What is a Sports Medicine Provider, and Can I See One?

You may be asking yourself what is a Sports Medicine provider? To be honest with you, I only found out the difference between sports medicine and general orthopedics in my last semester of Nurse Practitioner school. Because of this, I want to provide more insight into the differences so that you can be educated and empowered in choosing an orthopedic specialist that best fits your needs.

Sports Medicine is a specialty underneath the orthopedics umbrella. Just like you can see specialists who see only hips, shoulders and knees, foot and ankle, or the spine, you can see a sports medicine specialist. Dr. Clarke Holmes and I are Orthopedic Sports Medicine Providers. What might differentiate a sports medicine provider from a general or specialty orthopedist? Here are few key points:

1.      One stop shop: Sports Medicine Providers see orthopedic conditions from the top of your head (concussions) to the tip of your toes, and everything in between

2.      Conservative treatment options versus jumping right into surgery: Dr. Holmes and I will always be transparent with our patients if surgery is the best option, but why not try utilizing all the nonsurgical options first if surgery is not necessary?

3.      We are experts in minimally-invasive procedures that can either prevent surgery or be an alternative to surgery: For example, Platelet Rich Plasma (PRP) injections are very successfully used for partial tendon tears and osteoarthritis of numerous joints. See our PRP blogs or check out our social media posts to learn more about PRP.

4.      Improved accuracy of our injections by utilizing musculoskeletal (MSK) ultrasound guidance. Ultrasound is becoming a mainstay in the sports medicine world, and we’ve used MSK ultrasound for over a decade. We also use this daily to diagnose tendon tears, bursitis, joint swelling and ganglion cysts.

5.      Holistic treatment: We care about the patient as a whole person and do not see them as just a body part, a diagnosis or a potential surgery.  We develop a plan of action with the  patient that considers what activities they like to do, their occupation, weight, nutrition, mental health and any other contributors to formulate an individualized treatment plan.

6.      YOU DO NOT HAVE TO BE AN ATHLETE TO SEE A SPORTS MEDICINE PROVIDER. Yes, we experts in treating athletes ranging from the youth to the professional ranks, but we also treat those who do not consider themselves an athlete. In addition, we see patients of all ages and all activity levels. One of my favorite things to treat is arthritis, even in those who do not exercise and just want their pain to decrease and daily function/activities to improve.

Hopefully this has provided clarification on the differences between a sports medicine orthopedic specialist and a other types of orthopedists. As always, let us know if we can be a resource to you!

Taylor Moore, NP

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.

Three Common Financial Misconceptions in the Medical World

Understanding the complexity of various medical expenses can be overwhelming for a patient. We medical professionals are patients too! Even for us, sometimes the numbers just don’t make sense. At Impact Sports Medicine and Orthopedics, our desire is to educate patients regarding the value of these office visits and procedures and their potential out-of-pocket costs, so that they can make informed decisions regarding their health care from both a medical and economic perspective.

Here are three common misconceptions when it comes to medical expenses:

1. If my physician is not in-network with my insurance company, my medical expenses will be higher: until patients meet their deductibles, they typically will pay out-of-pocket for office visits, diagnostic tests and procedures. The amount a patient pays can also depend on a patient’s out-of-network provisions in their plan and/or the amount an out-of-network provider chooses to bill the patient. Often an out-of-network provider will ask the patient to pay cash, and this amount can be and often is less than the contracted amount an in-network provider has with your insurance. Example: you have Insurance X, a plan that has accepted very few in-network physicians. You have not met your deductible and you see an in-network orthopedic specialist for a consult. You have an office visit and x-rays. Insurance X allows $150 for the office visit and $50 for the x-rays. You now owe that in-network physician $200. Alternatively, you see a provider at our practice as we are in-network with most insurance plans, but not with Insurance X. We charge you $120 for the office visit and $30 for x-rays. Thus, your bill with us is $150, a $50 savings compared to the in-network provider.

