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.
PRP: The Details Matter. Give Us 3 Minutes
/More practices than ever are offering platelet-rich plasma (PRP) injections to their patients, especially those with osteoarthritis, tennis and golfer’s elbow, partial rotator cuff tears, Achilles and patellar tendonopathy and plantar fasciitis, just to name a few.
We often say, “not all PRP is the same.” There are so many details that go into the success rate of the injections. On that subject, how do you define success? Less pain, better function, healing of damaged tissue and/or the slowing of the deterioration of cartilage, especially in osteoarthritis. PRP can truly be a disease-modifying treatment, not just something to make you temporarily feel better.
Now, what details really matter?
Experience of the physician: how long has he/she been giving PRP injections
Accuracy of the injection: ultrasound-guidance is paramount
Amount of blood used to produce the PRP: we’ve learned that a higher volume of blood is likely necessary to produce the optimal number of platelets
Creation of the PRP: constructing the optimal amount of PRP to inject for each condition. Creating a mixture either rich in leukocytes (white blood cells) or poor in leukocytes
Providing the best recommendations regarding what medications and supplements should be temporarily stopped before and after the injections
Providing the best recommendations regarding restrictions (use of a boot, crutches, bracing, type of rest) after the PRP
Deciding upon the optimal number and frequency of injections to give
Working with a physician who is frequently involved in medical education on the topic of orthobiologic injections, including PRP
Working with a physician who is transparent and communicative regarding outcomes, expectations and cost
If truth be told, only a few physicians in Middle Tennessee implement all of these details when it comes to PRP injections.
So, if you think you are candidate for this very natural, quite effective, and minimally-invasive treatment, then come see us!
F. Clarke Holmes, M.D.
Do I Need a Knee Replacement?
/Your 55 year-old knee is hurting and your brain immediately asks the question, “Do I need a knee replacement?”
An x-ray demonstrates moderate to severe osteoarthritis and thus, it’s time for a knee replacement, right? Not necessarily. It’s amazing how many patients have severe findings on their x-rays but minimal to mild pain and excellent function. Therefore, we always say, “Treat the patient, not the x-ray.”
Ok, now your pain has been running 5-7 out of 10 for weeks to months. Therefore, it’s time for a knee replacement, right? Well, pain is certainly a factor in this decision; however, we have many nonsurgical tools in the toolbox that will reduce or eliminate pain for extended periods of time.
Finally, you’ve been episodically limping now for several weeks. You suppose it’s time for a replacement, right? Persistent dysfunction is another reason to have a knee replacement, but function can often be significantly improved without the need for surgery.
To overcome the symptoms and dysfunction of knee arthritis, three factors can be addressed: the environment, the biomechanics and the structure. Only surgery can change the structure, yet significant improvements in the environment and biomechanics can often delay or eliminate the need for knee replacement.
How do we do this? The environment is best changed by injections such as platelet-rich plasma, an anti-inflammatory pattern of eating, supplements and occasionally medications.
The biomechanics can be improved through physical therapy, certain forms of exercise, bracing and changes in footwear.
So in summary, knee replacement can be the right option for many patients and produce successful outcomes in most patients, yet in 80-90% of the patients that walk (or limp) into our office, nonsurgical treatment will be quite effective.
As always, let us know if we can be of assistance to you!
F. Clarke Holmes, M.D.
PRP: The Simple and Not So Simple
/Many of you are either very familiar or somewhat familiar with platelet-rich plasma injections commonly known as PRP. These are great options for osteoarthritis of a joint, a chronic tendon problem as well as some ligament and fascia problems. Our top conditions treated with PRP include knee osteoarthritis, tennis & golfers’ elbow, plantar fasciitis, rotator cuff tears and Achilles tendon conditions.
When it comes to PRP, here are the simple and not so simple :
Simple
-This is an office procedure, that from start to finish, only takes 45 minutes or less
-A simple blood draw from an arm vein is typically painless
-For a joint injection, pain afterwards is typically very mild
-Risks are exceedingly low as abnormal bleeding, infection, a blood clot or nerve damage are basically nonexistent.
