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
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.
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.
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
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.
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.
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.
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.
5 Things You Have to Know If You Have Knee Pain
/1. Three factors play a role in knee pain: structural, biomechanical and environmental. Structural means damage, biomechanical means abnormal tracking or loading within a joint or tendon because of misalignment, weakness, and/or inflexibility. Environmental typically means inflammation within the joint or tendon. When formulating a treatment plan for you, we typically want to address one or two of these factors initially. Unless you have major damage, we’re normally not treating structure initially, as that results in a surgery.
2. Age often plays a role in these different factors: in the absence of injury, in patients under 20 years of age, the problem tends to be biomechanical. In patients ages 20 to 40, the problem tends to be biomechanical and inflammatory. In patients older than 40, structural, biomechanical and inflammatory are typically all playing a role.
3. Being proactive in the care of your knee problem usually produces better outcomes than being reactive. This means integrating treatments early on and not waiting until you have major pain or disability to see a physician. We term this “PIO,” Proactive Interventional Orthopedics.
4. Meniscus tears are commonly found on MRIs and may or may not be a source of pain. For decades, the trend was to treat these surgically, typically arthroscopically, removing the torn piece of meniscus. There’s now a trend towards repairing the meniscus tear when possible, but only about 10% can be successfully repaired. Thus, surgery for meniscus tears, especially those age 40 and above, is falling out of favor. On occasion, surgery is the better choice, but treating these initially nonsurgically is usually the best way to start. We often tell patients “a little torn meniscus is better than less meniscus,” especially long term. Less meniscus often equals greater arthritis.
5. Three types of injections can be used for most knee problems: steroid, hyaluronic acid, and orthobiologics. Orthobiologics include platelet-rich plasma (PRP) and stem cell injections. Each of these injections can be reasonably good choices, but for long-term success, PRP is likely your best option in terms of producing favorable outcomes, modifying the disease process, and these are often the most cost-effective option. Stay away from “stem cell” injections that are ordered by physician’s or chiropractic offices and do not come from you own bone marrow or fat. These are often being used inappropriately, and patients are charged exorbitant amounts of money to have these injections.
As always, let us know if we can be of assistance to you!
F. Clarke Holmes, M.D.
Our Top 5 Treatments for Knee OA
/Whether it be mild, moderate or severe knee osteoarthritis, here are our top 5 treatments. If you can incorporate these into your regimen, then you undoubtedly will see the benefits of less pain, better function and greater longevity for your knees.
1) Weight Loss: for every 1 pound a person is overweight, an extra 4 pounds of force are going through the knees. So, lose 10 pounds, and you have 40 pounds of less force on those knees. Lose 25 lbs, and 100 fewer lbs. of force! A recent study indicated that when those with knee OA lost 10% of their weight, their pain decreased by 50%
2) Healthy Eating with an Anti-Inflammatory Diet: healthy eating doesn’t always result in weight loss, but choosing the right foods often results in less inflammation in our body. This means less pain and a better environment for the joints. Choose fresh foods over processed ones. Reach for the fresh foods in the refrigerator more than packaged food in the pantry. Eat at home more and go out to restaurants infrequently. Fruits, vegetables, whole grains and lean meats should be the staples of your diet. Alcohol in moderation. Red meat, fried foods and processed food only on occasion and when necessary. Sodas rarely and watch out for artificial sweeteners.
3) Injections: these are often a faster path to relief for most patients. Platelet-rich plasma (PRP) injections utilizing your own blood and concentrated growth factors are the star of this category. Long-term benefits are most common with PRP. Hyaluronic acid injections (brand names: Orthovisc, Trivisc, Gelsyn, Euflexxa, etc.) are good options for many. At times, we combine the PRP and hyaluronic acid injections to boost the benefits. Steroid injections are the final option and can have great utility when a patient needs to feel better quickly such as during a flare or before a big trip.
4) Exercise/Physical Therapy: choose exercise you like, you will stick to, a variety and types that do not cause pain in your knee, both during and afterwards. Sometimes, it’s not just the type of exercise, but the intensity and duration. Find your “sweet spot,” meaning your knee might feel great if you walk a one mile but hurts if you go further. You can bike for 30 minutes, but beyond that causes swelling. So, stay below your pain threshold. Lower-impact options like biking, elliptical, rowing and swimming/aquatic exercises are often the best choices for most with knee OA. Physical therapy is often a good starting point to strengthen the muscles around the joints and to improve biomechanics, functional movement patterns and flexibility.