2. If a procedure is not covered by insurance, it will cost me more in the long run: as an example, let’s use a procedure such as a platelet-rich plasma (PRP) injection. PRP has been used in orthopedics for 15 years. It has never been covered by insurance (although it should be in certain circumstances…that’s a whole different conversation). You have stubborn plantar fasciitis. You’ve done all the typical treatments, but your heel still really hurts. You consult with a foot surgeon who offers an open or endoscopic plantar fascia release surgery. Guess what, your insurance covers this procedure! However, you have a $5000 deductible, and you are nowhere near meeting this. This surgery will have charges from the surgery center, the anesthesiologist and the foot surgeon. Let’s say that your total cost for this surgery is $3000 with a 75% success rate, a 4-month recovery and some risk of additional complications. Compare this to one or two PRP injections, with each injection costing you $800. PRP, in our opinion, will have similar success rates and recovery times with fewer complications. $1600 for PRP versus $3000 for the surgery, even though the surgery is “covered by insurance.”

3. When it comes to an office visit or the same procedure done at different practices, insurance companies pay or allow the same amount for each physician/practice: did you know that all practices, hospitals and other medical businesses have contracted rates of payments with private insurers (non-Medicare, non-Medicaid)? If a physician is part of a bigger organization such as a hospital or a large private practice, then that group typically has greater negotiating power and can obtain higher reimbursement rates from the insurance companies. These rates have nothing to do with the quality of medical care, the training or experience level of the providers or the success rates of their interventions. So, let’s say you see a physician associated with a hospital system. You haven’t met the deductible, and you are billed for a Level 4 new patient visit. Your insurance allows $200 for that visit to that provider. Alternately, your household family member sees a physician at a smaller practice like ours, also is billed for a Level 4 new patient visit, yet the same insurance only allows for $150 for that visit, even though the same level of care was provided. So, you owe $50 more to that hospital-based practice than your family member owes to the smaller private practice. Thus, it’s important to realize that often cost really does vary based on who you are seeing, and your cost is not associated with the quality of the care.

   At Impact Sports Medicine, cost education and financial transparency are very important to the physician-patient relationship. We strive to provide the highest quality of care for a reasonable out-of-pocket cost to you.

   F. Clarke Holmes, M.D.

TENex Gets a 10!

Are you looking for permanent relief from tennis or golfer’s elbow? Are you tired of having elbow and forearm pain with lifting, gripping and grabbing, even with items like your phone or coffee mug? Are your workouts in the gym or tennis or golf severely hampered by these symptoms? Well, then look no further than the Tenex procedure. This is an innovative minimally invasive procedure developed 13 years ago in conjunction with the renowned Mayo Clinic. Dr. Holmes has performed more Tenex procedures than any other physician in middle Tennessee over the past 10 years.

The Tenex procedure, also termed a percutaneous tenotomy, is a great option for tennis or golfer’s elbow (also known as lateral or medial epicondylitis, respectively) that has not healed with rest and other possible treatments such as medications, physical therapy, injections, or bracing.

We go to the operating room, give the patient an injection of lidocaine only, a numbing agent. We get to avoid the sedation, cost and side effects of general anesthesia (getting put to sleep).

A tiny incision of about 1/4 inch is made. A small hand piece with a needle tip is inserted through the incision. Under ultrasound-guidance, this tip is inserted to the damaged part of the tendon and ultrasonic energy allows the tip to debride and remove the unhealthy portion of the tendon while leaving the healthy portion alone. Two minutes of treatment time or less and you are on the road to recovery.

No stitches required, just a few small steri-strips, followed by a small dressing and you are out the door, headed towards tendon healing, and eventually becoming pain-free.

Post-operatively, you wear a wrist splint for at least 2 weeks, and we restrict lifting for about 6 weeks. Our golfers, tennis players and weightlifters can usually gradually resume these activities at the 3-month mark. There is no “quick fix” for these conditions, yet Tenex offers a permanent solution to an often-stubborn problem.

We’ve done in the range of 500 of these procedures over the past 11 years with excellent results.

This procedure really beats the option of steroid injections, which often make the condition worse in the long term. The alternative to Tenex is a larger surgery requiring a 2-inch incision and a much longer recovery.

