Orthopedic Injections: What Not To Do
/Injections are one of the most commonly used interventions in an orthopedic practice. Yet, where, how and what is injected is of vital importance, and certain approaches are just not in the best interest of the patient. Here are injections we prefer you avoid:
1) Injections for musculoskeletal conditions given in a chiropractic or primary care office. Both chiropractors, chiropractic mid-levels (NPs and PAs) along with PCPs all often do a great job in their respective specialties. However, giving injections optimally is just not in their wheelhouse. Therefore, if an injection is needed or suggested, then seek the expertise of an orthopedic specialist.
2) Receive a series of steroid injections for soft tissue conditions, such as plantar fasciitis, tennis/golfer’s elbow or gluteal tendinopathy (often mislabeled as “hip bursitis”). We often use the statement, “better in the short term, worse in the long-term.” This really applies to situations when multiple steroid injections are given in a short period of time, as they ultimately can lead to further breakdown and tearing of these tendons/fascia.
3) Receive a steroid injection for Achilles, patellar or quadriceps tendon problems. These tendons are much higher risk for rupture, especially if exposed to a steroid injection. If anyone suggests a steroid for one of these conditions, then RUN (figuratively)!
4) Pay top dollar for an orthobiologic injection such as platelet-rich plasma (PRP) without ultrasound guidance. It’s your choice to have this injection if it’s non-guided but just realize that accuracy is so important with this type of injection. There is no way to ensure the solution is making it to the intended area without ultrasound.
5) Receive “stem cell” injections that do not come from your own tissue. If a stem cell injection is being suggested, it should be derived from your bone marrow or your adipose (fat) tissue. Most of these products "ordered for you” do not actually contain any live stem cells, and at this point, are not approved by the FDA for usage in musculoskeletal conditions.
As always, let us know if we can help you!
F. Clarke Holmes, M.D.
I Don't Want Surgery But What Else Can I Do?
/Fortunately, 90% of problems that come into an orthopedic clinic do not require surgery.
Approximately 80% of those conditions treated nonsurgically can be treated with traditional treatment measures: rest, activity modification, physical therapy, medications, supplements, lifestyle changes, brace, splint, a boot walker, steroid injection, etc. This is “bread and butter“ treatment administered by an orthopedic/sports medicine physician.
Now, what about that last 20% of non-surgical treatment? That’s often where we have to think “outside the box.” Let’s say in the case of osteoarthritis and tendon problems, that’s where treatment like platelet-rich plasma (PRP) injections can be very helpful. For example, in the case of knee osteoarthritis, how would you like to have less pain, less stiffness, less swelling and better function? What if we could accomplish that with a treatment that is minimally-invasive, safe, proven and natural? As a bonus, this treatment has preventative benefits, meaning we likely are slowing down the cartilage breakdown in your knee. These are the benefits seen with PRP injections.
In the case of tendon or fascia problem like a rotator cuff partial tear, tennis or golfer’s elbow or plantar fasciitis, PRP is designed to be a healing agent. We are using these growth-factor rich injections to accomplish healing, not just make you feel better like a steroid injection might.
Check out a few of our previous blogs, and let us know if we can help you!
https://www.impactsportsnashville.com/blog/2023/12/8/prp-the-gift-of-health
https://www.impactsportsnashville.com/blog/2023/9/23/5-things-you-have-to-know-if-you-have-knee-pain
https://www.impactsportsnashville.com/blog/2023/8/5/our-top-5-treatments-for-knee-oa
F. Clarke Holmes, M.D.
Why Me? Why So Many Tendon Problems?
/If you are 40 years old or above, it’s probably not “if” but “when” you are going to have a tendon problem. Tendons connect our muscles to bones, but as we age, they become problematic. Common tendon problems include/involve the rotator cuff, tennis and golfer’s elbow, Achilles tendon, posterior tibialis tendon and then the plantar fascia, which behaves like a tendon but technically is a ligament.
Thus, these conditions are usually a disease of the middle-aged and older. What are the causative factors for what we call tendonopathy?
-acute injury to the tendon
-overuse activities
-genetics
-inflammation
-diet
-biomechanics
-weight
So, to treat tendonopathy, we have to address these factors with genetics being an exception, as this can’t be changed.
Thus. we have to modify activities, either temporarily or permanently, especially avoiding overuse situations.
