Our 5 Best Pieces of Advice for You
/Some specialty medical practices see you as a “knee,” an “ankle,” a “hip replacement,” or “that person with too many aches and pains.” At Impact, we see you as a whole person. We see you from head to toe and do our best to advise you on long-term lifestyle choices to keep you, your joints and soft tissues as healthy as possible.
Here are our current 5 best pieces of advice for you:
1) Use food to your advantage, not as a detriment: many think only of food as calories, but instead, let food be nutrition…something that can nourish your body. Choose wisely with lean meats, some plant-based protein sources, numerous fruits and vegetables and healthy fats. Really limit fried foods, fast foods, processed foods, foods high in sugars and artificial sweeteners. Don’t forget about healthy beverage choices: more water than anything, adding green tea or black coffee but keep soda and alcohol very much in moderation. Why is this important? Proper nutrition allows for healing and recovery. Poor food and beverage choices lead to more inflammation and pain.
2) Being at a healthy weight is very important for your joints and soft tissues: every 1 pound someone is overweight equals 4 pounds of extra force going through his/her lower body joints. On the positive side, you lose 10 pounds, you have 40 fewer pounds of force on your knees and other joints. Osteoarthritis of the hips and knees, plantar fasciitis and insertional Achilles tendonitis are the most common conditions we see in overweight individuals.
3) Make cost-effective medical decisions: did you know that seeing a physician employed by a hospital or one associated with a larger group practice is more expensive than seeing a physician in a smaller private practice? Why is this? It is because insurance companies and these larger organizations have negotiated higher reimbursement rates. Is this based on a higher quality care? Absolutely not! It’s just the behind-the-scenes business of medical economics, and not many patients are aware of this. An office visit at “Hospital/Large Practice X” may cost you $300. A similar and possibly even more comprehensive visit at our practice may cost you $200.
4) Stay moving, as “motion is lotion”: whether your knee or low back hurts, or you are just stiff quite often, staying mobile will help your musculoskeletal system. Don’t sit for too long. Don’t keep your hips, knees or spine in one position for too long. Set a goal for a certain number of steps each day, even if you are not classifying this as formal exercise. Walk while you talk on the phone. Choose an adjustable or standing desk if possible.
5) Find your sweet spot when it comes to exercise and activity: perhaps 2 miles of walking is too much for your arthritic knee, but 1.5 miles feels good, both during and after the walk. 25 minutes of the bike is great, 30 minutes creates pain. 2 sets of bench press with 30 pound dumbbells feels right, but 3 sets with 40 pounds causes shoulder pain. “Sweet spot” exercise is essential, especially for us middle-agers and older.
As always, let us know if we can be of assistance to you!
F. Clarke Holmes, M.D.
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.
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.
You Turned 50 and Now Have Pain. You Are Not Alone!
/Yes, so many of our patients reach the harsh reality that their body doesn’t feel “normal” when they reach those glorious middle ages. For many, this can be a lonely feeling, as they feel like they are unique with their aches and pains. Well, we are here to tell you, you’re not unique, and you’re not alone. And that’s a good thing.
Although there is a reality check that has to occur with an understanding that those aches and pains will often be there, that doesn’t mean that you have to “give in” to these. Some of these conditions can be effectively cured while others can be managed to the point where symptoms are mild, tolerable and do not significantly inhibit you. The good news is that the large majority of these conditions do not need surgery. More than ever, we have a large number of tools in the toolbox to manage chronic tendon problems, arthritis as well as ongoing strains and sprains.
Don’t just rely on “Dr. Google” for your health care. We can provide cost-effective, but very sound advice and treatment interventions to help you feel better, function better and have a greater quality of life.
Typically, when a patient presents with a pain or injury, we will cover all of these aspects of care:
what forms of exercise can still be utilized
what “relative rest” looks like for you
appropriate use of medication
supplements that may benefit you
the potential for physical therapy or a rehab program
various types of injections that may help manage or overcome your condition
lifestyle modifications including weight loss, improvement in ergonomics & sleep habits and stress reduction
only surgery if we feel it is absolutely necessary
An older physician once told me, “pain is inevitable, suffering is optional.” So, don’t suffer and know that we are here to help you!
F. Clarke Holmes, M.D.
Knee Replacement Soon? Hit the Pause Button...
/So many patients with knee osteoarthritis ask me the question “well, if I’m eventually going to require knee replacement, shouldn’t I go ahead and have it done now?”