Not So Simple
-We have been performing PRP injections for nearly 15 years. Literally hundreds of hours have been poured into training and fine-tuning the knowledge and skill set it takes to be highly competent to perform this procedure
-Some of our patients have very small veins. Fortunately, we have developed a skill set of ultrasound-guided venipuncture, making blood draws much more successful and less painful on those more challenging patients
-Ultrasound guidance, in our opinion, is a must when giving PRP injections. If you want these growth factor rich platelets to make it to the intended location with great accuracy, then ultrasound guidance is necessary. This is a skill set we have developed over the past 16 years
-With some soft tissue PRP injections, such as partial tears of tendons, we have to prepare our patients that there will be a spike in pain after the procedure, often for one to two weeks. Fortunately, the pain is typically not as significant as it would be if you had a surgery
-Finally, patients have to be patient! PRP exerts its positive effects very gradually. Most patients are seeing a benefit within one to two months, and the maximum benefit often is seen between 6 and 12 months. Thus, we have to advise our patients that with many orthopedic conditions, there is no “quick fix”
Ultimately, PRP can be simple and not so simple, depending on your perspective. Generally speaking, we leave the simple part up to the patient, and we will handle the not so simple aspects of the procedure.
As always, let us know if we can be of assistance to you!
F. Clarke Holmes, M.D.
I Have Knee Arthritis. Can I Still Run?
/The answer is, “yes,” “maybe” or “no.” Thus, it really depends on your situation, and fortunately, a period of relative rest may only need to be temporary.
Here’s the really good news: several recent studies have indicated that running a reasonable number of miles does not cause knee osteoarthritis and may actually have a protective effect.
If you are a runner and your knee is symptomatic, then our role is to help you reduce or eliminate your symptoms and safely return to running. We know that running has numerous health benefits, not only including protection of the joints, but also calorie burning, weight control, improvement of cardiovascular health and many mental health benefits.
As a patient though, it’s sometimes difficult to know when you need to stop running for a while, what’s a reasonable amount of running for your body and what treatment options may be available to not only reduce your symptoms, but also to protect your knees on a long-term basis.
That’s where we come in! We love treating runners and understand how you think. We typically focus on a nonsurgical and minimally-invasive approach to your care.
Physical therapy, bracing, footwear changes, custom orthotics, medications, supplements, and various injections can all play a role in the treatment of knee osteoarthritis. One of the best long-term treatment options, especially for those with mild to moderate osteoarthritis, would be platelet plasma (PRP) injections. These can have a very protective effect for the knee, and not only by reducing symptoms, but also by slowing or stopping the deterioration of the cartilage within the joint. Only a couple weeks of rest are typically required after these PRP injections.
Check out a few blogs on PRP as well as running as it relates to knee osteoarthritis:
https://www.impactsportsnashville.com/blog/2023/8/5/our-top-5-treatments-for-knee-oa
https://www.impactsportsnashville.com/blog/2023/5/12/five-keys-to-successful-outcomes-with-prp-injections
https://pubmed.ncbi.nlm.nih.gov/36875337/
As always, let us know if we can be of assistance to you!
F. Clarke Holmes, M.D.
I Don't Want Surgery But What Else Can I Do?
/Fortunately, 90% of problems that come into an orthopedic clinic do not require surgery.
Approximately 80% of those conditions treated nonsurgically can be treated with traditional treatment measures: rest, activity modification, physical therapy, medications, supplements, lifestyle changes, brace, splint, a boot walker, steroid injection, etc. This is “bread and butter“ treatment administered by an orthopedic/sports medicine physician.
Now, what about that last 20% of non-surgical treatment? That’s often where we have to think “outside the box.” Let’s say in the case of osteoarthritis and tendon problems, that’s where treatment like platelet-rich plasma (PRP) injections can be very helpful. For example, in the case of knee osteoarthritis, how would you like to have less pain, less stiffness, less swelling and better function? What if we could accomplish that with a treatment that is minimally-invasive, safe, proven and natural? As a bonus, this treatment has preventative benefits, meaning we likely are slowing down the cartilage breakdown in your knee. These are the benefits seen with PRP injections.
In the case of tendon or fascia problem like a rotator cuff partial tear, tennis or golfer’s elbow or plantar fasciitis, PRP is designed to be a healing agent. We are using these growth-factor rich injections to accomplish healing, not just make you feel better like a steroid injection might.