5) Supplements: our favorites are collagen, curcumin (the active ingredient of turmeric) and for more advanced knee OA, glucosamine and chondroitin. Others like fish oil may have benefits for the joints as well. The key here is choosing a high-quality brand and taking these on daily basis. Admittedly, they don’t help everyone, and you need to make sure that your physician knows you are taking these, especially if you are taking other medications and/or will soon have a medical procedure.
As always, let us know if we can be of assistance to you!
F. Clarke Holmes, M.D.
Knee Replacement Soon? Hit the Pause Button...
/So many patients with knee osteoarthritis ask me the question “well, if I’m eventually going to require knee replacement, shouldn’t I go ahead and have it done now?”
Well, there’s not just one answer to that question, but here are some of my replies:
-Most knee replacements only last 15 to 25 years. After that, the implants start to loosen, creating pain, swelling or a sense of instability.
-Most patients are at higher risk for surgical complications at the time of a second surgery, known as a “revision,” simply due to their age and likelihood of having more significant medical conditions.
-Surgical techniques are improving with breakthroughs every two or three years. Robotically-assisted replacements and having replacements as an outpatient surgery are two recent examples. More advancements are sure to come.
-One should never base the need to have knee replacement on the appearance of the x-rays. Some patients with “bone-on-bone” arthritis have minimal pain and excellent function. These patients don’t need a replacement.
-What often produces the most pain is an unhealthy environment within the knee joint, some of which may be controlled with injections like platelet-rich plasma (PRP).
-We also believe that PRP may put a stop sign or at least a yellow light on cartilage deterioration. We do not make guarantees about cartilage regrowth, but if we can stabilize a patient’s current cartilage and slow or stop the deterioration, then we are slowing the process of osteoarthritis and perhaps delaying the need for knee replacement.
-For a joint condition like arthritis, we often think of PRP as a maintenance treatment, not just a one-time application. Much like the maintenance for your car, you don’t just take it to the mechanic once or twice and then get a new car. This is an ongoing process.
-Assuming a patient is in that 80% success group with PRP treatments, one should plan on likely having repeat PRP injections every 1 to 2 years. This is a great long-term investment in the health of your knee.
-Want to know more about PRP? Check out this blog:
Five Simple Reasons You Should Consider Platelet-Rich Plasma — Impact Sports Medicine & Orthopedics (impactsportsnashville.com)
In summary, for some individuals, knee replacement is inevitable, but there can be great value in delaying this surgery to increase the odds that it is required just once in a patient’s lifetime. For others, treatments like PRP can eliminate the need to have a replacement.
As always, let us know if we can be of assistance to you!
F. Clarke Holmes, M.D.
Insurance Companies Say PRP Is Experimental…We Sigh
/Platelet-rich plasma (PRP) injections first presented in the orthopedic medical literature in 2004, nearly 20 years ago. Now, new PRP studies hit the orthopedic journals monthly. The overwhelming majority of the evidence suggests that PRP injections are safe, beneficial and have positive effects on soft tissue and joints. Somehow though, insurance companies continue to classify these as “experimental” and will not pay for PRP injections. Thus, these remain cash-pay procedures. PRP injections are not alone, as some of the best procedures now in medicine are not covered by insurance.
PRP is not just used in orthopedics, but also in dentistry, ENT, neurosurgery, ophthalmology, urology, wound healing, cosmetic, hair restoration, cardiothoracic, and maxillofacial surgery. Could all of these specialties be wrong about PRP? I really doubt it.
So, we ask the question: what does it take for something to no longer be classified as experimental? In my opinion, as a physician of 25 years, treatments should no longer be considered experimental if they meet the following basic criteria:
1) They have been used consistently in medicine for 10 years or longer by a reasonably high percentage of specialists in a particular field.
2) Quality studies published in the reputable medical journals demonstrate a clinically significant benefit.
