PRP: Natural, Preventative & Proven

More and more patients are telling us they want treatments that are natural, less invasive, and focused on healing — not just masking pain.

That’s exactly where platelet-rich plasma (PRP) comes in.

We’ve used PRP in our clinic for over 15 years, and it’s helped hundreds of patients avoid surgery, reduce pain, and heal from chronic conditions. This is not a trendy or unproven therapy — it’s a powerful, evidence-based treatment that works with your body to stimulate repair.

💥 For Knee Osteoarthritis

If your arthritis isn’t yet at the point of needing a knee replacement, PRP may be your most effective option to:

• Reduce pain

• Improve mobility

• Slow or stop cartilage breakdown

Steroid shots and gel (hyaluronic acid) injections may offer short to medium-term relief, but they don’t protect your cartilage the way PRP can.

🎯 For Chronic Tendon Injuries

PRP can help actually heal conditions like:

• Rotator cuff tendonitis

• Tennis or golfer’s elbow

• Achilles tendon pain

• Plantar fasciitis

  
  

While steroid injections might ease pain quickly, studies show PRP gives better long-term results — with more lasting pain relief and true tissue repair between 3 and 12 months.

🧘‍♂️ Whole-Body Support

Of course, we take a comprehensive approach to your care. PRP works best when combined with:

• Physical therapy

• Weight loss (if appropriate)

• Bracing

• Anti-inflammatory nutrition

• Targeted supplements and exercise

  
  

Ready to Take the Next Step?

If 2025 is the year you’re ready to invest in healing, not just managing, let’s talk. PRP might be exactly what your body needs.

F. Clarke Holmes, M.D.

“Orthopedic Maintenance” – Why Waiting Isn’t Always Wise

For years, patients have been told there’s nothing to do for arthritis until they’re ready for surgery. But that couldn’t be further from the truth.

Think about your car—do you only take it to the shop when it breaks down? Of course not! You get oil changes, tire rotations, and routine inspections to avoid major repairs. So why wouldn’t you do the same for your joints?

Welcome to orthopedic maintenance.

Just like your car, your knees (and other joints) need attention before things break down. That means treating pain and stiffness early—not just chalking it up to “getting older.”

Here’s how we help maintain your joints and avoid or delay surgery, especially for knee arthritis:

1. Steroid (Cortisone) Injections

Quick relief for pain and swelling—great for flare-ups or important life events. These can also be a smart option for patients who aren’t good candidates for surgery

2. Hyaluronic Acid (Viscosupplement) Injections

Think of these as your “oil change” injections. They cushion and lubricate the knee and can give relief for 4–12 months. Safe, effective, and often covered by insurance.

3. Orthobiologic Injections (like PRP)

These are your game changers. Platelet-Rich Plasma (PRP), made from your own blood, is backed by hundreds clinical studies. They help reduce inflammation, ease pain, improve function, and likely slow down cartilage damage. We’ve been doing these for almost 15 years with great results. These typically provide the longest lasting relief of 1-2 years in most patients. 

The Bottom Line:

Arthritis isn’t all-or-nothing. There’s a lot we can do before surgery. And like dentists and primary care doctors, orthopedic specialists are now focusing on preventive care—not just reacting when things get bad.

If you’re ready to be proactive about your joint health, we’re here to guide you every step of the way

F. Clarke Holmes, M.D.

PRP Is Evolving — And That’s Great News for You

One of the most exciting things about platelet-rich plasma (PRP) therapy is that it’s always improving. This isn’t a static treatment. It continues to evolve through better science, smarter techniques, and new technology.

I’ve been using PRP since 2011, and today’s approach looks very different from when I started. At a recent regenerative medicine conference, I had the chance to learn from national experts, exchange ideas with peers, and explore the latest advances in PRP and stem cell therapy.

What’s Changing with PRP?

We’re upgrading our PRP system to deliver a higher concentration of platelets to the areas where you hurt. That means more growth factors—natural healing signals that reduce inflammation, encourage repair, and help preserve tissue.

More Platelets = More Power to Heal

In addition to increased platelets, we’re now able to add important components like:

• Alpha-2 macroglobulin (A2M): A protein that helps protect cartilage and reduce inflammation.