We want to reduce inflammation, and this can be achieved multiple ways: medications, steroid injections, supplements and an improved diet can all play a role. Medications and steroids can be very helpful in the short term but are not always a long-term solution. Platelet-rich plasma injections can be a great option to promote long-term management of inflammation and the actual healing of a tendon.
Biomechanics are often improved through changes in movement patterns, improved flexibility and strengthening. At times, footwear changes and orthotics can play a role as well.
As we often preach, early treatment of a tendon problem usually produces better outcomes than late treatment, but either way, we’ve got you covered. Don’t be discouraged if you have one or more tendon problems, knock on our door and we’ll be more than happy to share our expertise!
F. Clarke Holmes, M.D.
PRP: The Gift of Health
/As we near the major holiday gift-giving season of the year, consider one the best gifts you can give to yourself: the gift of health! Platelet-Rich Plasma (PRP) injections are a great option for you in 2024 if you are looking to boost your orthopedic health and longevity. Here are 5 great adjectives that apply to PRP injections:
1) Safe: adverse effects and complications associated with PRP injections are exceedingly rare.
2) Effective: 80-90% of our patients that receive PRP injections have very good outcomes and are satisfied with their results.
3) Natural: these injections use your blood, specifically your platelets and your growth factors to exert their positive effects.
4) Proven: once considered experimental, there are now hundreds of studies that demonstrate clinical benefit with PRP injections.
5) Preventative: PRP injections are touted in their ability to prevent many degenerative joint and soft conditions from further deterioration.
Want to know more? Check out some of our blogs:
Insurance Companies Say PRP Is Experimental…We Sigh — Impact Sports Medicine & Orthopedics (impactsportsnashville.com)
Five Keys to Successful Outcomes with PRP Injections — Impact Sports Medicine & Orthopedics (impactsportsnashville.com)
PRP And The Three "Es" — Impact Sports Medicine & Orthopedics (impactsportsnashville.com)
As always, let us know if we can be of assistance to you!
F. Clarke Holmes, M.D.
Three Roadblocks to Your Health: Time, Fear and Money
/
Time: we’re all so busy, at least we think we are. Let’s be real, going to see the doctor does take time. Driving, parking, filling out forms, waiting, talking, testing and deciding. The average visit from start to finish. meaning door-to-door is in the range of 2 to 3 hours. Yet, that 2 to 3 hours could be the difference in you getting a diagnosis, relieving anxiety, feeling better, promoting better function and doing something that can help your body long-term. Are you willing to binge watch a show for 2 to 3 hours? Are you willing to go to dinner for 2 to 3 hours? Are you willing to surf social media and watch videos for 2 to 3 hours? Are you willing to go to the mall for 2 to 3 hours? Are you willing to go to the gym for 2 to 3 hours? If the answer to these questions is “yes,” then you definitely have time for a doctor’s visit.
Fear: so many patients skip that doctor’s visit because of fear of a frightening diagnosis, a recommendation that surgery is necessary or because of potential expenses that come with that visit and subsequent treatment. Here’s the good news: often that fear fades away once you get into the doctor’s office and actually are able to learn why you have certain symptoms and then are able to develop a plan of action. I’ve seen it for decades, as many patients, even when given news that they did not want to hear, find a sense of relief. Frequently though, we are able to provide good news and reassurance, calming the patient’s fears. In a nutshell, fear of the unknown is often much greater than the fear of the known. More good news here… 95% of patients that present to our office do not require surgery!
Money: sometimes the most expensive course of medical treatment is the one that was developed late in the game. Meaning, if a patient would have sought treatment earlier, a much less expensive plan of action could have been developed. There is no greater investment than the one in your health. We are all willing to spend money on trips, hobbies, clothes, restaurants, cars, etc. While all these can have value, they don’t hold a candle when compared to your health. So, make sure that you are budgeting enough money to pay for your necessary healthcare. Finally, when making financial decisions about your health, attempt to think long-term, not just short-term.
As always, let us know if we can be of assistance to you!
F. Clarke Holmes, M.D.
Five Financial "Must Knows" Relating To Your Healthcare
/Not too long ago, it was considered taboo for physicians to discuss money issues with patients. Now, it’s irresponsible not to do so. Therefore, let me share 5 quick considerations pertaining to the blending of your finances and your healthcare:
You must save additional money for your healthcare. Deductibles are rising, fewer procedures are being covered and overall, all costs in healthcare are rising. You can’t just save enough money to pay your insurance premium each month. You must plan with an additional reserve.
