My Elbow Really Hurts, and I Feel Like a Wimp!

We hear this comment or one very similar to it on a frequent basis. Good ole’ tennis elbow, also know as lateral epicondylitis. Despite these names, this is not a problem limited to tennis players and does not typically involve the bone on the outside of the elbow named the lateral epicondyle. It is actually a tendon problem. The common extensor tendon on the outside of the elbow is highly involved in gripping, grabbing and lifting. When you shake someone’s hand, this tendon is under a lot of stress. When you lift the coffee mug with a handle, the positioning of your wrist transmits stress to this tendon. When you pull your sheets up to you when in bed, the position and action of the wrist and forearm send stress to this tendon. Finally, when this tendon is inflamed and/or partially torn, it HURTS! I mean, it really hurts. You are not a wimp for complaining about tennis elbow. Fortunately, this is one of my favorite conditions to treat. Why? For many reasons: we usually can cure this problem. Patients are so grateful to see this pain go away. Finally, it’s gratifying to see patients return to things they love to do after successful treatment such as tennis, golf, weight lifting, gardening and even typing!

Turning our attention to treatment options, there are traditional and innovative options. At Impact Sports Medicine and Orthopedics, we specialize in both types:

Traditional:

1) REST and changing the biomechanics- how and how much you lift, grip and grab

2) A wrist splint- yes, immobilizing the wrist and forearm unload the tendon far more than immobilizing the elbow

3) A cortisone injection- in our hands, 90% of patients experience relief with an ultrasound-guided injection. However, since tendon damage is often the cause of the stubborn pain, cortisone, at times, may only provide temporary benefit.

4) Physical Therapy- helpful in changing the biomechanical problems that led to the tendon damage. However, the benefit can be limited if tendon is partially torn.

Innovative:

1) The Tenex procedure- a true game-changing minimally-invasive procedure. This is our favorite option for those patients that have not improved with the traditional treatments. Local anesthesia only, a tiny incision, 2 minutes of tendon treatment with a small probe, no stitches, typically covered by insurance and a 90% success rate. How does that sound? We've loved this procedure for 7+ years.

2) Orthobiologic/”Regenerative” injections- platelet-rich plasma (PRP) and amniotic membrane are very solid choices, utilizing solutions rich in human growth factors to stimulate healing of the tendon.

3) Nitroglycerin patches- placed on the skin over the tendon, these are good choices for those patients needing something extra, but prefer a treatment that is non-invasive. These work by producing nitric oxide in the tissues, which then can be responsible for tendon healing.

In summary, we hate that you have "tennis elbow," but always appreciate the opportunity to treat you. It's our mission to make this common cause of elbow pain leave your life and never return! Let us know if we can help.

-F. Clarke Holmes, M.D.

Will Platelet-Rich Plasma (PRP) Injections Replace Cortisone?

The answer to this question is simple: Yes, No and Maybe. Platelet-Rich Plasma injections have taken the orthopedic world by storm. Why is this? They are safe. They are natural. They can be done in the office in a short period of time. They may prevent surgery in some cases. They can be disease-altering, not just symptom-reducing. Most importantly, in many cases of tendon, ligament and joint problems, they are EFFECTIVE.

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

Cortisone injections, known medically as steroids, have been around for decades. They simply are very strong anti-inflammatories. They can reduce pain and swelling within hours to days of an injection. However, they are known to have catabolic, or “breakdown” effects, meaning, numerous exposures to steroids can worsen the structure and strength of a soft tissue or joint. They also can produce short-term systemic side effects, including fluid retention, headache, insomnia, changes in emotions, skin flushing/redness and increases in blood sugar, particularly in diabetics. Cortisone injections are still used quite frequently to treat tendonitis, arthritis and disc problems in the spine.

Now, back to the question in the title. In our practice, we still use both types of injections. However, the percentage of PRP injections is increasing, while the percentage of cortisone is dropping. Why? We want our patients to have “game-changing” treatments whenever possible. We want conditions to improve over the long-term. We want to stop that deterioration process and to promote healing when possible. Also, we know that in the case of cortisone injections, some patients feel so good, so quickly, that they are prone to re-injure themselves. Thus, short-term improvement, but long-term worsening with some cortisone injections.