• Extracellular vesicles (EVs): Tiny messengers that carry proteins and RNA to promote healing and calm inflammation.

These additions enhance the effectiveness of PRP—especially for joint pain, soft tissue injuries, and degenerative conditions.

Better PRP. Better Results.

If PRP has helped you before—or if you’ve been considering it—this is a great time to revisit it. With these upgrades, we’re seeing even greater potential to relieve pain, improve function, and support long-term healing.

And we’re not stopping here. Stay tuned as we begin to introduce autologous (your own adipose/fat tissue) stem cell therapies into our practice soon.

F. Clarke Holmes, M.D.

PRP Means Prevention

If there is a relatively low-risk and minimally invasive option for cancer prevention, would you choose to do it? If there is a similar option to reduce your risk of heart disease, would you do it? These would be potentially life-saving measures.

Now in the case of orthopedics, we are talking more about quality-of-life saving measures. Platelet-rich plasma (PRP) is one of those options.

We know that PRP is very beneficial in terms of reducing symptoms and improving function in most patients, yet did you know that it has also has a preventative benefit? Slowing the deterioration within your joint, particularly of the articular cartilage, is a benefit of the PRP.

How does being in less pain sound? What about being able to go up and down stairs much more easily? What about being out to enjoy longer walks and hiking? What about enjoying your grandkids with less pain during and afterwards?

What about more fulfilling trips to the gym? What about using fewer prescription medications to manage your symptoms? These are the goals of PRP, especially when we are treating osteoarthritis. When we are treating most tendon problems like of the rotator cuff, tennis/golfer’s elbow, lateral hip and the Achilles, the goal of PRP is not only to feel better, but actual healing.

This week, we repeated PRP on a patient with moderate knee osteoarthritis (OA) that last had PRP with us 5 years ago. Her benefit has lasted that long. This week we updated x-rays on a patient with knee OA and noted that in the last 2 years, his x-rays have not changed. This means no substantial loss of cartilage. In contrast, the average OA patient is losing 4%-6% of cartilage per year. What if we can change that to 0%-2%? Would you take it? If so, come see us, as we’re doing more PRP than ever, and the results remain very promising.

F. Clarke Holmes, M.D.

PRP Vs. Stem Cell Injections: How to Choose

We often get the question when patients come in looking for nonsurgical treatment of osteoarthritis or a chronic tendon problem: “How do I choose between a platelet-rich plasma (PRP) and stem cell injection?”

First, let’s define the differences: PRP comes from your own blood and involves a simple blood draw from an arm vein. Stem cell injections are prepared after bone marrow or adipose (fat) tissue is extracted from a patient. Obviously, the PRP preparation is simpler, less invasive and lower risk for the patient. Venipuncture takes about 2-3 minutes, whereas obtaining bone marrow involves inserting a larger needle-like device into the iliac crest (bone at top/back of the pelvis) and takes about 10-15 minutes or longer. Obtaining adipose tissue from the lower abdomen is a more complex and time-consuming procedure, often requiring about 30-45 minutes.

Both types of injections have the potential to reduce pain by reducing inflammation and promote healing. PRP uses a variety of growth factors, while stem cells utilize mesenchymal signaling cells and may have a greater potential to regenerate tissue. That being said, we are often using these injections for osteoarthritis, which is a cartilage deficiency problem. At this time, it is debatable whether any type of injection can regenerate cartilage.

What about success rates? Well, the jury is still out regarding which option is better. The good news is that in the large majority of studies, both PRP and stem cell treatments result in less pain and better function. Soft tissue problems like tendons and ligaments often demonstrate an improved or healed appearance on imaging studies. Some studies suggest that PRP and stem cell injections produce equal outcomes in the treatment of knee osteoarthriitis, while some suggest stem cells have better results. For now, we are putting our eggs in the PRP basket exclusively. Why is that?

-PRP is less-invasive, lower risk and faster to prepare

-PRP has a longer track record of use and success

-Although neither are covered by insurance, stem cell injections tend to be 3-10x more expensive than PRP injections. Example: $1000 for PRP on the average versus $5000 for a stem cell treatment.

We often state that PRP injections are like buying a Honda: safe, reliable, and gets the driver from Point A to Point B quite well. Stem cell injections are like a Maserati: fancy, expensive and unique but don’t necessarily get you from Point A to Point B any better or faster.