In our book, the Tenex procedure gets a rating of 10!

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.

Frozen Shoulder... More Than Just a Winter Occurrence

We’ve talked a lot about PIO (Proactive Interventional Orthopedics) recently and this concept really applies when it comes to a frozen shoulder, also known as adhesive capsulitis. This is a condition most commonly seen in middle-aged women around the time of menopause with the average age of a frozen shoulder being 51.

It starts as shoulder pain, often unrelated to a particular injury or overuse situation, and is followed by a very stiff shoulder with loss of motion. Although a frozen shoulder can be a self-limiting condition, with our interventions, we can greatly expedite the recovery process while alleviating pain.

Other risk factors for adhesive capsulitis include thyroid disease, diabetes and recent shoulder surgery. In the early “pain” stage, it’s often difficult to determine whether a patient has a frozen shoulder, osteoarthritis, or rotator cuff and/or biceps tendon problem. An MRI can be helpful, especially to see tendon or joint pathology, but in the presence of isolated adhesive capsulitis, the MRI can be normal or near normal. The next stage is the “stiff” or “frozen” stage, highlighted by the loss of motion both actively (what the patient can do) and passively (how someone else can move the shoulder). The final stage is the “thawing” or “recovery” stage. Each stage typically last 2-6 months, and early treatment often shortens these stages.

Being proactive and interventional often means an ultrasound-guided steroid injection into the joint. Without ultrasound guidance, it is often very difficult to achieve accuracy. This tends to be a very inflammatory condition, and thus, the potent anti-inflammatory effects of the steroid can provide rapid relief of pain. Early treatment within the first few weeks or months of the onset of the shoulder pain is the optimal path to a faster and more complete recovery. After that steroid injection, a rehab program, often made much more effective by the steroid injection, is the mainstay of treatment. 20% of patients with a frozen shoulder develop the same condition on the opposite shoulder within 5 years, so if pain in the other shoulder develops, it’s wise to seek treatment early.

Check out this brief article:

Steroid injection may be the best medicine for frozen shoulder - Harvard Health

If you think you may have a frozen shoulder, let us use PIO to help you!

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?

1. Obtain blood from a vein.

2. Spin it in a centrifugation system in our office. This separates the components of the blood and concentrates the platelets.

3. We take the plasma that has platelets that are rich in growth factors to create the PRP injectable solution.

4. 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

You Want To Run in the Turkey Trot, and You Haven’t Even Been Exercising: 5 Tips

Turkey Trot races can be a ton of fun, a great way to celebrate the holiday with the masses and can jump start the winter “get back into shape” mindset. Fortunately, many of these races attract a wide variety of competitors, many of which are not even currently exercising. So, these tips are directed towards those individuals.

1) Update your footwear: If your shoes are greater than a year in age or show wear on the tread, then it’s time to get new shoes ASAP. Choose a high-quality shoe store where an actual shoe-fitting can be done. Just remember, if you’re not paying at least $75, you’re probably getting a lower quality shoe.

2) Start with run-walk intervals, especially if you’ve not run in a good while: Start with intervals of three minutes of walking and then one minute of running. Consider training every other day for the first 2 weeks, then you can start to train daily. Each week, you can phase out some of the walking and add more running. Your ratio can go from 2:1, then 1:1 and eventually, to a majority of running. However, if you don’t consider yourself a big runner, there’s nothing wrong with doing intervals during the race or simply just walking the race.

3) Set realistic goals: It’s less than four weeks to Thanksgiving, and you’re not even exercising. Thus, your goal is to simply to get to the finish line. Don’t put an emphasis on your time either. Enjoy the process of training, getting back into shape and accomplishing a goal on or around Thanksgiving day.

4) Get the race-day wardrobe ready: Pay attention to the weather report a few days before the race. Don’t forget about something to keep your head warm as well as high-quality socks and gloves, especially if the temperature is going to be in the 40s or lower.