Thus, how do we choose what type of injection to recommend to a patient? Here are some examples:

-A 60-year-old woman will be traveling on a bucket-list trip to Italy in one week. Her arthritic knee is painful and swollen, and she needs some quick relief to really enjoy this trip. We choose a CORTISONE injection to provide that relief. She will likely feel better within a few days of the injection and will probably see a benefit for 1-3 months.

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

-A 65-year old woman has had 2 weeks of lateral hip pain after a trip to the beach with frequent walking. She can’t sleep on the side of her painful hip and going up stairs is difficult. We diagnose her with trochanteric bursitis and gluteal tendonitis. A CORTISONE injection here may do the trick. She has an acute inflammatory response and needs some relief to simply sleep better at night and handle her activities of daily living with less pain.

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

-A 70-year-old has mild to moderate hip and knee osteoarthritis. He can play golf a couple days a week, but relies on frequent doses of ibuprofen after his golf games and on days he plays with his grandchildren. His hoping to avoid joint replacement in his lifetime and knows that long-term use of NSAIDs is not good for his blood pressure, stomach or kidneys. We offer him PRP as a great option, with an injection into the knee and hip joints on the same day. He then will return a month later for his 2nd set of injections. After that, we hope and expect that he will have less pain and better function for 6 to 24 months, while also lowering his chances of joint replacement in the intermediate future. These PRP injections can be safely repeated months to years later, if necessary.

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

In conclusion, cortisone/steroid injections are not going away any time soon. They still play a role in helping patients in select situations. However, the world of orthobiologic injections such as PRP will only continue to expand as we strive to find more natural and less-invasive ways to treat a variety of orthopedic conditions.

Tennis Elbow: The Most Misnamed Orthopedic Condition

Fewer than 10% of patients that have tennis elbow actually play tennis. In addition, the medical term for this condition is "lateral epicondylitis." This also is misnamed. Why? The lateral epicondyle is the bony prominence on the outside of the elbow. This sometimes stubborn condition is not a bone problem, but a tendon problem, actually involving what we call the common extensor tendon. This also can be a very humbling condition. It can cause significant pain with some simple, everyday activities- lifting a coffee cup, shaking hands, pulling your bedsheets, just to name a few. Why you ask? Stress to this tendon is not only related to the weight of a lifted object, but also the arm and wrist position. Certain positions cause overloading of the damaged and/or inflamed tendon. Turning our attention to treatment options, there are traditional and innovative options. At Impact Sports Medicine, we actually specialize in both types:

Traditional:

1) REST and changing the biomechanics- how and how much you lift, grip and grab

2) A wrist splint- yes, immobilizing the wrist and forearm unload the tendon far more than immobilizing the elbow

3) A cortisone injection- in our hands, 90% of patients experience relief with an ultrasound-guided injection. However, since tendon damage is often the cause of the stubborn pain, cortisone, at times, may only provide temporary benefit.

4) Physical Therapy- helpful in changing the biomechanical problems that led to the tendon damage. However, the benefit can be limited if tendon is partially torn.

Innovative:

1) The Tenex procedure- a true game-changing minimally-invasive procedure. This is our favorite option for those patients that have not improved with the traditional treatments. Local anesthesia only, a tiny incision, 2 minutes of tendon treatment with a small probe, no stitches, covered by insurance and a 90% success rate. How does that sound? We've loved this procedure for 6+ years.

2) Regenerative injections- platelet-rich plasma (PRP) and amniotic membrane are very solid choices, utilizing solutions rich in human growth factors to stimulate healing of the tendon.

3) Nitroglycerin patches- placed on the skin over the tendon, these are good choices for those patients needing something extra, but prefer a treatment that is non-invasive. These work by producing nitric oxide in the tissues, which then can be responsible for tendon healing.

In summary, we hate that you have "tennis elbow," but love the opportunity to treat you. It's our mission to make this common cause of elbow pain leave your life and never return! Let us know if we can help.

Regenerative Injections- Let's Be Honest Here

Concerned. Disappointed. Those are the first words that come to mind when I read or hear about another non-physician 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 doesn’t 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 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. They 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 10 years and only after taking a minimum of 6 courses on the subject. We are carefully studying the science and trends pertaining to regenerative injections and have provided these to our patients over the past 8 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.