Well, there’s not just one answer to that question, but here are some of my replies:
-Most knee replacements only last 15 to 25 years. After that, the implants start to loosen, creating pain, swelling or a sense of instability.
-Most patients are at higher risk for surgical complications at the time of a second surgery, known as a “revision,” simply due to their age and likelihood of having more significant medical conditions.
-Surgical techniques are improving with breakthroughs every two or three years. Robotically-assisted replacements and having replacements as an outpatient surgery are two recent examples. More advancements are sure to come.
-One should never base the need to have knee replacement on the appearance of the x-rays. Some patients with “bone-on-bone” arthritis have minimal pain and excellent function. These patients don’t need a replacement.
-What often produces the most pain is an unhealthy environment within the knee joint, some of which may be controlled with injections like platelet-rich plasma (PRP).
-We also believe that PRP may put a stop sign or at least a yellow light on cartilage deterioration. We do not make guarantees about cartilage regrowth, but if we can stabilize a patient’s current cartilage and slow or stop the deterioration, then we are slowing the process of osteoarthritis and perhaps delaying the need for knee replacement.
-For a joint condition like arthritis, we often think of PRP as a maintenance treatment, not just a one-time application. Much like the maintenance for your car, you don’t just take it to the mechanic once or twice and then get a new car. This is an ongoing process.
-Assuming a patient is in that 80% success group with PRP treatments, one should plan on likely having repeat PRP injections every 1 to 2 years. This is a great long-term investment in the health of your knee.
-Want to know more about PRP? Check out this blog:
Five Simple Reasons You Should Consider Platelet-Rich Plasma — Impact Sports Medicine & Orthopedics (impactsportsnashville.com)
In summary, for some individuals, knee replacement is inevitable, but there can be great value in delaying this surgery to increase the odds that it is required just once in a patient’s lifetime. For others, treatments like PRP can eliminate the need to have a replacement.
As always, let us know if we can be of assistance to you!
F. Clarke Holmes, M.D.
Here Comes Volleyball Season: We Are Ready in the Ortho World!
/Volleyball season is fast-approaching. Today, let’s discuss the four most common areas of injury, treatment and prevention.
Volleyball was my sport as a youth. I played all year-round, and if I wasn’t in practice or a tournament, I was working out. But is the constant wear and tear on our bodies without rest hurting us even at a young age? In parts, yes. We commonly see athletes whose injuries could have been prevented with a short period of rest or prevention methods. Let’s talk about that:
1. Ankle
Most common: ankle sprain. It comes as no surprise that ankle injuries are one of the most common injuries seen in volleyball. Initial treatment includes RICE (rest, ice, compression, and elevation). However, it is always wise to see an orthopedic provider who can help guide you in treatment, prevention, and return to play. What many people do not know is younger children and teenagers’ growth plates are still open and are also at risk of injury with a twist of the ankle. When growth plates are still open, they are the most vulnerable and at risk for a Salter-Harris fracture which involves the growth plate. After growth plates close, the ligaments become the most vulnerable. I like to tell my patients that ligaments are like the candy Laffy Taffy. Once they are stretched out, they don’t necessarily return to their original state. Thus, prevention and strengthening are imperative.
Prevention: ankle range of motion, strengthening, and balance exercises; keeping footwear up to date; purchasing well-fitting and high-quality footwear; and ankle braces during practice and games.
2. Knee
Most common: patellar tendonitis (chronic) and ACL tears (acute)
Patellar tendonitis, also known as jumper’s knee, is very common due to the amount of jumping volleyball requires. Many times, the athlete will localize the pain right under the kneecap at the proximal aspect of the patellar tendon. Our office utilizes diagnostic ultrasound to look at the characteristics of patellar tendon, identify if there is tearing, compare it to the unaffected size, and determine if there is any new blood vessel formation (neovascularization). Prevention and treatment include stretching and strengthening exercises, a period of rest from jumping, and a patellar tendon strap. Short-term anti-inflammatories can helpful. In difficult cases, we can turn to platelet-rich plasma injections (PRP). Those with an open growth plate at the tibial tuberosity are at risk of developing Osgood-Schlatter’s.
Anterior Cruciate Ligament (ACL) tears: Volleyball is relatively high risk for ACL tears due to potentially landing awkwardly after a jump or during pivoting maneuvers frequently required. The ACL is under the most load when the knee is under sudden valgus (knock-kneed) stress. The best preventative options are to strengthen the outer hip, upper thigh, and gluteal muscles along with jump-training techniques to help protect the knee. If diagnosed with an ACL tear, treatment can be conservative or surgical. Those who wish to continue participating in high-risk sports generally opt for surgical intervention.