5) If you want to do this race with company, then find some friends and family who have a similar pace to you: Don’t plan on competing in a race with a peer who is much faster or slower than you. This can certainly steal your joy and/or put you at risk for injury.

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

Clarke Holmes, M.D.

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

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

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

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

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

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

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

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

F. Clarke Holmes, M.D.

Impact Sports Medicine and Orthopedics

Why Does an Orthopedic Practice Care About a Patient's Weight?

Let’s talk weight. It’s not a fun topic to talk about, but necessary in the medical field. A poll taken earlier this year showed that 48% of Americans admit they have gained weight since the beginning of the Covid outbreak.

Why is this important to orthopedic providers? Weight is a contributor to orthopedic pain. Let me give you an example: there are two patients of the same age and gender with equal severity of knee arthritis. One maintains a healthy weight level, and the other has had a 10 lb. weight gain. For every one pound you’re overweight, there’s an estimated extra four pounds of force on the joints. Therefore, even though they have the same degree of arthritis, it is likely that the overweight patient is struggling more with flares of pain and dysfunction due to that extra 40 lbs. of force going through the knees. 

Not only does maintaining a healthy weight help orthopedic pain, it helps fight against high blood pressure, high cholesterol, diabetes, cardiovascular disease, sleep apnea and other sleep disturbances, gallbladder and liver disease, and mental disorders. Overall, a healthy weight has significant health benefits. 

All that being said, losing weight and maintaining a healthy weight isn’t easy, especially when life gets busy. We fall into routines, and it just never seems like there’s enough time in the day. Many people get caught up in the numbers on the scale. If monitoring this is motivational for you, keep stepping on the scale. If weighing yourself is discouraging, use other tools such as how are your clothes fitting, whether you feel better, and are you holding yourself accountable to feeding your body the fuel foods it needs while moving your body more. 

Weight management is 80% eating habits and 20% exercise, and impacting each of these is one huge factor: your overall mental approach to both. Let’s break down each. 

Eating Habits 

Wouldn’t it be nice if we could lose weight while frequently eating foods like sweets and pasta. That would be AMAZING. Unfortunately, that’s not reality. But it doesn’t mean you can’t eat the deemed “unhealthy foods,” or that healthy foods can’t taste good. Another factor to consider is that eating healthier tends to be more expensive.

-limit unhealthy foods and then control the portion sizes when you do splurge. Another good tip is if you know you’re going out for that pizza for dinner, eat healthier for breakfast and lunch. 

-use a free calorie tracking app such as MyFitness Pal. The amount of calories needed depends on age, size, height, gender, and activity level. A calorie deficit is needed to lose weight, but that doesn’t mean you have to always be hungry. It’s all about the foods you choose! Eat foods that keep you full and choose healthy snacks in between. 

-intermittent fasting doesn’t work for everyone. If you’re interested, try fasting from 8 p.m. until 12 p.m. the next day. Black coffee and water are still acceptable to drink during this time. 

-drink plenty of water. The amount will be different from everyone. Drinking an excess amount of water can drop your body’s sodium levels, so don’t go overboard. 

-be mentally prepared on how to approach that dreaded spiral when opportunities to consume unhealthy food present themselves and then have the mental fortitude to decline the temptations.

-don’t go to the grocery store when you’re hungry. This increases the likelihood of buying unhealthy foods. We all know if it’s in the house, it will get eaten. 

-limit eating out or if you do eat out, make healthier choices. 

-incorporate color into every meal, as more color often means more fruits and vegetables. 

-eat when you are hungry, not necessarily simply because it’s meal time, and stop when you are full. 

-if you want to follow or need the accountability through a weight management program, consider Weight Watchers or Noom.

-if you overeat at a meal, move on and don’t shame yourself.

-fueling your body with healthy food choices can also help combat full body inflammation. Here is a link to one of our favorite resources on anti-inflammatory foods that we like to share with our patients. 

https://www.drweil.com/diet-nutrition/anti-inflammatory-diet-pyramid/dr-weils-anti-inflammatory-food-pyramid/

*Eating habits are not a “one plan fits all”*

Exercise

Our biggest tip is to just keep moving! Find an activity that gets you moving and that you enjoy physically and mentally. At least 3-4 times a week. Choose an activity that gets your heart rate up and cross train with strengthening. You don’t have to spend hours in the gym. 