The Top 5 Reasons to Have a Regenerative Injection

Regenerative injections, also known as orthobiologic injections, include platelet-rich plasma (PRP), amniotic membrane and fluid, alpha-2 macroglobulin and mesenchymal stem cell (MSC)

1)      Cortisone has not gotten the job done- corticosteroid injections are potent anti-inflammatories and can be effective in treating inflammatory conditions, but these have either zero or even a detrimental effect on healing. Most chronic tendon problems are not inflammatory, and thus, cortisone will provide minimal long-term benefit. Not all cases of arthritis are inflammatory either.

2)      You are hoping to avoid surgery or you had surgery and are less than satisfied- we know that certain surgeries produce superior outcomes compared to nonsurgical treatment, particularly in younger and active individuals. Examples include ACL reconstruction after a full ACL tear and shoulder stabilizing procedures after multiple dislocations. However, there are numerous conditions that have equal or superior outcomes with nonsurgical treatment. These include small tears of the rotator cuff, hamstring, patellar and Achilles tendons; plantar fasciitis; degenerative meniscal tears; tennis and golfer’s elbow and mild to moderate osteoarthritis of the knee, hip, shoulder and basal thumb joint. These conditions are ideal candidates for regenerative injections, especially when traditional surgical and nonsurgical treatments are not producing major levels of benefit

3)      Cost- no, insurance does not cover regenerative injections. However, these injections are designed to provide long-term or permanent benefit. The expected goals are months to years of reduction in pain, improvement in function, soft tissue healing and slowing or suspending joint degeneration, i.e., preventing osteoarthritis from getting worse. Thus, these injections have a very good chance of saving you money. These benefits translate into fewer physician’s visits, fewer trips to physical therapy (although we still see the value of PT), fewer medications and potentially, the elimination of the need for an expensive surgery.

4)      You want a game-changing treatment, not one that just treats symptoms- regenerative injections are designed to change the environment of the area injected. Through the introduction of nutrients, growth factors and potentially stem cells, the goal of these injections is to not only make a patient feel and function better, but also to produce a healing response. This can mean tendon or ligament re-growth, cartilage regeneration and/or the reduction of unhealthy inflammation in the area of damage.

5)      The medical literature- although insurance companies would like to paint regenerative injections as “experimental” and thus not pay for them, the truth is that there are now hundreds of studies that demonstrate a clinically significant benefit in the treatment of chronic tendon problems and osteoarthritis with regenerative injections. In fact, hot off the press, a prominent sports medicine journal just posted a detailed review of orthobiologic injections. The authors came to this conclusion:  There was a total of 21 PRP (platelet-rich plasma) studies in the study. All PRP studies showed clinical improvement with PRP therapies in outcomes surveys measuring patient satisfaction, pain, and function…. The one PRP study that had a 2nd look arthroscopy reported increased cartilage regeneration with PRP. All 8 MSC (mesenchymal stem cell) studies with follow-up MRI and all 7 MSC studies with 2nd look arthroscopy showed improvement in cartilage regeneration in terms of coverage, fill of the defect, and/or firmness of the new cartilage.

Translation: patients are very satisfied with their outcomes after receiving these injections, and there is evidence that new cartilage is growing in response to these injections.

In conclusion, regenerative injections are rapidly entering and evolving within the world of orthopedic medicine. At this point, both their present and future look very bright. When considering a regenerative injection, seek the consultation of a medical doctor who has vast experience in researching and performing these procedures.

-Clarke Holmes, M.D. 

The Guide to Regenerative Injections

Dr. Holmes’ Guide to Regenerative Injections

Regenerative injections are those specifically utilized to promote healing of damaged tissue, reduce or eliminate unhealthy inflammation and slow or halt the progression of soft tissue and joint deterioration. We now use them regularly for tendon problems including tennis elbow, golfer's elbow, the rotator cuff, the high hamstring, patellar and Achilles tendons. We also have seen great success in treating osteoarthritis of the knees, shoulders, hips, thumb and great toe joints. Plantar fasciitis, ligament and muscle tears are great candidates for regenerative injections as well. 