Check out a few of our previous blogs, and let us know if we can help you!
https://www.impactsportsnashville.com/blog/2023/12/8/prp-the-gift-of-health
https://www.impactsportsnashville.com/blog/2023/9/23/5-things-you-have-to-know-if-you-have-knee-pain
https://www.impactsportsnashville.com/blog/2023/8/5/our-top-5-treatments-for-knee-oa
F. Clarke Holmes, M.D.
PRP: The Gift of Health
/As we near the major holiday gift-giving season of the year, consider one the best gifts you can give to yourself: the gift of health! Platelet-Rich Plasma (PRP) injections are a great option for you in 2024 if you are looking to boost your orthopedic health and longevity. Here are 5 great adjectives that apply to PRP injections:
1) Safe: adverse effects and complications associated with PRP injections are exceedingly rare.
2) Effective: 80-90% of our patients that receive PRP injections have very good outcomes and are satisfied with their results.
3) Natural: these injections use your blood, specifically your platelets and your growth factors to exert their positive effects.
4) Proven: once considered experimental, there are now hundreds of studies that demonstrate clinical benefit with PRP injections.
5) Preventative: PRP injections are touted in their ability to prevent many degenerative joint and soft conditions from further deterioration.
Want to know more? Check out some of our blogs:
Insurance Companies Say PRP Is Experimental…We Sigh — Impact Sports Medicine & Orthopedics (impactsportsnashville.com)
Five Keys to Successful Outcomes with PRP Injections — Impact Sports Medicine & Orthopedics (impactsportsnashville.com)
PRP And The Three "Es" — Impact Sports Medicine & Orthopedics (impactsportsnashville.com)
As always, let us know if we can be of assistance to you!
F. Clarke Holmes, M.D.
5 Things You Have to Know If You Have Knee Pain
/1. Three factors play a role in knee pain: structural, biomechanical and environmental. Structural means damage, biomechanical means abnormal tracking or loading within a joint or tendon because of misalignment, weakness, and/or inflexibility. Environmental typically means inflammation within the joint or tendon. When formulating a treatment plan for you, we typically want to address one or two of these factors initially. Unless you have major damage, we’re normally not treating structure initially, as that results in a surgery.
2. Age often plays a role in these different factors: in the absence of injury, in patients under 20 years of age, the problem tends to be biomechanical. In patients ages 20 to 40, the problem tends to be biomechanical and inflammatory. In patients older than 40, structural, biomechanical and inflammatory are typically all playing a role.
3. Being proactive in the care of your knee problem usually produces better outcomes than being reactive. This means integrating treatments early on and not waiting until you have major pain or disability to see a physician. We term this “PIO,” Proactive Interventional Orthopedics.
4. Meniscus tears are commonly found on MRIs and may or may not be a source of pain. For decades, the trend was to treat these surgically, typically arthroscopically, removing the torn piece of meniscus. There’s now a trend towards repairing the meniscus tear when possible, but only about 10% can be successfully repaired. Thus, surgery for meniscus tears, especially those age 40 and above, is falling out of favor. On occasion, surgery is the better choice, but treating these initially nonsurgically is usually the best way to start. We often tell patients “a little torn meniscus is better than less meniscus,” especially long term. Less meniscus often equals greater arthritis.
5. Three types of injections can be used for most knee problems: steroid, hyaluronic acid, and orthobiologics. Orthobiologics include platelet-rich plasma (PRP) and stem cell injections. Each of these injections can be reasonably good choices, but for long-term success, PRP is likely your best option in terms of producing favorable outcomes, modifying the disease process, and these are often the most cost-effective option. Stay away from “stem cell” injections that are ordered by physician’s or chiropractic offices and do not come from you own bone marrow or fat. These are often being used inappropriately, and patients are charged exorbitant amounts of money to have these injections.
As always, let us know if we can be of assistance to you!
F. Clarke Holmes, M.D.
Our Top 5 Treatments for Knee OA
/Whether it be mild, moderate or severe knee osteoarthritis, here are our top 5 treatments. If you can incorporate these into your regimen, then you undoubtedly will see the benefits of less pain, better function and greater longevity for your knees.