3. Shoulder
Most Common: Impingement, Labral Tears, Instability, and Rotator Cuff Tendinitis
Those who are hitters in volleyball are at risk for all of these shoulder conditions. Once again, relative rest, recovery, and strengthening are imperative in preventing these conditions. Improvement in form and hitting techniques are often helpful. Injections (occasional steroid, but more commonly PRP) can play a role in more difficult cases.
4. Low Back
Most Common: Lower Back Strain/Sprain (acute) or Spondylolysis
Volleyball requires repetitive bending, twisting, and hyperextension movements which put the low back in vulnerable positions. The biggest takeaway is if you or your child is experiencing low back pain that is not relieved after a couple weeks, please see an orthopedic provider. This could indicate a spondylolysis (a stress fracture) or stress reaction in the bones of the lumbar spine. Low back strains/sprain can be muscular or ligamentous and tend to improve within 2 weeks. If that’s not the case, then we often look for spondylolysis or even disc problems.
As mentioned, strengthening and adequate rest while allowing our bodies to recover are the best ways to prevent these common injuries. However, if these injuries occur and you or your child’s symptoms are unresolved beyond a week or two, please give us a call!
Taylor Moore, NP
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.
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.
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:
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.
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.”
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.
What Does "Being Proactive Over Reactive" Mean?
/Proactive Interventional Orthopedics (PIO)…a concept we will continue to promote. What does it mean in orthopedics to be proactive over reactive? Here are some examples and brief explanations:
Choose maintenance and more long-term injections over short-term steroid/cortisone injections: platelet-rich plasma (PRP) and hyaluronic acid injections often produce a more clinically significant and longer duration of benefit than steroid injections. For your knee and hip arthritis, tennis and golfer’s elbow and plantar fasciitis, just to name a few, choose these injections.
A course of physical therapy over exercises you simply found online: patient outcomes are generally better when you work with a physical therapist over Dr. Google or YouTube. We have fantastic relationships with physical therapists across Middle Tennessee and can work with you to find the best fit.
Regular use of supplements over prescription or over-the-counter medications: there’s a time and place for prescription meds when managing orthopedic conditions. However, for long-term management, we prefer options like curcumin/turmeric, collagen, and glucosamine/chondroitin. That being said, it’s always wise to consult with a physician before starting new supplements.
Don’t wait for your pain or disability to reach high levels before you seek treatment: orthopedic conditions treated early after the onset of symptoms and when pain and dysfunction are at a low level typically respond better to less-invasive treatments, and this early treatment can lower the risk of further damage to the joint or tissue.
Choose a specialist over a primary care physician for your orthopedics needs: PCPs work really hard and a do a great job to care for your overall health, but they do not necessarily have the expertise, the tools such as on-site imaging and advanced equipment or the time to dedicate to your orthopedic conditions.
Healthy eating patterns over a fad diet: weight loss is a vital part of the treatment plan when it comes to weight-bearing joint problems like hip and knee osteoarthritis. Through a variety of options, we can help you a structure a plan to gradually lose weight in a manner that the weight will stay off and through means that can be maintained for the long-term.
As always, let us know if we can help you overcome an injury, treat an orthopedic condition or find the pathway to greater wellness with an improved quality of life!
F. Clarke Holmes, M.D.
Introducing the Concept of PIO
/As sports medicine providers, we are all about “getting ahead in the game.” Therefore, we have coined the term and are developing the concept of PIO (“pie-o”). PIO stands for proactive interventional orthopedics. You’ve possibly heard of interventional cardiologists or interventional radiologists. These are the physicians that are specialists in their field, but use less-invasive means to treat your condition. For example, the interventional cardiologist will perform angioplasty or a stent procedure, whereas the cardiovascular surgeon would be the physician to do the more-invasive coronary artery bypass surgery, when necessary.
In our field, PIO involves using less-invasive interventions such as injections, weight loss, physical therapy/exercise programs, and various supplements to “get ahead” of your musculoskeletal conditions that either currently are or will soon bring you pain, disability, and dysfunction. The field of orthopedics has typically been “reactive,” meaning you only go to the doctor when you have a significant problem. Unfortunately, when you are only reactive instead of proactive, treatment interventions become more invasive, higher risk, and sometimes less successful.
Here’s how we can use PIO to help you if have arthritis, tennis/golfer’s elbow, rotator cuff or Achilles problems, plantar fasciitis or other chronic conditions: we will customize a plan to reduce pain, improve function and quality of life in a cost-effective manner.