·      Platelet-Rich Plasma Injections

o   Blood obtained from an arm vein is centrifuged for 15-20 minutes, isolating the platelet-rich plasma

o   Platelets are very rich in our natural growth factors (healing agents), and are concentrated 6-10 times their natural concentration

o   Under ultrasound-guidance, the PRP is injected into the damaged tendon, ligament, fascia, joint or muscle

o   Great option for tennis elbow, golfer’s elbow, small rotator cuff tears, small patellar tendon tears, high hamstring tendon tears, Achilles tendon tears, plantar fasciitis, etc.

o   Widely-used also for osteoarthritis of numerous joints

o   PROS: very natural and safe (your blood); used in orthopedics for ~10 years, Dr. Holmes has used for 7 years; numerous medical studies confirm significant benefit; 2-3 areas can be injected at one time; long-term benefit for most patients

o   CONS: these work gradually, over weeks to months; increased pain after the procedure for 2 days to 2 weeks; immobilization required with a splint or boot for some injections

o   UNKNOWNS: length of benefit (can be months to years); number and frequency of required injections. 1-2 injections initially for most soft tissue problems; 2-3 initially for arthritis/joint problems

·      Amniotic Membrane Allograft Injections (brand- AmnioFix)

o   Utilize one of the placental membranes (these cover the fetus during pregnancy) to form a product containing numerous types of growth factors

o   Intended to reduce inflammation, reduce scar tissue formation and enhance healing

o   The membrane undergoes a rigorous purification and sterilization process, and is stored as a dehydrated powder; sterile saline is added to become an injectable solution

o   Great option for plantar fasciitis (#1 use), tennis elbow, golfer’s elbow, small rotator cuff tears, small patellar tendon tears, high hamstring tendon tears and small Achilles tendon partial tears

o   PROS: very safe, with no significant reportable adverse effects; Dr. Holmes has used for 5 years; no rejection, despite not being one’s own tissue; no blood draw required; typically less post-procedure pain than PRP

o   CONS: probably not as effective for joint pain/arthritis; otherwise, same cons as PRP

·      Amniotic Fluid Injections (brand- Catalyst PDA-HAF)

o   Very similar to amniotic membrane injections, but often stored in a frozen form and thawed immediately before injection

o   Contain over 200 different growth factors

o   Great option for soft tissue as well as joint problems such as osteoarthritis

o   PROS: theoretically, a more powerful amniotic product than a dehydrated membrane

o   CONS: more expensive than the dehydrated membrane product

·      Alpha-2-Macroglobulin Injections

o   A natural substance found in our bloodstream

o   Blood drawn from the patient, centrifuged, manually separated and then placed in a separation pump to further isolate and concentrate the A2M

o   45-minute procedure done in one office visit

o   Functions as a “protease inhibitor,” binding the inflammatory proteins that cause the degradation of cartilage in the joint

o   Utilized to reduce pain, inflammation, halt the progression of osteoarthritis and provide “longevity” to the joint

o   PROS: very safe and natural substance; presumed long-term benefit, less post-procedure discomfort than other injections; two to three injection sites can often be chosen with one procedure

o   CONS: newest type of regenerative injection; very few medical studies proving effectiveness thus far, but studies are underway; frequency of injections not known at this point (likely every 6-24 months)

With any of these injections, all forms of ORAL and TOPICAL anti-inflammatories must be stopped for 1 week before and 2 weeks after, as to not interrupt the initial healing cascade initiated by the injections. This includes:

·      Advil/Motrin/ibuprofen

·      Aleve/naproxen

·      Aspirin- any doses above 81 mg

·      Mobic/meloxicam, Celebrex/celecoxib, Voltaren/diclofenac

·      Fish oils/Omega-3 fatty acids

·      Turmeric

·      Oral green tea

·      Glucosamine/chondroitin

·      Arnica

COST: Regenerative injections are rarely ever covered by insurance. Although we closely monitor their coverage status, in the current climate of healthcare and insurance companies reducing their coverage of even typical treatment measures, we do not expect these injections to be covered in the near future.

With rising deductibles, many patients pay out-of-pocket for traditional treatment measures as well. Thus, a regenerative injection may ultimately be a similar out-of-pocket cost to traditional treatments but more clinically effective and cost-effective over the long-term.

A patient should view these injections as an investment into the long-term health of their tendons, fascia, ligaments and joints.

We are here to serve you! 

F. Clarke Holmes, M.D.