1) Weight Loss: for every 1 pound a person is overweight, an extra 4 pounds of force are going through the knees. So, lose 10 pounds, and you have 40 pounds of less force on those knees. Lose 25 lbs, and 100 fewer lbs. of force! A recent study indicated that when those with knee OA lost 10% of their weight, their pain decreased by 50%
2) Healthy Eating with an Anti-Inflammatory Diet: healthy eating doesn’t always result in weight loss, but choosing the right foods often results in less inflammation in our body. This means less pain and a better environment for the joints. Choose fresh foods over processed ones. Reach for the fresh foods in the refrigerator more than packaged food in the pantry. Eat at home more and go out to restaurants infrequently. Fruits, vegetables, whole grains and lean meats should be the staples of your diet. Alcohol in moderation. Red meat, fried foods and processed food only on occasion and when necessary. Sodas rarely and watch out for artificial sweeteners.
3) Injections: these are often a faster path to relief for most patients. Platelet-rich plasma (PRP) injections utilizing your own blood and concentrated growth factors are the star of this category. Long-term benefits are most common with PRP. Hyaluronic acid injections (brand names: Orthovisc, Trivisc, Gelsyn, Euflexxa, etc.) are good options for many. At times, we combine the PRP and hyaluronic acid injections to boost the benefits. Steroid injections are the final option and can have great utility when a patient needs to feel better quickly such as during a flare or before a big trip.
4) Exercise/Physical Therapy: choose exercise you like, you will stick to, a variety and types that do not cause pain in your knee, both during and afterwards. Sometimes, it’s not just the type of exercise, but the intensity and duration. Find your “sweet spot,” meaning your knee might feel great if you walk a one mile but hurts if you go further. You can bike for 30 minutes, but beyond that causes swelling. So, stay below your pain threshold. Lower-impact options like biking, elliptical, rowing and swimming/aquatic exercises are often the best choices for most with knee OA. Physical therapy is often a good starting point to strengthen the muscles around the joints and to improve biomechanics, functional movement patterns and flexibility.
5) Supplements: our favorites are collagen, curcumin (the active ingredient of turmeric) and for more advanced knee OA, glucosamine and chondroitin. Others like fish oil may have benefits for the joints as well. The key here is choosing a high-quality brand and taking these on daily basis. Admittedly, they don’t help everyone, and you need to make sure that your physician knows you are taking these, especially if you are taking other medications and/or will soon have a medical procedure.
As always, let us know if we can be of assistance to you!
F. Clarke Holmes, M.D.
Knee Replacement Soon? Hit the Pause Button...
/So many patients with knee osteoarthritis ask me the question “well, if I’m eventually going to require knee replacement, shouldn’t I go ahead and have it done now?”
Well, there’s not just one answer to that question, but here are some of my replies:
-Most knee replacements only last 15 to 25 years. After that, the implants start to loosen, creating pain, swelling or a sense of instability.
-Most patients are at higher risk for surgical complications at the time of a second surgery, known as a “revision,” simply due to their age and likelihood of having more significant medical conditions.
-Surgical techniques are improving with breakthroughs every two or three years. Robotically-assisted replacements and having replacements as an outpatient surgery are two recent examples. More advancements are sure to come.
-One should never base the need to have knee replacement on the appearance of the x-rays. Some patients with “bone-on-bone” arthritis have minimal pain and excellent function. These patients don’t need a replacement.
-What often produces the most pain is an unhealthy environment within the knee joint, some of which may be controlled with injections like platelet-rich plasma (PRP).
-We also believe that PRP may put a stop sign or at least a yellow light on cartilage deterioration. We do not make guarantees about cartilage regrowth, but if we can stabilize a patient’s current cartilage and slow or stop the deterioration, then we are slowing the process of osteoarthritis and perhaps delaying the need for knee replacement.
-For a joint condition like arthritis, we often think of PRP as a maintenance treatment, not just a one-time application. Much like the maintenance for your car, you don’t just take it to the mechanic once or twice and then get a new car. This is an ongoing process.
-Assuming a patient is in that 80% success group with PRP treatments, one should plan on likely having repeat PRP injections every 1 to 2 years. This is a great long-term investment in the health of your knee.