A Health Savings Account (HSA) is a great tool to have. Either you can contribute to this periodically and use it for your out-of-pocket medical expenses as they arise, or you can choose to invest this money in your HSA account and allow it grow to tax free while saving it for later. Either way, your contributions are tax deductible.
Insurance companies’ mantra: “Deny, Deny, Deny.” We are seeing more procedures and valuable interventions such as MRIs, physical therapy visits and certain injections get denied by insurance. Now, some of these can eventually get approved, but not without a lot of extra work put in by the physician and his/her office staff. Insurance denials are a cost-containment measure for these for-profit companies. There’s nothing wrong with being a for-profit business, but you have to realize this as you approach your relationship with your insurance company.
Some of the best procedures in orthopedics are not covered by insurance. This includes innovative procedures such as PRP injections and certain surgeries. Insurance companies are often slow to catch-up with the latest and most effective treatments in medicine.
Except for those with Medicare and Medicaid, we really need to consider insurance coverage as “catastrophic” medical coverage. Meaning, we have insurance to help cover the majority of the expenses in the event of a major surgery, a hospitalization or cancer treatment as examples.
In summary, we have to shift our thinking regarding how we budget for our current and future healthcare. I want all of us to receive the best medical care possible. To do that, we have to be prepared financially.
As always, let us know if we can be of assistance to you!
F. Clarke Holmes, M.D.
5 Things You Have to Know If You Have Knee Pain
/1. Three factors play a role in knee pain: structural, biomechanical and environmental. Structural means damage, biomechanical means abnormal tracking or loading within a joint or tendon because of misalignment, weakness, and/or inflexibility. Environmental typically means inflammation within the joint or tendon. When formulating a treatment plan for you, we typically want to address one or two of these factors initially. Unless you have major damage, we’re normally not treating structure initially, as that results in a surgery.
2. Age often plays a role in these different factors: in the absence of injury, in patients under 20 years of age, the problem tends to be biomechanical. In patients ages 20 to 40, the problem tends to be biomechanical and inflammatory. In patients older than 40, structural, biomechanical and inflammatory are typically all playing a role.
3. Being proactive in the care of your knee problem usually produces better outcomes than being reactive. This means integrating treatments early on and not waiting until you have major pain or disability to see a physician. We term this “PIO,” Proactive Interventional Orthopedics.
4. Meniscus tears are commonly found on MRIs and may or may not be a source of pain. For decades, the trend was to treat these surgically, typically arthroscopically, removing the torn piece of meniscus. There’s now a trend towards repairing the meniscus tear when possible, but only about 10% can be successfully repaired. Thus, surgery for meniscus tears, especially those age 40 and above, is falling out of favor. On occasion, surgery is the better choice, but treating these initially nonsurgically is usually the best way to start. We often tell patients “a little torn meniscus is better than less meniscus,” especially long term. Less meniscus often equals greater arthritis.
5. Three types of injections can be used for most knee problems: steroid, hyaluronic acid, and orthobiologics. Orthobiologics include platelet-rich plasma (PRP) and stem cell injections. Each of these injections can be reasonably good choices, but for long-term success, PRP is likely your best option in terms of producing favorable outcomes, modifying the disease process, and these are often the most cost-effective option. Stay away from “stem cell” injections that are ordered by physician’s or chiropractic offices and do not come from you own bone marrow or fat. These are often being used inappropriately, and patients are charged exorbitant amounts of money to have these injections.
As always, let us know if we can be of assistance to you!
F. Clarke Holmes, M.D.
TENex for TENnis Elbow
/At times, tennis elbow, also known as lateral epicondylitis, can be so stubborn that an advanced procedure is needed to overcome this condition. There are two basic types of surgeries used to treat this condition. The first and by far our favorite is a percutaneous tenotomy under ultrasound guidance, commonly referred to as the Tenex procedure. The other is an open release of the tendon which involves cutting the tendon off the bone. Let’s briefly highlight the differences between the two:
Anesthesia
Tenex: Local-lidocaine injection only
Open: General- patient is put to sleep
Incision Size
Tenex: 1/4 inch
Open: 1-2 inches
Trauma To Tissue
Tenex: Minimal
Open: Moderate
Infection Risk
Tenex: Minimal
Open: Mild
Sutures/Stitches
Tenex: None
Open: 1-2 layers required
Recovery Time
Tenex: 2-6 months
Open: 4-12 months
Success Rate
Tenex: 90-95%
Open: 75-90%
Are we biased towards the Tenex? You better believe it! Look at those comparisons above. In our mind, it’s an obvious choice: the Tenex procedure is the better overall option. Why do more physicians not perform the Tenex procedure? Because you are required to have proficiency in musculoskeletal ultrasound to perform this procedure. Not many physicians have taken the time and made the investment in ultrasound-guided procedures, so they tend to revert to the more traditional, sometimes higher-risk and less successful options.