Here are links to two of our other blogs that explain the process and benefits of platelet-rich plasma (PRP) injections, often part of PIO treatment program.
Why Insurance Does Not Pay For Platelet-Rich Plasma Injections, But Why That Should Not Deter You — Impact Sports Medicine & Orthopedics (impactsportsnashville.com)
Five Simple Reasons You Should Consider Platelet-Rich Plasma — Impact Sports Medicine & Orthopedics (impactsportsnashville.com)
If you would like to discuss the concept of Proactive Interventional Orthopedics and how this may be a benefit to you in 2023, then please give us a call. We would love to customize a treatment protocol for you.
Why Insurance Does Not Pay For Platelet-Rich Plasma Injections, But Why That Should Not Deter You
/Platelet-rich plasma injections, commonly known as PRP, have been utilized in orthopedics for at least the past 15 years. The first studies in orthopedics looked at PRP being utilized for tennis elbow, and the results were promising.
Fast forward 15 years and now platelet rich plasma has become a mainstay in the treatment of many orthopedic conditions, ranging from osteoarthritis to tendon and ligament problems. An estimated 60% of orthopedic practices now offer PRP to their patients and while some physicians can claim true expertise in this type of treatment, other practices remain novices when it comes to the application of PRP.
Now, to answer the question in the title of this blog, “why do insurance companies not cover PRP….” We will provide an educated opinion with several bullet points.
-Many insurance companies claim that PRP injections are “experimental.” Experimental is a very broad term that can be applied in numerous ways. What classifies something as experimental? In my opinion, this is something that has been utilized for a very short period of time and has very few studies or anecdotal pieces of evidence to demonstrate a sustained rate of efficacy. Meaning, this treatment hasn’t been used for very long, has not been used on very many patients, and we really don’t know what the short-term or long-term results are.
When it comes to PRP, I would say we are light years beyond the experimental stage. For many years, PRP has been used not only in orthopedics, but also in plastic surgery, wound care, dermatology/aesthetics and hair-loss situations, to just name a few. PRP has demonstrated a long track record of safety, and the overwhelming majority of studies demonstrate that patients benefit from these procedures. So, in my mind as a physician of nearly 25 years who has studied medical data for his entire career, I would no longer classify PRP broadly as experimental. Are more studies regarding PRP necessary? Of course. Yet this is true for every treatment in medicine. Trust me when I tell you that there are numerous treatments in all fields of medicine being utilized right now that have been studied far less than PRP.
-Next, the truth is that insurance providers these days are looking to pay for fewer and fewer of your medical expenses. We have to get away from the mentality that “I have health insurance, and it should cover all of my medical needs.” In truth, we are probably getting back to a model where insurance should be used for major health expenses and catastrophic situations, not for most of your routine day-to-day medical care. Almost all of private insurance companies are for-profit organizations. There’s nothing wrong with that. However, you must realize that their first goal is making a profit to sustain their business. Their first priority is not providing the optimal care for the patient, as often is the case, the optimal care is not the least expensive. So, we are constantly preaching to our patients these days that the best treatments in orthopedics are not necessarily the ones you can expect your insurance to cover.
-Finally, to partially take the side of the insurance company, an argument against covering PRP would be that it cannot be “standardized.” We can standardize a medication or certain forms of medical equipment, but we cannot standardize a patient’s blood. Therefore, one person’s PRP may not look like another patient’s PRP, meaning the number of platelets, white cells, etc. may be fairly variable between patients. Also, there are probably 20 to 30 commercially available PRP systems on the market now. None of these produce PRP in exactly the same way, once again, making the argument that PRP injections cannot be completely standardized. For this reason, insurance companies often take a pass on something they don’t view as uniformly the same treatment for every patient.
Now, let’s turn attention to why it really may not matter whether insurance companies cover PRP or not and why you should not be deterred from seeking this treatment.
-First, let’s look at the financial piece. So many of our private insurances require that we first meet our deductible before insurance will pay a significant portion of our medical bill. These deductibles are rising. Until you meet your deductible, you are going to pay out-of-pocket for any office visit, diagnostic test, medical procedure, or medication. Therefore, let’s say you were choosing between a steroid injection versus a platelet-rich plasma injection. Technically, the steroid injection is “covered by your insurance,” but until you meet that deductible, you are going to pay for an office visit and the cost of that steroid injection. So, “covered by insurance” doesn’t mean it’s an expense-free treatment.