-Want to know more about PRP? Check out this blog:
Five Simple Reasons You Should Consider Platelet-Rich Plasma — Impact Sports Medicine & Orthopedics (impactsportsnashville.com)
In summary, for some individuals, knee replacement is inevitable, but there can be great value in delaying this surgery to increase the odds that it is required just once in a patient’s lifetime. For others, treatments like PRP can eliminate the need to have a replacement.
As always, let us know if we can be of assistance to you!
F. Clarke Holmes, M.D.
Insurance Companies Say PRP Is Experimental…We Sigh
/Platelet-rich plasma (PRP) injections first presented in the orthopedic medical literature in 2004, nearly 20 years ago. Now, new PRP studies hit the orthopedic journals monthly. The overwhelming majority of the evidence suggests that PRP injections are safe, beneficial and have positive effects on soft tissue and joints. Somehow though, insurance companies continue to classify these as “experimental” and will not pay for PRP injections. Thus, these remain cash-pay procedures. PRP injections are not alone, as some of the best procedures now in medicine are not covered by insurance.
PRP is not just used in orthopedics, but also in dentistry, ENT, neurosurgery, ophthalmology, urology, wound healing, cosmetic, hair restoration, cardiothoracic, and maxillofacial surgery. Could all of these specialties be wrong about PRP? I really doubt it.
So, we ask the question: what does it take for something to no longer be classified as experimental? In my opinion, as a physician of 25 years, treatments should no longer be considered experimental if they meet the following basic criteria:
1) They have been used consistently in medicine for 10 years or longer by a reasonably high percentage of specialists in a particular field.
2) Quality studies published in the reputable medical journals demonstrate a clinically significant benefit.
3) Use of a particular treatment steadily grows because of positive results with a low likelihood of adverse events.
If you evaluate PRP with this criteria, then it’s a no-brainer…it is no longer an experimental treatment.
Insurance companies do serve a valuable role in our medical system. Without them, health care would be unaffordable for many Americans. However, the criteria they sometimes use to classify whether a particular treatment or test is covered or not is often very flawed and/or “behind the times.” Here’s a classic example: we could choose to give 10 steroid/cortisone injections into a patient’s knee in just one year, and almost all insurance companies would pay us for each injection. This could be very damaging to the joint, but it would be a “covered” procedure. In contrast, PRP injections, which have been shown to be superior to steroid injections for knee osteoarthritis in dozens of studies, would not be covered by insurance.
So, as a patient, you have to be discerning and partner with a physician who understands what treatment options are best for you. Basing these decisions on what insurance covers can be a short-sighted approach.
In conclusion, both physicians and insurance companies play vital roles in the care of the patient, but these roles are different. I say, “let doctors doctor and administrators administer.” For now, don’t count on a PRP injection to covered by insurance companies any time soon, but that should not deter you from choosing these valuable treatments. Want even more info? Check out one of our recent blogs on the topic:
As always, let us know if we can be of assistance to you.
F. Clarke Holmes, M.D.
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
Five Keys to Successful Outcomes with PRP Injections
/Quality Equipment- we’ve chosen a PRP system created by one of the industry’s leaders in orthobiologic injections.. This is our 5th PRP system to use over the past 12 years. Thus, we are always searching for the best option to produce a high-quality PRP solution.
Appropriate Selection of Patients- we attempt to choose patients and conditions that are excellent candidates for PRP injections. Admittedly, not every patient is an ideal candidate, yet their options may be limited in terms of other forms of treatment, or they are willing to have PRP due to its excellent risk-benefit and cost-benefit ratio compared to more invasive treatments. Partial tendon tears, plantar fasciitis and osteoarthritis of the knee, hip and shoulder comprise 95% of our PRP injections.
Appropriate Pre-Procedure and Post-Procedure Instructions and Compliance-little things can be the difference between PRP succeeding or not succeeding or between a good outcome and a great outcome. For example, it’s important for a patient to be off any anti-inflammatories at least a week before and 2 weeks after a PRP injection. It’s also important to rest the treatment area, and this form of rest really varies depending on the patient and their area treated. A patient’s timetable for return to exercise and/or rehabilitation must be carefully outlined.