In summary, we anticipate that the application of stem cell treatments in the U.S. will continue to expand as studies demonstrate increased success and safety, while preparation will become easier, and the cost will decrease. Until then, PRP will be our successful “go-to” orthobiologic injection.

Want more info?

Patients With Knee Osteoarthritis Who Receive Platelet-Rich Plasma or Bone Marrow Aspirate Concentrate Injections Have Better Outcomes Than Patients Who Receive Hyaluronic Acid: Systematic Review and Meta-analysis - PubMed

Bone Marrow Aspirate Concentrate Is Equivalent to Platelet-Rich Plasma for the Treatment of Knee Osteoarthritis at 2 Years: A Prospective Randomized Trial - PubMed

Bone Marrow Aspirate Concentrate Is Equivalent to Platelet-Rich Plasma for the Treatment of Knee Osteoarthritis at 1 Year: A Prospective, Randomized Trial - PubMed

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

F. Clarke Holmes, M.D.

5 Things You Want 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 becoming less popular. 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. Now, we are adding protein concentrate to many PRP injections, utilizing your excess plasma that we previously would just discard. 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.

Harness the Power of Protein Concentrate Added to your PRP

We are always finding innovative ways to help our patients, especially those with osteoarthritis. Platelet-Rich Plasma injections have been very successful, yet now we have another option to boost the benefits of PRP. We call this “Protein Concentrate.” By filtering the additional plasma after your blood is centrifuged, we are able to trap a high concentration of proteins that can also significantly relieve the symptoms of OA and potentially slow the deterioration of the cartilage in the joint. Two of these proteins are Alpha-2-Macroglobulin (A2M) and Interleukin-1 Receptor Antagonist Protein (IL-1ra).

A2M is the key to slowing the progression of osteoarthritis. A2M is a powerful chemical in destroying proteins that cause arthritis that captures and inactivates the three major chemicals that lead to joint breakdown and cartilage damage. It is also reported that A2M can act as a powerful anti-inflammatory and aid in pain management.

Research on IL-1ra has shown that it also plays a role in slowing the progression of osteoarthritis in joints.  

Who should consider adding Protein Concentrate to their PRP injections? We believe that those with repetitive swelling in the joint are the most likely to benefit from the addition of the protein concentrate to the PRP.

Want to know more about PRP?

Learn about the key details of PRP here

How is PRP simple and not-so-simple? Read here

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

F. Clarke Holmes, M.D.

PRP For Knee Pain: Almost A No-Brainer

Knee pain is often caused by a meniscus tear, osteoarthritis, patellar tendinopathy, low-grade ACL or MCL sprain or some combination of these.

Don’t want surgery, don’t need surgery or already had surgery with a less than satisfactory outcome?

Platelet rich plasma (PRP) has been a star in the world of orthopedics, particularly as it pertains to knee conditions.

Once considered experimental, this innovative, minimally-invasive treatment using your own blood and concentrated growth factors is now is becoming a standard-of-care treatment for many knee conditions.

Over 45 studies have demonstrated clinically significant benefit in the treatment of knee osteoarthritis (OA). The overwhelming majority of studies demonstrate that PRP is more effective in the long-term when compared to steroid or hyaluronic acid injections for knee OA.

Want something safe, natural, effective, and a disease-modifying intervention that will relieve pain, improve function, provide stability and/or healing for tissues that can be done in the office? Then PRP can be a great option for you.

I've been giving ultrasound-guided PRP injections for 15 years. I’ve spent countless hours on the educational process, training and fine-tuning of techniques to make this a excellent option for our patients. I’ve been a patient myself, receiving PRP for shoulder and knee conditions and I've experienced the success firsthand.

Want to know more about PRP?

Learn about the key details of PRP here

How is PRP simple and not-so-simple? Read here

If you think you may be a candidate or want to discuss further, then

come see us. We are always happy to help!

F. Clarke Holmes, M.D.

PRP: The Details Matter. Give Us 3 Minutes

More practices than ever are offering platelet-rich plasma (PRP) injections to their patients, especially those with osteoarthritis, tennis and golfer’s elbow, partial rotator cuff tears, Achilles and patellar tendonopathy and plantar fasciitis, just to name a few.