-set a timer every hour at work to get up and walk around. Take a walk during your lunch break. 

-get a sit-to-stand desk and alternate every 30 minutes to 1 hour. “Sitting is the new smoking.”

-find a routine and stick to it. Choose a few different activities you can alternate. 

Finally, here are the main keys to successful weight management: consistency, maintaining a positive mindset, positive reflection, smart food choices while also allowing yourself to eat what you want in moderation, and get moving. It’s definitely not easy, but the overall improvement in your physical or mental health will be well worth it. 

If you have found success in losing or maintaining a healthy weight, let us know what helped you!

Taylor Moore, FNP-C

Impact Sports Medicine and Orthopedics

The Top 5 Reasons Why An Injection May NOT Work For You

1) The injection missed the spot: We take a lot of pride in using ultrasound guidance for all of our injections. This tremendously improves accuracy, making an injection much more likely to be effective. However, this is a skill set we have honed for 10 years and is still not considered the standard of care in orthopedics. Therefore, many injections by very good clinicians are still given without ultrasound, and unfortunately, the target is often missed. Even missing by a few millimeters can decrease the effectiveness. Medical studies have demonstrated that some of the most commonly given injections in orthopedics without guidance are inaccurate anywhere from 10% to 70% of the time.

2) Steroids don’t help everything: Steroids are great anti-inflammatories but do not reverse damage. They may help in some cases of arthritis, and if so, often are temporary, providing weeks to months of benefit. In addition, in many cases of tendon problems such as tendonosis (degeneration or tendon tearing), inflammation is not the primary source of pain and thus, the steroid injections are unlikely to help for any significant period of time.

3) The pathology is too great to see benefit from an injection: For example, in some cases of severe arthritis, no injection is going to help to a significant degree. A prime example would be severe hip osteoarthritis where total hip arthroplasty (hip replacement) is usually far more effective than any type of injection. There are some ligament and tendon tears that are full thickness, and no injection will get the job done. Thus once again, surgical treatment would be the top recommendation, with an ACL tear being a prime example.

4) After the injection, you do not treat the injected area the correct way: We are very specific in our “dos” and “don’ts” after an injection. For example, after the majority of our steroid/cortisone injections, we recommend a minimum of 5 to 7 days of rest of the affected area. So, if you have a knee joint injection you are not going for a power walk, playing golf, or doing heavy yardwork for 5 to 7 days after the injection. Those who return to rigorous activity too soon often do not see the expected benefit after certain injections. After more complex injections like platelet-rich plasma (PRP), we generally have very specific restrictions and recommendations in our aftercare protocol. For example, after a lateral elbow PRP injection, we typically hold patients out of golf or tennis for 2 to 3 months to allow for healing of the tendon.

5) Lack of experience by the clinician providing the injection: There are many small nuances when it comes to giving a successful injection, including needle length, the right dosing of the injected solution, whether guidance is used effectively or not, how quickly the material is injected, the correct volume of the injected solution and patient positioning during the injection. Those clinicians who have fine-tuned their skill set over years to decades have developed an ability to make the right choices when it comes to these decisions, thus putting the injection in a position to be successful.

Injections are some of the most effective tools in the treatment of musculoskeletal conditions. They can be used to reduce pain, improve function, improve quality of life, serve as diagnostic tools, and in some cases, can promote healing of damaged tissue and/or decrease the deterioration of certain types of tissue such as cartilage within the joint. Therefore, choose your clinician wisely when it comes to injections and utilize someone who has an expertise in this field of medicine.

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

What Supplements Might Be Useful In Orthopedics?

Many people prefer to try a natural approach when it comes to preventing conditions or treating symptoms by taking various vitamins and supplements. There are many options for supplements and vitamins out there, but are they really effective? Unfortunately, there is little education or research on these products.