3) Use of a particular treatment steadily grows because of positive results with a low likelihood of adverse events.
If you evaluate PRP with this criteria, then it’s a no-brainer…it is no longer an experimental treatment.
Insurance companies do serve a valuable role in our medical system. Without them, health care would be unaffordable for many Americans. However, the criteria they sometimes use to classify whether a particular treatment or test is covered or not is often very flawed and/or “behind the times.” Here’s a classic example: we could choose to give 10 steroid/cortisone injections into a patient’s knee in just one year, and almost all insurance companies would pay us for each injection. This could be very damaging to the joint, but it would be a “covered” procedure. In contrast, PRP injections, which have been shown to be superior to steroid injections for knee osteoarthritis in dozens of studies, would not be covered by insurance.
So, as a patient, you have to be discerning and partner with a physician who understands what treatment options are best for you. Basing these decisions on what insurance covers can be a short-sighted approach.
In conclusion, both physicians and insurance companies play vital roles in the care of the patient, but these roles are different. I say, “let doctors doctor and administrators administer.” For now, don’t count on a PRP injection to covered by insurance companies any time soon, but that should not deter you from choosing these valuable treatments. Want even more info? Check out one of our recent blogs on the topic:
As always, let us know if we can be of assistance to you.
F. Clarke Holmes, M.D.
Bet You Didn't Know: Tennis Elbow
/Tennis Elbow, one of the most common conditions seen by an orthopedist, is one our favorite diagnoses to make. Why?…because we are almost always able to see complete resolution of the symptoms. Plus, we have numerous traditional and innovative tools in the toolbox to help our patients overcome this often stubborn and humbling condition. Here are some fast facts about tennis elbow you probably did not know:
-90% of those with tennis elbow, also known as lateral epicondylitis, do not play tennis. Weight-lifting, frequent typing, CrossFit, repetitive labor in one’s work or with household chores are frequent causes.
-Teenagers almost never get tennis elbow. Why? They have an amazing ability for their tendons to recover much faster and more efficiently than middle age and older individuals.
-Lateral epicondylitis is the medical term for tennis elbow and may be one of the more misnamed conditions in orthopedics. This implies there is inflammation of the bone on the outside of the elbow, but instead, this is a tendon problem.
Patients who receive cortisone/steroid injections are often better in the short term but worse in the long term. Our own experience and the medical literature validates this.
Neovascularization, essentially new blood for vessel formation, commonly occurs in advanced cases of tennis elbow. Increased blood flow seems like it would be a good thing for the tendon, but in reality, is a sign of more advanced tendon damage.
We believe that adjacent to those new blood vessels in the tendon are new nerves that are very hypersensitive and only make you feel pain. This is why many patients with advanced cases of tennis elbow complain of “burning” over the lateral elbow.
Platelet-rich plasma injections, now a commonly used and innovative treatment option for many orthopedic conditions, were first studied in the medical literature about 15 years ago in treating tennis elbow. PRP remains one of our advanced treatment options for tennis elbow.
One of our best treatment options for very stubborn cases of tennis elbow is the Tenex procedure. Not many people know about Tenex because we are one of the few physicians in middle Tennessee who have expertise in performing this procedure. We’ve done it for 11 years, and it involves a tiny incision, local anesthesia only, and use of a small needle-like device to excise the unhealthy part of the tendon. No stitches are required and only about two minutes of actual treatment time in the operating room. It carries a 95% success rate in our experience.
If you have pain on the outside of your elbow that is interfering with your quality of life, then come see us. We will have some great options for you!
F. Clarke Holmes, M.D.
Five Keys to Successful Outcomes with PRP Injections
/Quality Equipment- we’ve chosen a PRP system created by one of the industry’s leaders in orthobiologic injections.. This is our 5th PRP system to use over the past 12 years. Thus, we are always searching for the best option to produce a high-quality PRP solution.
Appropriate Selection of Patients- we attempt to choose patients and conditions that are excellent candidates for PRP injections. Admittedly, not every patient is an ideal candidate, yet their options may be limited in terms of other forms of treatment, or they are willing to have PRP due to its excellent risk-benefit and cost-benefit ratio compared to more invasive treatments. Partial tendon tears, plantar fasciitis and osteoarthritis of the knee, hip and shoulder comprise 95% of our PRP injections.