Quality Preparation of the PRP solution- not all PRP is the same. The platelet concentration and number of platelets can vary and are important aspects of the potential success of PRP. How much blood we take from the patient and the PRP system dictate these numbers. Also, we typically create a leukocyte-poor (low numbers of white blood cells) for joint injections and leukocyte-rich (higher white blood cells and the highest number of platelets) solution for tendon injections.
Accuracy of the Injection, Preferably with Ultrasound Guidance- using ultrasound for the injection often results in less pain, lower risk, and greater accuracy. We place the PRP exactly where it needs to be and avoid hitting other structures like bone, cartilage, nerves and blood vessels. We often say, “if you’re going to invest your time and money in this procedure, don’t you want it done as precisely as possible?”
More medical professionals are performing platelet-rich plasma injections than ever. This innovative treatment is not going away and will only evolve in the years to come. If you think you are a first-time or repeat candidate for a PRP injections, then come see us!
F. Clarke Holmes, M.D.
PRP And The Three "Es"
/This sounds like the name of a band, right? Well, we’re referring to platelet-rich plasma (PRP) injections and three important words that start with an “E” when discussing these procedures.
First, a quick reminder that we use your own blood obtained from an arm vein, a special kit, a centrifuge and a precise separation process to create the PRP. PRP is then a great treatment choice for osteoarthritis of the knee, hip, shoulder and other joints. It’s also an effective treatment for tennis and golfer’s elbow, plantar fasciitis, Achilles and rotator cuff tendon problems, just to name a few. When considering who will perform your PRP injection, you absolutely need to consider the three Es:
Experience: At Impact, Dr. Holmes has been performing PRP injections since 2009. Very few physicians in the Nashville area can claim that level of experience. In addition, we are giving more PRP injections than ever as more and more patients are realizing the benefits of this procedure. Thus, in 2009, we may have given 1-2 PRP injections a month, and now, we give 12-15 a month on average.
Expertise: With experience comes expertise, yet expertise also comes with putting in the work. This means attending conferences, reading and interpreting studies, participating in webinars and interacting with peers who are also experts in the field. Hardly a week goes by that we don’t spend some time fine tuning our expertise in this field. Next, we’ve been pioneers in the sports medicine industry through our ultrasound-guided injections. 14 years of experience with ultrasound and over 10,000 injections later, we consider this to be an area of expertise.
Equipment: PRP is not just PRP, meaning some kits, equipment and the preparation process are better than others. Novices in the field tend to choose lower cost and lower quality PRP systems which often produce fewer numbers and a lower concentration of platelets. At Impact, we are on our 5th PRP system over the past decade. These systems continue to improve, and you deserve a high-quality option. Finally, ultrasound-guidance is paramount when having a PRP injection. Don’t you want this high-powered solution to be injected into the precise location? Without ultrasound guidance, you are proceeding “blindly” and can only hope the injection makes it to the intended location.
Considering a PRP injection for your orthopedic condition? Remember the 3 Es and let us know if we can be of any assistance to you!
F. Clarke Holmes, M.D.
What Does "Being Proactive Over Reactive" Mean?
/Proactive Interventional Orthopedics (PIO)…a concept we will continue to promote. What does it mean in orthopedics to be proactive over reactive? Here are some examples and brief explanations:
Choose maintenance and more long-term injections over short-term steroid/cortisone injections: platelet-rich plasma (PRP) and hyaluronic acid injections often produce a more clinically significant and longer duration of benefit than steroid injections. For your knee and hip arthritis, tennis and golfer’s elbow and plantar fasciitis, just to name a few, choose these injections.
A course of physical therapy over exercises you simply found online: patient outcomes are generally better when you work with a physical therapist over Dr. Google or YouTube. We have fantastic relationships with physical therapists across Middle Tennessee and can work with you to find the best fit.
Regular use of supplements over prescription or over-the-counter medications: there’s a time and place for prescription meds when managing orthopedic conditions. However, for long-term management, we prefer options like curcumin/turmeric, collagen, and glucosamine/chondroitin. That being said, it’s always wise to consult with a physician before starting new supplements.
Don’t wait for your pain or disability to reach high levels before you seek treatment: orthopedic conditions treated early after the onset of symptoms and when pain and dysfunction are at a low level typically respond better to less-invasive treatments, and this early treatment can lower the risk of further damage to the joint or tissue.