We’ve performed more Tenex procedures in Middle Tennessee than any other physician. So, if you, a loved one or friend has tennis elbow, then come see us!
F. Clarke Holmes, M.D.
Bet You Didn't Know: Tennis Elbow
/Tennis Elbow, one of the most common conditions seen by an orthopedist, is one our favorite diagnoses to make. Why?…because we are almost always able to see complete resolution of the symptoms. Plus, we have numerous traditional and innovative tools in the toolbox to help our patients overcome this often stubborn and humbling condition. Here are some fast facts about tennis elbow you probably did not know:
-90% of those with tennis elbow, also known as lateral epicondylitis, do not play tennis. Weight-lifting, frequent typing, CrossFit, repetitive labor in one’s work or with household chores are frequent causes.
-Teenagers almost never get tennis elbow. Why? They have an amazing ability for their tendons to recover much faster and more efficiently than middle age and older individuals.
-Lateral epicondylitis is the medical term for tennis elbow and may be one of the more misnamed conditions in orthopedics. This implies there is inflammation of the bone on the outside of the elbow, but instead, this is a tendon problem.
Patients who receive cortisone/steroid injections are often better in the short term but worse in the long term. Our own experience and the medical literature validates this.
Neovascularization, essentially new blood for vessel formation, commonly occurs in advanced cases of tennis elbow. Increased blood flow seems like it would be a good thing for the tendon, but in reality, is a sign of more advanced tendon damage.
We believe that adjacent to those new blood vessels in the tendon are new nerves that are very hypersensitive and only make you feel pain. This is why many patients with advanced cases of tennis elbow complain of “burning” over the lateral elbow.
Platelet-rich plasma injections, now a commonly used and innovative treatment option for many orthopedic conditions, were first studied in the medical literature about 15 years ago in treating tennis elbow. PRP remains one of our advanced treatment options for tennis elbow.
One of our best treatment options for very stubborn cases of tennis elbow is the Tenex procedure. Not many people know about Tenex because we are one of the few physicians in middle Tennessee who have expertise in performing this procedure. We’ve done it for 11 years, and it involves a tiny incision, local anesthesia only, and use of a small needle-like device to excise the unhealthy part of the tendon. No stitches are required and only about two minutes of actual treatment time in the operating room. It carries a 95% success rate in our experience.
If you have pain on the outside of your elbow that is interfering with your quality of life, then come see us. We will have some great options for you!
F. Clarke Holmes, M.D.
Hamstring Strains- The All Too Common Injury
/Picture this….an explosive movement that involves hip flexion and knee extension. What could go wrong? Well, this is the mechanism of a hamstring strain or tear. The classic actions are jumping, kicking, or running. Occasionally, a pop will be felt. We see hamstring strains and tears in our practice often, and frequently, the patient is mistreating their hamstring pathology by the time they get to us. Because of this, we hope this blog will provide education on appropriate first-line treatment before and when you seek medical attention.
First, can anyone name the three hamstring muscles? The answer is: Biceps femoris, semitendinosus, and semimembranosus. What’s the common injury in Major League Baseball: you’re thinking a shoulder or elbow problem, right? Not so fast…a hamstring strain is the most common injury in baseball, and likely the NFL and Major League Soccer as well.
Hamstring strain/tear prevention: proper warm-up, dynamic stretching, adequate rest and recovery, and strengthening. Specifically, the quadriceps muscles tend to get a lot more attention than our hamstrings because they are “look good” muscles. However, neglecting the hamstrings and creating a muscle imbalance definitely increases one’s risks of a hamstring injury. Also in regards to prevention, when a hamstring starts to feel tight or crampy, then that’s a warning sign. It’s then wise to minimize those explosive activities that often lead to a major strain.
In terms of radiographic diagnosis, x-rays are primarily only helpful to evaluate a patient for an avulsion fracture when the pain and strain is near the ischial tuberosity. These fractures are most common in skeletally immature patients such as younger teenagers with open growth plates. Musculoskeletal ultrasound, one of our areas of expertise, is a great and inexpensive way to visualize and grade hamstring strains in our office. Finally, an MRI is the most complete test to visualize a hamstring injury, but is not necessary in most patients and certainly the most expensive and time-consuming test.