Appropriate Pre-Procedure and Post-Procedure Instructions and Compliance-little things can be the difference between PRP succeeding or not succeeding or between a good outcome and a great outcome. For example, it’s important for a patient to be off any anti-inflammatories at least a week before and 2 weeks after a PRP injection. It’s also important to rest the treatment area, and this form of rest really varies depending on the patient and their area treated. A patient’s timetable for return to exercise and/or rehabilitation must be carefully outlined.
Quality Preparation of the PRP solution- not all PRP is the same. The platelet concentration and number of platelets can vary and are important aspects of the potential success of PRP. How much blood we take from the patient and the PRP system dictate these numbers. Also, we typically create a leukocyte-poor (low numbers of white blood cells) for joint injections and leukocyte-rich (higher white blood cells and the highest number of platelets) solution for tendon injections.
Accuracy of the Injection, Preferably with Ultrasound Guidance- using ultrasound for the injection often results in less pain, lower risk, and greater accuracy. We place the PRP exactly where it needs to be and avoid hitting other structures like bone, cartilage, nerves and blood vessels. We often say, “if you’re going to invest your time and money in this procedure, don’t you want it done as precisely as possible?”
More medical professionals are performing platelet-rich plasma injections than ever. This innovative treatment is not going away and will only evolve in the years to come. If you think you are a first-time or repeat candidate for a PRP injections, then come see us!
F. Clarke Holmes, M.D.
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.
Introducing the Concept of PIO
/As sports medicine providers, we are all about “getting ahead in the game.” Therefore, we have coined the term and are developing the concept of PIO (“pie-o”). PIO stands for proactive interventional orthopedics. You’ve possibly heard of interventional cardiologists or interventional radiologists. These are the physicians that are specialists in their field, but use less-invasive means to treat your condition. For example, the interventional cardiologist will perform angioplasty or a stent procedure, whereas the cardiovascular surgeon would be the physician to do the more-invasive coronary artery bypass surgery, when necessary.
In our field, PIO involves using less-invasive interventions such as injections, weight loss, physical therapy/exercise programs, and various supplements to “get ahead” of your musculoskeletal conditions that either currently are or will soon bring you pain, disability, and dysfunction. The field of orthopedics has typically been “reactive,” meaning you only go to the doctor when you have a significant problem. Unfortunately, when you are only reactive instead of proactive, treatment interventions become more invasive, higher risk, and sometimes less successful.
Here’s how we can use PIO to help you if have arthritis, tennis/golfer’s elbow, rotator cuff or Achilles problems, plantar fasciitis or other chronic conditions: we will customize a plan to reduce pain, improve function and quality of life in a cost-effective manner.
Here are links to two of our other blogs that explain the process and benefits of platelet-rich plasma (PRP) injections, often part of PIO treatment program.
Why Insurance Does Not Pay For Platelet-Rich Plasma Injections, But Why That Should Not Deter You — Impact Sports Medicine & Orthopedics (impactsportsnashville.com)
Five Simple Reasons You Should Consider Platelet-Rich Plasma — Impact Sports Medicine & Orthopedics (impactsportsnashville.com)
If you would like to discuss the concept of Proactive Interventional Orthopedics and how this may be a benefit to you in 2023, then please give us a call. We would love to customize a treatment protocol for you.
Why Insurance Does Not Pay For Platelet-Rich Plasma Injections, But Why That Should Not Deter You
/Platelet-rich plasma injections, commonly known as PRP, have been utilized in orthopedics for at least the past 15 years. The first studies in orthopedics looked at PRP being utilized for tennis elbow, and the results were promising.
Fast forward 15 years and now platelet rich plasma has become a mainstay in the treatment of many orthopedic conditions, ranging from osteoarthritis to tendon and ligament problems. An estimated 60% of orthopedic practices now offer PRP to their patients and while some physicians can claim true expertise in this type of treatment, other practices remain novices when it comes to the application of PRP.
Now, to answer the question in the title of this blog, “why do insurance companies not cover PRP….” We will provide an educated opinion with several bullet points.