Remember, the FDA does not regulate supplements and vitamins. Talk to your healthcare provider before beginning any supplements or vitamins. If you are pregnant or breastfeeding, discuss supplements and vitamins with your provider.

Here are a few common vitamins and supplements we discuss with our patients in orthopedics.

Turmeric

Known for its anti-inflammatory properties, turmeric is a great tool to help combat full body inflammation. We recommend a turmeric supplement that contains extract instead of ground root powder, 95% curcuminoids, curcumin, and bioperine (black pepper) to help with absorption. Daily dose recommendation is 500mg-2,000mg. Turmeric can slow blood clotting and should be avoided in those who take blood thinners, have bleeding disorders, anemia, gallbladder conditions, or pregnant. Caution should be used in those who take diabetes medication, as turmeric may make the effects of these medications stronger and therefore may result in hypoglycemia. Note: cooking occasionally with turmeric does not provide the amount needed to reach anti-inflammatory effects.

Glucosamine

Glucosamine is thought to increase cartilage and fluid around joints and/or help prevent cartilage breakdown, therefore, decreasing pain and improving function. Research studies’ results have shown conflicting information. Taking this does not reduce your risk of getting osteoarthritis. The recommended dose is 1,500mg daily. Do not take this supplement if you take warfarin (coumadin) as it increases the effects of warfarin, elevating your risk of serious bruising or bleeding. Do not take this supplement if you have personal or family history of glaucoma, are on cancer treatments, or have allergies to shellfish. Take caution if you have diabetes, as glucosamine has been shown to increase blood sugar levels and decrease the effectiveness of diabetic medications. Also, take caution if you are pregnant and/or breastfeeding, have asthma, glaucoma, hyperlipidemia (high cholesterol/triglycerides), and hypertension.

Chondroitin

Usually taken in combination with glucosamine, chondroitin sulfate is one of the building blocks of cartilage. Used to help decrease osteoarthritis pain and improve function. Recommended daily dose is 800-1,200mg. Do not take if you have prostate cancer or are pregnant/breastfeeding. Take caution in those with asthma. There is an increased risk of bleeding if taken with warfarin.

Hyaluronic Acid (HA)

HA’s action in orthopedics is to lubricate the joints and maintain normal joint cushioning to provide more support, resulting in decreased pain and increased functioning. In osteoarthritis and as we age, this substance becomes naturally depleted due to wear and tear. It comes in many different forms, but injections are the most widely used and most effective in sports medicine and orthopedics. We like to tell our patients to think of HA injections like an oil change for your knee; the oil is the HA substance and, your joints are the car. HA oral supplements have not shown to be effective for musculoskeletal use.

Vitamin D

Most people do not receive enough daily vitamin D from food and sun alone. Vitamin D has many benefits. From an orthopedic standpoint, vitamin D modulates inflammation, prevents involuntary muscle spasms, and cramps, and enhances calcium absorption into the bone which helps with bone growth and bone remodeling. Vitamin D plays a key role in helping prevent osteopenia and osteoporosis (thin and brittle bones). The recommended dose is 600-800 international units (IUs) daily, yet supplementing with 1000-2000 IUs of D3 is safe for most patients. Some patients are found to have vitamin D deficiencies with a blood test and will require higher dosing often for at least a month. Foods high in vitamin D include salmon, sardines, tuna, egg yolks, mushrooms, cow’s milk, soy milk, yogurt, orange juice, cheese, fortified cereal, and oatmeal.

Calcium

Calcium helps build and protect bones. A low calcium intake can result in fractures, osteopenia, and osteoporosis. Most people get enough calcium in their normal diet. The daily recommended amount of calcium needed is dependent on age.

1-3 years old: 700mg

4-8 years old: 1,000mg

9-18 years old: 1,300mg

19-50 years: 1,000mg,

51 years to 70 years: males 1,000mg and females 1,200mg

71 years and older: 1,200mg.