Choose a specialist over a primary care physician for your orthopedics needs: PCPs work really hard and a do a great job to care for your overall health, but they do not necessarily have the expertise, the tools such as on-site imaging and advanced equipment or the time to dedicate to your orthopedic conditions.
Healthy eating patterns over a fad diet: weight loss is a vital part of the treatment plan when it comes to weight-bearing joint problems like hip and knee osteoarthritis. Through a variety of options, we can help you a structure a plan to gradually lose weight in a manner that the weight will stay off and through means that can be maintained for the long-term.
As always, let us know if we can help you overcome an injury, treat an orthopedic condition or find the pathway to greater wellness with an improved quality of life!
F. Clarke Holmes, M.D.
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
Five Simple Reasons You Should Consider Platelet-Rich Plasma Injections For Your Tendon Or Joint Pain
/Let’s make this one quick and easy. Some blogs, we may hit with you great details, information rich in scientific data and opinions full of medical jargon. Today, let’s share some simple information regarding why platelet-rich plasma (PRP) injections should be on your radar if you have OSTEOARTHRITIS, TENNIS OR GOLFER’S ELBOW, ACHILLES TENDONOSIS, PLANTAR FASCIITIS, LATERAL HIP, PATELLAR AND ROTATOR CUFF TENDONOSIS, just to name a few.
1) Most of the time, it works: let’s be real, nothing in medicine works all of the time. If we see a significant benefit in 75% of patients or more, then we are all pretty happy with a treatment. In our patient population, PRP meets this criteria.
2) Most medical studies suggest a clinically significant benefit: do a “pub med” search for PRP as it relates to orthopedic conditions. Although some studies always will be too small or of lower quality, once you start to pool the data, you find that PRP is not really “experimental” any more. There are now hundreds of studies looking at patients receiving PRP for arthritis and chronic tendon problems, and the majority of these studies demonstrate a clinically significant benefit with PRP.
3) It’s both natural and safe: PRP is derived from your own blood. It’s designed to concentrate your platelets that contain your growth factors. These growth factors have many positive effects, ranging from inflammation reduction to slowing down the deterioration process within a tendon or joint. Major side effects are extremely rare, and when compared to steroid injections, prescription medications and surgical intervention, PRP is a safer treatment option with fewer adverse effects.
4) It’s a relatively quick office procedure: 5 minutes to set-up and draw the blood, 5 minutes to transfer the blood to the centrifuge system, 10 minutes to spin the blood, 3 minutes to further separate the blood components and capture the PRP, 2 minutes to prep the patient, and 1 minute to give the injection. In some instances, we may first inject a numbing medication (anesthetic) and then give that 10 minutes to work. So, in total, 36 minutes for this procedure done in the office, all in one sitting.
5) Although typically not covered by insurance, it’s likely a wise investment in your health and may save you money in the long run: the days of insurance always covering the best and most innovative procedures for orthopedic conditions are over. If PRP works for you like we expect it to, then you will potentially save money on doctor’s visits, medications, physical therapy, surgical interventions and other treatments. Not to mention that if you have not yet met your deductible, you will pay out-of-pocket for all of the other treatments “covered by insurance” that may be less effective than PRP.
In an nutshell, PRP is not for everyone and every orthopedic condition. We carefully select those patients who we think can “win the battle” with their orthopedic condition with one or more PRP injections. 20+ years of experience in sports medicine and orthopedics and 10+ years utilizing PRP have given us the knowledge to determine what patients may truly benefit from PRP injections. Come see us if you are curious!
F. Clarke Holmes, M.D.
Impact Sports Medicine and Orthopedics
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 Dirty Little Secrets Some Chiropractors Aren’t Telling You About Stem Cell Injections
/“Judy,” our middle-aged patient, presents to our practice with chronic knee pain due to arthritis. She is seeking another opinion. She relates that three months ago she went to a “Dr. X’s” chiropractic office seeking the miracle cure of her chronically painful knee. She had seen a Facebook post from the chiropractor’s office advertising “stem cell” injections for patients with painful orthopedic conditions. The ad looked great. The testimonials on the website captured her even more. After two previous knee arthroscopies (“scope surgeries”), this was now her chance to get that knee better without a knee replacement. Per the advertisement, “regrow cartilage and become pain-free, all with just a simple injection.” She placed the phone call and within a week, she was in “Dr. X’s” office writing that rather large check to receive her miracle shot of stem cells. Fast forward 3 months and now “Judy” has paid $5000 out-of-pocket for her pseudo stem cell injection and another $1000 for a knee brace. It’s obscene. Has she seen improvement? A “little bit” she tells us, but not enough to justify that $6000 check.