-Many insurance companies claim that PRP injections are “experimental.” Experimental is a very broad term that can be applied in numerous ways. What classifies something as experimental? In my opinion, this is something that has been utilized for a very short period of time and has very few studies or anecdotal pieces of evidence to demonstrate a sustained rate of efficacy. Meaning, this treatment hasn’t been used for very long, has not been used on very many patients, and we really don’t know what the short-term or long-term results are.
When it comes to PRP, I would say we are light years beyond the experimental stage. For many years, PRP has been used not only in orthopedics, but also in plastic surgery, wound care, dermatology/aesthetics and hair-loss situations, to just name a few. PRP has demonstrated a long track record of safety, and the overwhelming majority of studies demonstrate that patients benefit from these procedures. So, in my mind as a physician of nearly 25 years who has studied medical data for his entire career, I would no longer classify PRP broadly as experimental. Are more studies regarding PRP necessary? Of course. Yet this is true for every treatment in medicine. Trust me when I tell you that there are numerous treatments in all fields of medicine being utilized right now that have been studied far less than PRP.
-Next, the truth is that insurance providers these days are looking to pay for fewer and fewer of your medical expenses. We have to get away from the mentality that “I have health insurance, and it should cover all of my medical needs.” In truth, we are probably getting back to a model where insurance should be used for major health expenses and catastrophic situations, not for most of your routine day-to-day medical care. Almost all of private insurance companies are for-profit organizations. There’s nothing wrong with that. However, you must realize that their first goal is making a profit to sustain their business. Their first priority is not providing the optimal care for the patient, as often is the case, the optimal care is not the least expensive. So, we are constantly preaching to our patients these days that the best treatments in orthopedics are not necessarily the ones you can expect your insurance to cover.
-Finally, to partially take the side of the insurance company, an argument against covering PRP would be that it cannot be “standardized.” We can standardize a medication or certain forms of medical equipment, but we cannot standardize a patient’s blood. Therefore, one person’s PRP may not look like another patient’s PRP, meaning the number of platelets, white cells, etc. may be fairly variable between patients. Also, there are probably 20 to 30 commercially available PRP systems on the market now. None of these produce PRP in exactly the same way, once again, making the argument that PRP injections cannot be completely standardized. For this reason, insurance companies often take a pass on something they don’t view as uniformly the same treatment for every patient.
Now, let’s turn attention to why it really may not matter whether insurance companies cover PRP or not and why you should not be deterred from seeking this treatment.
-First, let’s look at the financial piece. So many of our private insurances require that we first meet our deductible before insurance will pay a significant portion of our medical bill. These deductibles are rising. Until you meet your deductible, you are going to pay out-of-pocket for any office visit, diagnostic test, medical procedure, or medication. Therefore, let’s say you were choosing between a steroid injection versus a platelet-rich plasma injection. Technically, the steroid injection is “covered by your insurance,” but until you meet that deductible, you are going to pay for an office visit and the cost of that steroid injection. So, “covered by insurance” doesn’t mean it’s an expense-free treatment.
-Next, that steroid injection may not be the best treatment for your particular condition. Let’s say you have a partial rotator cuff tear. You either don’t want or don’t need surgery for it. The steroid injection may temporarily alleviate symptoms, but certainly will not heal the partially torn tendon, and in fact, some patients worsen within weeks to months after a steroid injection. Thus, assuming you then are still seeking care for your shoulder pain and torn tendon, you will require additional tests and treatments. This may mean an MRI, a long course of physical therapy, additional medication, or even surgery. Those options, especially when combined, can be very expensive. Although platelet-rich plasma injections are not covered by insurance, they could be the long-term solution to your problem, saving you hundreds to thousands of dollars on other necessary potential treatments. Therefore, why not choose the treatment that will be most successful, not just the one that your insurance states that it covers?