Complete tears: If a complete tear is found, particularly proximally (at the origin at the “sit bone”), then surgical reconstruction is the typical treatment. I once knew someone who had liquid courage, (a.k.a., too much alcohol) on board and attempted to do the splits. He made it down into the splits but the explosiveness of the movement caused his hamstring to avulse off of the ischial tuberosity. He had to undergo surgery to reattach it. Needless to say, don’t try to do the splits, folks! Fortunately, complete tears are rare.
Strain/partial tear: This is most commonly the hamstring pathology we see. Hamstring injuries take a long time to heal. With proper treatment, this can be accelerated. The BIGGEST piece of advice I can give initially after the strain is DO NOT STRETCH the hamstring. It will commonly feel tight and feel like you need to stretch, but this will only strain the tendon and muscle belly further. Rest and activity modification are important steps in recovery. This even means to not lead up the stairs with the affected leg or bending at the waist, but instead with at your knees. Any activity that can tug on the hamstring, you should avoid. Other treatment options include thigh sleeve, steroid injection, physical therapy, and platelet-rich plasma (PRP) injections under the guidance of musculoskeletal ultrasound. PRP becomes a great option for proximal hamstring tendon problems that persist beyond a few months. We most commonly see this problem in long distance runners.
Recurrence: hamstring injuries are highly prone to recurrence. This is often due to a return to activity or sport too quickly and/or inadequate rehabilitation. This is why having an expert guide you in your recovery often decreases your risk of re-injury.
In a nutshell, if you have an acute or chronic hamstring injury, it’s best to seek medical attention as opposed to managing this yourself. Proper diagnosis, grading of the strain, discussion of treatment and prevention strategies along with a return-to-play/exercise plan is what we offer our patients.
As always, let us know if we can be of assistance to you!
Taylor Moore, NP and F. Clarke Holmes, M.D.
Tiger Woods and You...
/You or someone you know may have something in common with Tiger: plantar fasciitis. Tiger dropped out of the Masters golf tournament last weekend due to severe heel pain caused by plantar fasciitis. This all-too-common orthopedic condition afflicts a huge number of middle-aged Americans every year. The most common symptoms are heel pain when first getting out of bed, when barefoot or with prolonged walking, running or sports. Here are some key “Dos” and “Don’ts” when it comes to plantar fasciitis:
What To Do When You Have Plantar Fasciitis:
1) Seek medical attention early: We have many tools in the toolbox to treat this condition, but we first need to need to confirm the diagnosis, set-up a multi-faceted treatment plan, and guide you on your prognosis. Ultrasound, which can be done in our office, is by far the best imaging study to see the plantar fascia. This factors into our concept of PIO- Proactive Interventional Orthopedics.
2) Wear good footwear at ALL times: when in the house, in the yard, at the gym, at the pool, while shopping, going to that concert, socializing with friends and at church. Good footwear means very supportive, not too flexible, and not too cheap. Cheap unfortunately often means lower quality.
3) Consider inserts/orthotics for your shoes: over-the-counter can get the job done, but you’ll need some advice on how to choose these. A high-quality athletic shoe store or a visit to your sports medicine doctor can supply that information. However, custom orthotics prescribed by your physician may really be what you need. We are fortunate to have custom orthotic specialists that work directly with our practice.
4) Consider physical therapy as it’s beneficial for most patients: many cases of PF are related to biomechanical problems, meaning that your calves are too tight, your foot pronates or supinates, your foot muscles are weak or you are overweight. Physical therapy along with weight loss in some individuals can help correct these biomechanical problems.
5) Realize that 10-20% of cases of PF will need an advanced treatment: in our practice, our first-line innovative and advanced treatment for stubborn PF is a platelet-rich plasma injection. PRP uses your own blood and the concentrated growth factors we have produced to reduce inflammation and pain while stimulating a healing response. If this fails, then we move on to a minimally-invasive surgery called a percutaneous fasciotomy using the Tenex system.
What Not To Do When You Have Plantar Fasciitis:
1) Stretch the bottom of the foot: many cases of PF involve tears in the plantar fascia. Although stretching the calf can help, stretching the bottom of the foot often irritates the fascia and can inhibit the healing process.