Who needs a calcium supplement? Those who are vegans, lactose intolerance, consume large amounts of protein or sodium, on long term steroid treatment, those who have inflammatory bowel disease and celiac disease, and those who do get enough calcium in the foods they eat. Overall, it is better to get the calcium your body needs through food instead of a supplement. There are some studies that have linked calcium supplements to heart disease, colon polyps, kidney stones, and heart attacks. Foods high in calcium: almonds, oranges, dried figs, soybeans, garbanzo beans, white beans, pinto beans, milk, yogurt, dark leafy green vegetables.

Ashwagandha

Ashwagandha helps in reducing anxiety and stress. On the label you want to look for root extract, as this is more potent that ground root powder. KSM-66 ashwagandha root extract has been studied in many clinical trials with positive outcomes. Daily dose recommended is between 500-1,500mg.

Potential side effects include gastrointestinal upset or headache. It can potentially lower blood pressure, lower blood sugar, and affect thyroid hormones, and in rare cases, have a negative effect on the liver. Women who are pregnant or breastfeeding should not take this.

Taylor Moore, FNP-C

Impact Sports Medicine and Orthopedics

What Shoes Should I Buy?

Buying shoes is almost as complicated as finding the perfect home. There is an abundance of athletic and casual shoe options, but not many helpful suggestions about the best brands. When you do find a brand you like, many buyers get frustrated at which style to choose because there is never a clear-cut answer on what the difference is between all of the different types. Not only do shoes allow you to do activities you enjoy, but they can even decrease joint pain and orthopedic conditions. However, the opposite is also true. An improperly fit shoe that does not provide support, changes your biomechanics, or is too hyperflexible contributes to increased incidence of foot, ankle, knee, hip, and even spine symptoms. Unfortunately, there is not one shoe that is perfect for everyone, as everyone’s foot and gait style is unique.

So here are a few tips to decrease the frustration when it comes to shoe-shopping.

1.      Try all footwear on in-person.

2.      Place two fingers on the sole of the toe. If you can fold it onto itself or side to side easily, the shoe is probably too hyperflexible and will likely not provide enough support and shock absorption. We call this the “Holmes Rule.”

3.      Check the tread wear on your shoes. If the tread is worn, it is time to go shopping for new shoes. Evaluate where the tread is most worn. If on the outside of the forefoot (near the toes), then you are likely supinating. If towards the inside (closer to the big toe area), then you are likely pronating.

4.      Try to go to a shoe store that can identify the best shoe match for you based on your foot shape, the way you walk or run, and your activity. We recommend Fleet Feet, Team Nashville, or Nashville Running Company if you live in the Nashville area.

5.      Remember, a manufactured shoe may not fit your needs perfectly. Over-the-counter or custom orthotics/inserts can help your foot to achieve normal realignment and promote proper foot mechanics. Having an appropriate orthotic/insert that is interchangeable amongst all your shoes can decrease foot, knee, hip, and even back pain! We have specific orthotic specialists that work with our practice.

6.      A good quality shoe will begin at $75. Be careful buying shoes that are highly- discounted.

Recommended shoe brands:

BRANDS

Asics

Brooks

Hoka

On Cloud

Saucony

New Balance

Karhu

Altra

Mizuno

WIDE TOE BOX

Hoka

Mizuno

Altra

Brooks

Asics

New Balance

CASUAL SHOE

Clarks

Merrell

Johnston & Murphy (XC4 Technology)

Vionic

WALKING/RUNNING

Brooks

Hoka

Asics

New Balance

Mizuno

On Cloud

Karhu

Alta

AGILITY ACTIVITIES

Brooks

Asics

New Balance

Nike

HIKING **

Merrell

Keen

Hoka

Saucony

Altra

Salomon

(**specific hiking versions of these brands)

This is not a complete list of recommended shoes for each category, but a compilation of recommendations based on research and patient feedback.

SHOES FOR SPECIFIC SPORTS: follow sport-specific recommendations for shoe wear

Taylor Moore, FNP-C

Impact Sports Medicine and Orthopedics

What is a Nurse Practitioner?

I have had the pleasure to meet and take care of many of our awesome patients since I joined Impact Sports Medicine in August 2020. However, questions still occasionally arise about what my role is at Impact.