-Finally, gone are the days that you can depend on insurance companies decide what is best for you and your health. I tell patients all the time that I literally could give them 10 steroid injections over the course of the year and cause bodily harm to them and their particular joint or tissue. Insurance companies would reimburse me to do this, often without question. Nevertheless, that is just not the right thing to do. I took an oath as a physician to “first do no harm” which I have continued to practice to the best of my ability. In addition, not only do I want to not do harm, but I also truly desire to help my patient. Therefore, I will help you choose what I believe to be the best and most customized treatment option for your particular situation. This is not always in line with what insurance companies would prefer that I do. I have no desire to be a “rogue” physician, but I’ve dedicated my career to developing an expertise to help my patients. Part of our ability to help our patients lies in the fact that we get to know them personally and their particular situations, goals, desires, comorbidities, and even their financial situations. Therefore, we work as a team with our patients to decide what we believe is best for them. Although it’s very natural to want to pay as little as possible but still get the best outcome, you just can no longer rely on insurance companies to have the authority over these decisions for you.
I realize what is said above gives you a lot to consider. I have a passion for educating our patients on the best treatments for their particular situation, and I am dedicating to doing that for the remainder of my career.
As always, please let us know if we can be of assistance to you!
F. Clarke Holmes, M.D.
Impact Sports Medicine and Orthopedics
BEING PROACTIVE, NOT REACTIVE, WHEN IT COMES TO PLATELET RICH PLASMA (PRP) INJECTIONS
/I am a 28 year-old nurse practitioner and former competitive athlete, and I am strongly considering getting platelet-rich plasma (PRP) injections for my knees. Why? For one, as a provider, I have witnessed many improved patient outcomes. Two, this procedure is safe, has relatively no side effects, and is minimally-invasive. Lastly, we are seeing that by being proactive with PRP versus reactive when symptoms are present shows even further benefit.
After many years of intense volleyball training, games, and working out without any downtime throughout the year, I developed bilateral knee pain. Although I have no x-ray evidence of osteoarthritis at this time, based on my symptoms, there is no doubt I have cartilage damage. Because of this, I feel that PRP injections, in addition to other conservative treatments I’ve used, will boost the longevity of my knees.
PRP helps soft tissue, joint, and cartilage pathology. It is a great way to use your own body’s healing system to improve musculoskeletal problems, and there is minimal risk because it uses your own blood.
What’s our process?
Obtain blood from a vein.
Spin it in a centrifugation system in our office. This separates the components of the blood and concentrates the platelets.
We take the plasma that has platelets that are rich in growth factors to create the PRP injectable solution.
The PRP is then injected under ultrasound guidance in the targeted area.
When injecting the PRP solution to the targeted area, it creates an espresso shot-like effect for your body’s growth factors and repair cells to travel to this area. The main goal is to help repair the damaged area, decrease pain, and improve function. Keep in mind that this is a slow and methodical approach that can take up to 6 months to see maximum benefits. Sometimes more than one PRP injection is needed. How long does PRP last? It varies based on the severity of the patient’s condition, a patient’s activity level, and incorporation of other conservative treatments. Cost can vary per practice. We typical charge $800-$950 (*subject to change) depending on how many locations we are injecting and which centrifugation system we use. Keep in mind that PRP injections are NOT stem cell injections.
My goal with this blog is to change the thought process that PRP injections should only be used reactively to treat orthopedic conditions and their accompanying symptoms to one instead that utilizes PRP in a proactive approach to slowly repair and stabilize conditions.
So, why haven’t I had PRP injections in my knees already? Honestly, the only thing holding me back is my nervousness when it comes to needles.
Interested to see if PRP injections would be helpful for you? We would love to have a consult with you to discuss these in detail!
Taylor Moore, FNP
Impact Sports Medicine and Orthopedics
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
It’s Time To Start Treating Your Arthritic Knee Like Your Car
/“Orthopedic Maintenance”…that’s a term you may start to hear, especially in our practice. For years, patients have been led to believe that in the case of their arthritis, there’s “nothing you can do about it” until you want or choose to have a replacement. Also, our medical system has been developed to be reactive instead of proactive, especially again in the setting of arthritis. So, let me ask you this, do you only take your car to the mechanic when you have a problem? If the answer is yes, then you are on the fast track to either a needing a new car or paying your mechanic a pretty penny for all the repairs your car will need! If you are a wise car owner, then you take your car in at regular intervals for the oil change, fluid additions, tire rotation, alignment, brake maintenance and various inspections. So I then ask, should you be doing the same for your arthritic knee? The answer is a resounding “Yes!”