2) Buy expensive orthotics that are rigid or produced by an “orthotics store”: in our experience, these tend to be very uncomfortable for patients and unsuccessful in treating patients’ symptoms. Stick with an orthotics specialist recommended by an orthopedic/sports medicine physician.
3) Have multiple steroid/cortisone injections: although offered by some orthopedic doctors and podiatrists, we rarely offer these injections for PF and essentially never do more than one. Steoid injections can contribute to further tearing and often impede healing. Some patients feel better in the short term with steroid injections, but are worse in the long term.
4) Run/Walk through the pain: unfortunately, PF will just not get better if you keep doing the things that are causing the problem. So, a period of complete rest or relative rest will be necessary for PF to improve. Relative rest can mean dialing down your walking/running frequency or distance to the point that you stay below your pain threshold.
5) Become impatient: recovery from PF is often in the range of months, not days or weeks. So, once a treatment plan is in place, you’ll have to be patient. We often construct a Plan A, Plan B and Plan C. Each plan has 2-4 treatment entities within it and we insitute these for 1-2 months, judge their success and then move on to the next plan if we are not seeing the expected results.
In summary, plantar fasciitis is a condition that requires methodical treatment under the care of an experienced physician. Don’t just trust the advice from your non-medical friend, Dr. Google or YouTube. We are always here to help!
F. Clarke Holmes, M.D.
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.
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
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
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!
The 5 Biggest Mistakes Inexperienced Runners Make Leading to Injury
/1) Training for a ½ or full marathon when you’ve never run a 5K or 10K- because of variability of muscle types, bone density, running mechanics and the efficiency of oxygen consumption, not everybody was made to run long-distance races. Some great athletes are hardly capable of running 5 miles. Then, you have those individuals who can run a ½ marathon and barely train to do it. If a novice runner, see what your body is capable of first by training for and completing shorter races before attempting much longer runs.
2) Pushing through pain to get through a run- there’s fatigue, soreness, the muscle burn and then, there’s pain. Concerning pain includes sharp discomfort, pain that results in limping, constant pain and pain associated with swelling. Pain around a tendon or right over a bone is a warning sign. Don’t ignore the “check engine light” that comes on in your body. Learn to recognize the difference between the types of discomfort and seek medical attention when the concerning form of pain is present.
3) The wrong footwear- this can be shoes that are too old or the wrong type for your foot and particular gait pattern. It’s time for new shoes when there’s visible wear of the tread, especially in the forefoot area (the third of the foot closest to the toes). Shoes should be updated every 300-500 miles or every 9-12 months, whichever comes first. Also, seek a true “fitting” for your shoes. The right size, width and style (stability, neutral, zero drop, etc.) are important choices, and you should avoid choosing the latest “fad” shoe or the one that has the coolest design simply for the fashion statement. Find a quality running store that can help you with these choices.
4) Training with a partner of a different skill set- it’s generally best to train with someone of a similar skill set and set of goals. Many runners are competitive (whether they admit it or not!), and will push each other at times even on training runs. While this is not all bad, someone training for their first ½ marathon will likely struggle to keep up with someone that has run numerous long-distance races. What’s the net result? The inexperienced runner tries to keep up with the experienced runner in terms of speed, distance and mindset. This is a recipe for injury. If wanting to train with a partner, try to find one that is willing to follow a similar schedule and runs a similar pace.
5) Making up for lost time- sometimes a training schedule gets derailed. An illness, an injury or a life event knocks a runner off his/her training schedule for a couple of weeks. Race day is nearing, and thus, the runner tries to advance the training schedule by increasing the number of running days each week or jumping ahead and doing more miles or longer runs than what he/she should be doing. Example: it’s late in the training schedule for a ½ marathon, and the longest run you’ve done is 7 miles. You missed 2 weeks of training because of a sinus infection. You jump ahead on the schedule and do 10 miles on a Saturday. Now, your shin is throbbing. Shin splint or stress fracture? Either way, you’re done! No race for you. No running for weeks to months. What should you have done instead? Resumed your training schedule where you left off before the illness. Then, if not ready for this race, postpone and run another one. There are ½ marathons within a region almost every weekend, especially from the late winter until the late spring. Or, you could have still run the race, but adjusted your goals. Maybe you change your mindset to just finishing the race, even it meant walking part of race. The bottom line: skipping steps in your training often results in an increased risk of injury.
At Impact Sports Medicine, we would rather help you prevent an injury, but when one does occur, we are ready to help! Enjoy your running!