Concerned. Disappointed. Angry. Those are the first words that come to mind when I read or hear about another non-medical doctor advertising “regenerative” injections, such as stem cell or platelet-rich plasma. I’ll be honest here…the greatest number of advertisements come from the practices of chiropractors. Here’s the irony: chiropractors cannot legally give orthopedic-based injections. So, what’s the catch? Most hire mid-level providers, physician assistants (PAs) or nurse practitioners (NPs), to give these injections. Mid-levels serve very valuable roles in our healthcare system. Some are skilled enough to provide injections in a very competent fashion. However, our medical system has been designed such that mid-levels are mentored and directly supervised by medical doctors who have expertise in providing procedures such as injections. In the case of a chiropractor’s office, how can the supervising chiropractor mentor or teach the mid-level to do an injection when he or she has never given a joint, tendon or other similar injection in his or her entire career? It just does not make sense, plain and simple. Then, you are talking about very advanced injections, most of which are not covered by insurance and cost the patient hundreds to thousands of dollars. Finally, many of these injections done by mid-levels are not guided in any fashion, meaning neither ultrasound nor fluoroscopy (live x-ray) is used. Thus, the accuracy of the injection is likely less than optimal.
Here's another valuable piece of information: these injections claiming to be “stem cell” injections very likely have minimal to zero live stem cells. Most independent studies have verified this. Most of these injections primarily consist of amniotic fluid, the fluid surrounding a fetus when a woman is pregnant. Now, amniotic fluid does have value, as it is rich in growth factors. These growth factors can serve to reduce inflammation, and thus, lead to a reduction in pain and improvement in function. Can they help cartilage to regrow? The truth is that we don’t know. Right now, it’s unlikely that any injection can reliably regrow cartilage, so the honest clinician tells the patient that although cartilage regrowth is theoretically possible and may occur in some cases, we certainly cannot guarantee this will happen. So, when a medical practice is using an injection such as this that does not come from the patient’s own fat/adipose or bone marrow, then it is not a true stem cell injection. Thus, the claim that “stem cell” injections are being given is misleading at best, fraudulent at worst.
Quickly, we will also cover the cost of these injections. Admittedly, some of these best procedures in orthopedics are not covered by insurance. Thus, medical practices can set their own prices for these orthobiologic injections. What’s reasonable to charge? On top of the cost of injection and materials to provide the injection, add in the typical cost of an office visit, the cost of the injection procedure, ultrasound guidance (if used) and for the time/research it has taken to develop an expertise in this skill. What’s that worth? $300-$500 is our typical “mark-up” a for platelet-rich plasma or an amniotic fluid injection. We believe this is very reasonable and equal to or less than most of our peers who are experts in providing orthobiologic injections. When a patient pays $3000-$5000 out-of-pocket for an injection (other than a true stem cell injection), then you can bet that the mark-up is in the thousands, not hundreds. Once again, it is so disheartening that some medical practices decide to take advantage of patients desperately seeking relief from their painful orthopedic condition.
Here’s the bottom line: even with all the radio, magazine, TV and social media advertising done by some practices claiming to be experts in “regenerative injections,” you need to carefully choose who you want to provide these advanced office procedures. I have a very healthy respect for several of my colleagues who are chiropractors. I freely refer to them. Many do an excellent job with care of the spine and rehabilitation of some extremity issues as well. However, orthopedic injections are just not in their wheelhouse.
At Impact Sports Medicine and Orthopedics, we have used ultrasound guidance for 11 years and only after taking a minimum of 6 courses on the subject. We are carefully studying the science and trends pertaining to orthobiologic/regenerative injections and have provided these to our patients over the past 9 years. We are not the only ones in the Nashville area doing these advanced injections, but you will be hard-pressed to find any practice more experienced or dedicated to the honesty and integrity of the process.
-F. Clarke Holmes, M.D.