So, what does orthopedic maintenance look like? In very general terms, it means that if your body has aches, pains or dysfunction, then it’s wise to jump on these earlier than later, avoiding the temptation to ignore symptoms, and think, “I’m just getting old.” This translates to seeing your orthopedic/sports medicine physician to confirm a diagnosis and discuss treatment and prevention strategies. Let’s focus on one of the most effective forms of non-operative treatment for knee osteoarthritis: injections
1) Steroid (cortisone) injections are great for acute pain, when it’s important to reduce symptoms and swelling quickly. Steroids are really a more “reactive” treatment, such as when a patient needs to feel better quickly for a major life event (a trip, visit with the grandkids, have to feel better for work, etc.) but can be proactive for a patient trying to stave off a knee replacement or is not a good candidate for knee replacement. For example, the elderly patient whose risk of knee replacement outweighs the benefit, planning two steroid injections a year for his/her symptomatic knee arthritis may allow the patient to feel less pain, move better, be at lower risk for a fall and have a greater quality of life.
2) Hyaluronic Acid/Viscosupplement injections (brand names include Orthovisc, Gelsyn, Euflexxa, etc.) have a long track record of excellent safety and provide symptomatic relief in approximately 75% of patients for 4-12 months. They probably work as anti-inflammatories and lubricants for the knee, replenishing the hyaluronic acid in the arthritic knee that is depleted or less effective. These are probably more beneficial for those with mild to moderate arthritis as opposed to more severe cases. There are essentially no side effects except for mild injection-site soreness in some. Most insurance companies will authorize this 3-4 injection series every 6 months, so planning on about two series a year is a very proactive strategy. These are what we often term as the “oil change” injections.
3) Orthobiologic injections are really your “game-changer” injections. These have been used in orthopedics for 15 years and in our practice for over 10 years. Platelet-Rich Plasma (PRP) is the most commonly used orthobiologic injection. Insurance companies and even some medical providers still like to consider these as “experimental” or unproven treatments for osteoarthritis, yet there are now 39 randomized, controlled trials (studies) that demonstrate that PRP is effective in the treatment of knee osteoarthritis. PRP is derived from your own blood, as we obtain blood from an arm vein, spin this in a centrifuge, remove the majority of red and white blood cells, and concentrate the platelets which are rich in your own growth factors. These growth factors module inflammation, reduce pain, improve function, and most likely have a beneficial effect on the cartilage within the joint. This is how they are “game-changers.” They very likely stop or slow the progression of arthritis by stabilizing the cartilage and potentially improving the quality of the cartilage.
We typically start with two PRP injections 2-6 weeks apart and expect, on the average, 6-12 months of symptomatic benefit. Repeating these at regular intervals is likely the best plan of action in order to see continued, long-term benefits. PRP injections are here to stay, and how we continue to apply them in the treatment of osteoarthritis will continue to evolve.
Primary care providers and dentists have done a great job integrating maintenance evaluations and treatments into a patient’s health regimen. Now, we should likely be doing the same in orthopedics, and the treatment of knee osteoarthritis is a great place to start, as this is the most common medical condition seen in our office today. It is a tremendous source of pain and disability for millions of Americans and contributes to the spending of billions of health care dollars. It’s time for orthopedic physicians and patients to join together to be proactive over reactive and realize that less-invasive preventative strategies are preferred over more-invasive and costly interventions.
As always, we here to help and strive to be your resource for these innovative maintenance strategies!
F. Clarke Holmes, M.D.
Impact Sports Medicine and Orthopedics
The Dirty Little Secrets Some Chiropractors Aren’t Telling You About Stem Cell Injections
/“Judy,” our middle-aged patient, presents to our practice with chronic knee pain due to arthritis. She is seeking another opinion. She relates that three months ago she went to a “Dr. X’s” chiropractic office seeking the miracle cure of her chronically painful knee. She had seen a Facebook post from the chiropractor’s office advertising “stem cell” injections for patients with painful orthopedic conditions. The ad looked great. The testimonials on the website captured her even more. After two previous knee arthroscopies (“scope surgeries”), this was now her chance to get that knee better without a knee replacement. Per the advertisement, “regrow cartilage and become pain-free, all with just a simple injection.” She placed the phone call and within a week, she was in “Dr. X’s” office writing that rather large check to receive her miracle shot of stem cells. Fast forward 3 months and now “Judy” has paid $5000 out-of-pocket for her pseudo stem cell injection and another $1000 for a knee brace. It’s obscene. Has she seen improvement? A “little bit” she tells us, but not enough to justify that $6000 check.