We often say, “not all PRP is the same.” There are so many details that go into the success rate of the injections. On that subject, how do you define success? Less pain, better function, healing of damaged tissue and/or the slowing of the deterioration of cartilage, especially in osteoarthritis. PRP can truly be a disease-modifying treatment, not just something to make you temporarily feel better.

Now, what details really matter?

• Experience of the physician: how long has he/she been giving PRP injections

• Accuracy of the injection: ultrasound-guidance is paramount

• Amount of blood used to produce the PRP: we’ve learned that a higher volume of blood is likely necessary to produce the optimal number of platelets

• Creation of the PRP: constructing the optimal amount of PRP to inject for each condition. Creating a mixture either rich in leukocytes (white blood cells) or poor in leukocytes

• Providing the best recommendations regarding what medications and supplements should be temporarily stopped before and after the injections

• Providing the best recommendations regarding restrictions (use of a boot, crutches, bracing, type of rest) after the PRP

• Deciding upon the optimal number and frequency of injections to give

• Working with a physician who is frequently involved in medical education on the topic of orthobiologic injections, including PRP

• Working with a physician who is transparent and communicative regarding outcomes, expectations and cost

If truth be told, only a few physicians in Middle Tennessee implement all of these details when it comes to PRP injections.

So, if you think you are candidate for this very natural, quite effective, and minimally-invasive treatment, then come see us!

F. Clarke Holmes, M.D.

Do I Need a Knee Replacement?

Your 55 year-old knee is hurting and your brain immediately asks the question, “Do I need a knee replacement?”

An x-ray demonstrates moderate to severe osteoarthritis and thus, it’s time for a knee replacement, right? Not necessarily. It’s amazing how many patients have severe findings on their x-rays but minimal to mild pain and excellent function. Therefore, we always say, “Treat the patient, not the x-ray.”

Ok, now your pain has been running 5-7 out of 10 for weeks to months. Therefore, it’s time for a knee replacement, right? Well, pain is certainly a factor in this decision; however, we have many nonsurgical tools in the toolbox that will reduce or eliminate pain for extended periods of time.

Finally, you’ve been episodically limping now for several weeks. You suppose it’s time for a replacement, right? Persistent dysfunction is another reason to have a knee replacement, but function can often be significantly improved without the need for surgery.

To overcome the symptoms and dysfunction of knee arthritis, three factors can be addressed: the environment, the biomechanics and the structure. Only surgery can change the structure, yet significant improvements in the environment and biomechanics can often delay or eliminate the need for knee replacement.

How do we do this? The environment is best changed by injections such as platelet-rich plasma, an anti-inflammatory pattern of eating, supplements and occasionally medications.

The biomechanics can be improved through physical therapy, certain forms of exercise, bracing and changes in footwear.

So in summary, knee replacement can be the right option for many patients and produce successful outcomes in most patients, yet in 80-90% of the patients that walk (or limp) into our office, nonsurgical treatment will be quite effective.

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

F. Clarke Holmes, M.D.

When It Comes to Osteoarthritis, PRP is the Winner!

Although platelet-rich plasma (PRP) injections remain innovative and the science behind and techniques when using them are evolving, they are trending towards the injection of choice, especially in the case of osteoarthritis. Once considered “experimental,” there are now at least 45 studies validating the success of PRP in the treatment of knee osteoarthritis. So simply put, why would you choose PRP over a steroid injection or hyaluronic acid for knee osteoarthritis?

-Safer and more natural

-Longer-lasting relief of pain with often 6 months to 2 years of benefit for knee OA

-Most likely PRP is disease-modifying, meaning it is slowing the deterioration of cartilage in your knee

How about a study or two demonstrating these points made above:

PRP and Knee OA- Article 1

PRP and Knee OA- Article 2

Want to know more? Here are a couple of our previous blogs on the topic:

https://www.impactsportsnashville.com/blog/2024/2/16/7826kg4vvyebmp8bt2aph72i704hmc

https://www.impactsportsnashville.com/blog/2023/6/17/insurance-companies-say-prp-is-experimentalwe-sigh

As always, we are here to help! Let us know if we can be of assistance to you.

F. Clarke Holmes, M.D.

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.

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.

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.

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.

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.

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

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.