What is a Nurse Practitioner?

You may hear the following interchangeable terms: Nurse Practitioner, NP, Mid-level, Advanced Practice Registered Nurse (APRN). Nurse Practitioners are trained to assess patient needs, order and interpret imaging and laboratory tests, diagnose conditions, formulate and prescribe treatment plans, and provide patient education. There are many different Nurse Practitioner Specialty degrees. You commonly see NPs in inpatient and outpatient settings, primary care, and specialist offices, occupational health, the health department, and more!

Are a Nurse Practitioner and a Nurse the same thing?

No, these are not the same roles and have different scopes of practice. A nurse assists providers and has an associates or bachelors degree, whereas an NP requires at least a masters degree and special training through an NP educational program.

Nurse Practitioners function as a provider just like a Medical Doctor (M.D.). In Tennessee, all Nurse Practitioners are required to be under the supervision of a Medical Doctor.

What is the difference between a Nurse Practitioner (NP) and a Physician Assistant (PA)?

These two roles function very similarly with tiny nuances. Both are considered mid-level roles. A Nurse Practitioner is required to be a Registered Nurse (RN) before advancing their training to become an NP.

What is my role at Impact Sports Medicine and Orthopedics?

I see patients independently of, and at times along side, Dr Holmes. This means I can assess and examine patients, interpret imaging and labs, prescribe medications, diagnose conditions, provide treatment plans, perform ultrasound guided injections, and provide education to patients. Overall, think of me as a provider extension of Dr. Holmes.

What else do I want you to know about me as an NP?

Although you will see me independently, Dr. Holmes and I work as a team. This means I discuss patient cases and my decisions with him, and always have him review x-ray and MRI images as well. I want patients to know he is involved in their care, even if you don’t see him directly. Yet, have confidence that I will deliver safe, compassionate, and competent care to get our patients better! I work with my patients as a team to devise decisions that are tailored to each individual, their conditions, and their needs.

Hopefully this provides more clarity on what a Nurse Practitioner is and my role at Impact Sports Medicine and Orthopedics. Looking forward to providing care to y’all in the future!

Taylor Moore, FNP-C

Instagram: @taylormoore_nashvillenp

Facebook: Taylor Moore, FNP-C

Here are 4 reasons why some people DON'T want to see an orthopedic doctor (and why they should re-think that decision!):

1) "I was told I have arthritis, and there's nothing that can be done for it."....more than ever, we have numerous tools in the toolbox to treat symptomatic arthritis and also, means to prevent arthritis from progressing.

2) "I consulted with Dr. Google and got all the information I need to treat this problem."...Dr. Google can not listen to you, examine you, interpret your x-rays, evaluate an ultrasound, prescribe medications, perform a helpful procedure, demonstrate/supervise a rehab program, etc. We like Dr. Google. He's a wealth of information, but he has too many limitations to give you what you really may need.

3) "I already saw my primary care physician for this problem and he/she has started treating me."...We love PCPs and strongly endorse their role in the healthcare setting. We think every patient should have one. However, there is no substitute for specialist care. Don't you want to work with a physician that treats your problem on a daily basis?

4) "I don't want to be told I have to have surgery."...90-95% of the problems we encounter in our practice do not require surgery. Even our surgical peers that we really trust are conservative in their care and only operate on our patients when the condition will have a better outcome with surgical intervention. If we can't get you to the point where you need to be, then we will have partners that very likely will be able to do so.

We are here to help you!

F. Clarke Holmes, M.D.

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

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

A Steroid Injection Can Be Particularly Beneficial in These Situations:

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

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

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

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

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

A Steroid Injection Should be Avoided in These Situations:

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

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

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

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

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

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

-F. Clarke Holmes, M.D.

Impact Sports Medicine and Orthopedics

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

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

How Does it Present?

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

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

·       In endurance athletes, pain during and after exercise

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

Why Did I Get This?

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

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

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

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

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

How Do I Treat It?

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

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

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

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

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

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

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

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

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

What to Avoid:

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

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

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

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