Concerned. Disappointed. Angry. Those are the first words that come to mind when I read or hear about another non-medical doctor advertising “regenerative” injections, such as stem cell or platelet-rich plasma. I’ll be honest here…the greatest number of advertisements come from the practices of chiropractors. Here’s the irony: chiropractors cannot legally give orthopedic-based injections. So, what’s the catch? Most hire mid-level providers, physician assistants (PAs) or nurse practitioners (NPs), to give these injections. Mid-levels serve very valuable roles in our healthcare system. Some are skilled enough to provide injections in a very competent fashion. However, our medical system has been designed such that mid-levels are mentored and directly supervised by medical doctors who have expertise in providing procedures such as injections. In the case of a chiropractor’s office, how can the supervising chiropractor mentor or teach the mid-level to do an injection when he or she has never given a joint, tendon or other similar injection in his or her entire career? It just does not make sense, plain and simple. Then, you are talking about very advanced injections, most of which are not covered by insurance and cost the patient hundreds to thousands of dollars. Finally, many of these injections done by mid-levels are not guided in any fashion, meaning neither ultrasound nor fluoroscopy (live x-ray) is used. Thus, the accuracy of the injection is likely less than optimal.
Here's another valuable piece of information: these injections claiming to be “stem cell” injections very likely have minimal to zero live stem cells. Most independent studies have verified this. Most of these injections primarily consist of amniotic fluid, the fluid surrounding a fetus when a woman is pregnant. Now, amniotic fluid does have value, as it is rich in growth factors. These growth factors can serve to reduce inflammation, and thus, lead to a reduction in pain and improvement in function. Can they help cartilage to regrow? The truth is that we don’t know. Right now, it’s unlikely that any injection can reliably regrow cartilage, so the honest clinician tells the patient that although cartilage regrowth is theoretically possible and may occur in some cases, we certainly cannot guarantee this will happen. So, when a medical practice is using an injection such as this that does not come from the patient’s own fat/adipose or bone marrow, then it is not a true stem cell injection. Thus, the claim that “stem cell” injections are being given is misleading at best, fraudulent at worst.
Quickly, we will also cover the cost of these injections. Admittedly, some of these best procedures in orthopedics are not covered by insurance. Thus, medical practices can set their own prices for these orthobiologic injections. What’s reasonable to charge? On top of the cost of injection and materials to provide the injection, add in the typical cost of an office visit, the cost of the injection procedure, ultrasound guidance (if used) and for the time/research it has taken to develop an expertise in this skill. What’s that worth? $300-$500 is our typical “mark-up” a for platelet-rich plasma or an amniotic fluid injection. We believe this is very reasonable and equal to or less than most of our peers who are experts in providing orthobiologic injections. When a patient pays $3000-$5000 out-of-pocket for an injection (other than a true stem cell injection), then you can bet that the mark-up is in the thousands, not hundreds. Once again, it is so disheartening that some medical practices decide to take advantage of patients desperately seeking relief from their painful orthopedic condition.
Here’s the bottom line: even with all the radio, magazine, TV and social media advertising done by some practices claiming to be experts in “regenerative injections,” you need to carefully choose who you want to provide these advanced office procedures. I have a very healthy respect for several of my colleagues who are chiropractors. I freely refer to them. Many do an excellent job with care of the spine and rehabilitation of some extremity issues as well. However, orthopedic injections are just not in their wheelhouse.
At Impact Sports Medicine and Orthopedics, we have used ultrasound guidance for 11 years and only after taking a minimum of 6 courses on the subject. We are carefully studying the science and trends pertaining to orthobiologic/regenerative injections and have provided these to our patients over the past 9 years. We are not the only ones in the Nashville area doing these advanced injections, but you will be hard-pressed to find any practice more experienced or dedicated to the honesty and integrity of the process.
-F. Clarke Holmes, M.D.