-Next, that steroid injection may not be the best treatment for your particular condition. Let’s say you have a partial rotator cuff tear. You either don’t want or don’t need surgery for it. The steroid injection may temporarily alleviate symptoms, but certainly will not heal the partially torn tendon, and in fact, some patients worsen within weeks to months after a steroid injection. Thus, assuming you then are still seeking care for your shoulder pain and torn tendon, you will require additional tests and treatments. This may mean an MRI, a long course of physical therapy, additional medication, or even surgery. Those options, especially when combined, can be very expensive. Although platelet-rich plasma injections are not covered by insurance, they could be the long-term solution to your problem, saving you hundreds to thousands of dollars on other necessary potential treatments. Therefore, why not choose the treatment that will be most successful, not just the one that your insurance states that it covers?
-Finally, gone are the days that you can depend on insurance companies decide what is best for you and your health. I tell patients all the time that I literally could give them 10 steroid injections over the course of the year and cause bodily harm to them and their particular joint or tissue. Insurance companies would reimburse me to do this, often without question. Nevertheless, that is just not the right thing to do. I took an oath as a physician to “first do no harm” which I have continued to practice to the best of my ability. In addition, not only do I want to not do harm, but I also truly desire to help my patient. Therefore, I will help you choose what I believe to be the best and most customized treatment option for your particular situation. This is not always in line with what insurance companies would prefer that I do. I have no desire to be a “rogue” physician, but I’ve dedicated my career to developing an expertise to help my patients. Part of our ability to help our patients lies in the fact that we get to know them personally and their particular situations, goals, desires, comorbidities, and even their financial situations. Therefore, we work as a team with our patients to decide what we believe is best for them. Although it’s very natural to want to pay as little as possible but still get the best outcome, you just can no longer rely on insurance companies to have the authority over these decisions for you.
I realize what is said above gives you a lot to consider. I have a passion for educating our patients on the best treatments for their particular situation, and I am dedicating to doing that for the remainder of my career.
As always, please let us know if we can be of assistance to you!
F. Clarke Holmes, M.D.
Impact Sports Medicine and Orthopedics
BEING PROACTIVE, NOT REACTIVE, WHEN IT COMES TO PLATELET RICH PLASMA (PRP) INJECTIONS
/I am a 28 year-old nurse practitioner and former competitive athlete, and I am strongly considering getting platelet-rich plasma (PRP) injections for my knees. Why? For one, as a provider, I have witnessed many improved patient outcomes. Two, this procedure is safe, has relatively no side effects, and is minimally-invasive. Lastly, we are seeing that by being proactive with PRP versus reactive when symptoms are present shows even further benefit.
After many years of intense volleyball training, games, and working out without any downtime throughout the year, I developed bilateral knee pain. Although I have no x-ray evidence of osteoarthritis at this time, based on my symptoms, there is no doubt I have cartilage damage. Because of this, I feel that PRP injections, in addition to other conservative treatments I’ve used, will boost the longevity of my knees.
PRP helps soft tissue, joint, and cartilage pathology. It is a great way to use your own body’s healing system to improve musculoskeletal problems, and there is minimal risk because it uses your own blood.
What’s our process?
Obtain blood from a vein.
Spin it in a centrifugation system in our office. This separates the components of the blood and concentrates the platelets.
We take the plasma that has platelets that are rich in growth factors to create the PRP injectable solution.
The PRP is then injected under ultrasound guidance in the targeted area.
When injecting the PRP solution to the targeted area, it creates an espresso shot-like effect for your body’s growth factors and repair cells to travel to this area. The main goal is to help repair the damaged area, decrease pain, and improve function. Keep in mind that this is a slow and methodical approach that can take up to 6 months to see maximum benefits. Sometimes more than one PRP injection is needed. How long does PRP last? It varies based on the severity of the patient’s condition, a patient’s activity level, and incorporation of other conservative treatments. Cost can vary per practice. We typical charge $800-$950 (*subject to change) depending on how many locations we are injecting and which centrifugation system we use. Keep in mind that PRP injections are NOT stem cell injections.
My goal with this blog is to change the thought process that PRP injections should only be used reactively to treat orthopedic conditions and their accompanying symptoms to one instead that utilizes PRP in a proactive approach to slowly repair and stabilize conditions.
So, why haven’t I had PRP injections in my knees already? Honestly, the only thing holding me back is my nervousness when it comes to needles.
Interested to see if PRP injections would be helpful for you? We would love to have a consult with you to discuss these in detail!
Taylor Moore, FNP
Impact Sports Medicine and Orthopedics