing blood from a patient’s vein, typically in the arm. Then, the blood is centrifuged (spun) to separate out the red and white blood cells, while simultaneously concentrating your own platelets. Our platelets are known to have numerous growth factors that serve many beneficial roles in our musculoskeletal tissues. Just minutes later, this concentrated solution is then injected under ultrasound-guidance back into an area of damage, such as a partially torn tendon, the plantar fascia or an arthritic joint. We believe that these platelets help to modulate unhealthy inflammation that resides in damaged tissues. This helps over the long-term to reduce pain and subsequently, improve function. In some cases, damaged soft tissue can heal in the presence of these concentrated platelets. In other cases, the deterioration often seen in cases of osteoarthritis can be slowed or halted. Thus, there are some preventative benefits of PRP.

In our practice, the percentage of PRP injections is increasing, while the percentage of cortisone/steroid injections is dropping. Why? We want our patients to have “game-changing” treatments whenever possible. We want conditions to improve over the long-term. We want to stop that deterioration process and to promote healing when possible. Also, we know that in the case of steroid/cortisone injections, some patients feel so good, so quickly, that they are prone to re-injure themselves. Steroid injections also can be catabolic, meaning they contribute to the deterioration of tissue. Thus, short-term improvement, but long-term worsening with some steroid/cortisone injections.

Thus, here are some patient scenarios that demonstrate when PRP would be an excellent choice:

-A 50-year-old woman plays in a weekly tennis league. Her arthritic knee is painful and swollen, and she needs some long-term relief to keep playing the sport she loves. It’s a big part of her social life as well. We choose two leukocyte-poor (low white blood cells) injections 3-6 weeks apart to provide that relief and protect her knee from the “wear and tear” that comes from a high-impact sports like tennis. She will likely feel better within a few weeks of the injection and also likely will see a reduction of symptoms for 6 to 18 months.

-A 35-year-old runner tore his ACL at age 20 and had successful surgery. Now, he has mild osteoarthritis of the knee that is stiff in the morning, aches after long runs and occasionally swells. He is a another great candidate for PRP. PRP should help his keep inflammation down, reduce these aches and preserve the cartilage in his knee for years to come.

-A 65-year old woman has had 6 months of lateral hip pain after a trip to the beach with frequent walking. She can’t sleep on the side of her painful hip and going up stairs is difficult. We diagnose her with trochanteric bursitis and gluteal tendonosis Two CORTISONE injections at another office each helped for a few weeks, but the benefit was only temporary. An MRI confirms gluteus medius tendonosis, yet there is no large partial tear. We offer her a leukocyte-rich (higher white blood cells) PRP injection with the hope to overcome this condition, or at the very least, allow her to resume a walking program, climb stairs pain-free and lie on that hip while sleeping.

-A 42-year runner just can’t overcome her heel pain due to chronic plantar fasciitis, despite physical therapy, custom orthotics and one steroid injection. One leukoctye-rich PRP injection hopefully will do the trick. She will be in a boot for about 3 weeks after the injection, we’ll ask her to rest from running for at least 6 weeks.

-A 24-year-old recreational basketball player has patellar tendonopathy and pain every time he jumps and lands. Symptoms have been present for 6 months and despite physical therapy, a brace and NSAIDS, he is only 50% better. We offer him 1-2 PRP injections. We need to promote healing of that tendon. We want long-term reduction in symptoms and tissue improvement, so that he can continue to play basketball and with reduced risk of tearing the tendon. Plus, we never inject cortisone in or around certain tendons, including the patellar and Achilles tendons, due to the risk of tendon rupture.

-A 70-year-old has mild to moderate hip and knee osteoarthritis. He can play golf a couple days a week, but relies on frequent doses of ibuprofen after his golf games and on days he plays with his grandchildren. His hoping to avoid joint replacement in his lifetime and knows that long-term use of NSAIDs is not good for his blood pressure, stomach or kidneys. We offer him PRP as a great option, with an injection into the knee and hip joints on the same day. He then will return a month later for his 2nd set of injections. After that, we hope and expect that he will have less pain and better function for 6 to 18 months, while also lowering his chances of joint replacement in the intermediate future. These PRP injections can be safely repeated months to years later, if necessary.

These are everyday examples of how we customize our treatments for patients based on their symptoms, diagnosis and goals. Age of the patient can play a role, but one is never “too old” to have a PRP injection. When head-to-head studies compare PRP to steroid injections, PRP is declared the “winner” the large majority of the time. Thus, we know that for long-term benefits of many joint and tendon problems, PRP is the better choice.

The world of orthobiologic injections such as PRP will only continue to expand as we strive to find more natural and less-invasive ways to treat a variety of orthopedic conditions. Dozens of medical studies each year continue to demonstrate that PRP injections are a safe, beneficial and cost-effective option for osteoarthritis, plantar fasciitis and many chronic tendon problems.

-Clarke Holmes, M.D.

My Heel is Killing Me! What is This and How Do I Get Rid of It?

In middle-age individuals, 90% of the time, heel pain is caused by plantar fasciitis. The plantar fascia is a soft-tissue band, technically a ligament, that supports the hindfoot and midfoot. It is quite prone to inflammation, degeneration and tearing. Let’s quickly dive into this common cause of heel pain.

How Does it Present?

·       Heel pain, often sharp, with the first few steps out of bed and after a long day on your feet

·       Pain when rising from a seated position after prolonged sitting, such as in a car

·       In endurance athletes, pain during and after exercise

·       Tenderness on the bottom of the foot, specifically at the heel where the plantar fascia originates

Why Did I Get This?

·       Age- middle-agers are prone to this, as they are very active, but their rate of tissue breakdown exceeds their body’s repair rate. This is why younger individuals do not typically get this problem. They have a faster healing rate.

·       Poor footwear- shoes that are flimsy, too old or generally unsupportive contribute

·       Weight- gaining weight or being overweight overloads the tissue at the lowest point of our body

·       Too much activity/overuse- runners, walkers, and athletes repetitively load the plantar fascia, and at times, are in a situation of overuse or too much, too soon

·       Poor biomechanics- tight or weak calf muscles, a high arch or flat foot or a foot that excessively pronates or supinates can all contribute

How Do I Treat It?

Patience is the key. This condition may require a month or a year of treatment. Recovery can be slow. The underlying risk factors listed above must be corrected. What works for one patient may not be the best treatment for another. Care must be individualized.

·       Rest- yes, this is a dirty, four-letter word for many patients. Plantar fasciitis will NOT improve as long as one continues to run, walk or exercise to the same degree. Sometimes, activity modification will work- fewer miles, less frequent high-impact exercise and/or trying something lower impact such as biking or swimming

·       Improve the footwear and minimize going barefoot- remember with shoes, you often get what you pay for. Don’t go cheap!

·       Physical Therapy- helps most patients, can be curative for those with mild cases. Will not get the job done by itself for moderate to severe cases

·       Orthotics/Inserts- over-the-counter or custom. OTC ones are less expensive and worth a try for mild cases. Custom are more expensive but more beneficial for most patients. Orthotics alone will not cure plantar fasciitis. Other treatments must be combined

·       Anti-inflammatory medications- helpful in mild cases caught early. Not helpful in more severe cases or in patients that have had the problem for months or longer

·       Cortisone injections- occasionally helpful, occasionally harmful. We rarely utilize these, as they don’t promote healing, only reduce inflammation and can increase the risk of further tearing of the fascia. NEVER get a series of 3 cortisone injections as recommended by some.

·       Orthobiologic injections- very helpful for most. These are meant to “heal the heel!” Platelet-rich plasma injections introduce numerous growth factors to the area to promote tissue regeneration. These are game-changing injections and ones we have provided under ultrasound-guidance successfully now for many years.

·       Surgery- we favor a minimally-invasive procedure called the Tenex procedure. Tiny incision, local anesthesia only, no stitches required with minimal healthy tissue disruption. The “old-school” surgeries require larger incisions and involve “releasing”/cutting the fascia off the bone, are less successful, higher risk and have been abandoned by most orthopedic surgeons

In conclusion, heel pain affects a high percentage of middle-age Americans and can range from a nuisance problem to a disabling one. The key here is to seek care early and from someone who can customize a well-constructed treatment plan for you that has a variety of quality interventions. We are here to help!