Proactive Versus Reactive: Which One Are You Choosing?

We strongly encourage our patients to be proactive with their musculoskeletal health over just being reactive.

Let’s list some examples of the two different approaches:

Proactive

1. You’re trying to remain in great shape, yet your knee is starting to ache due to mild osteoarthritis. No surgery is necessary, but you want to do something that not only reduces symptoms, but also protects the knee in the long term that is likely disease-modifying. Thus, a series of platelet rich plasma (PRP) injections will meet those goals. PRP injections are one of the best treatment options for the management of osteoarthritis.

2. You’re starting to have heel pain when you first get out of bed. You suspect plantar fasciitis. Instead of ignoring the symptoms or simply relying on Dr. Google, you decide to consult with a sports medicine physician, so a comprehensive diagnostic and treatment plan can be constructed and customize for you. You realize an inexpensive ultrasound in the office can confirm this diagnosis, determine severity and help with prognosis. At that visit, you’ll be given numerous treatment options and successfully guided on your ability to continue exercising to maintain good health.

3. You have daily aches and pains, early arthritis and stiffness, but really don’t want to go on daily medications to manage the symptoms. However, you need some help making lifestyle choices as a pertains to diet, supplements and exercise choices. You understand that friends, family, and the Internet are not the optimal resources. Therefore, you decide to move forward with a physician consult so you may receive advice in great detail regarding the best supplements to choose for your particular situation, how to approach exercise and dietary choices. You understand that it is your physician’s to help you decide between what is fact and what is myth.

Reactive

1. Your heel starts to hurt after some longer walks, especially when you first get out of bed. You talk to friends who recommend rolling the heel, stretching the toes and obtaining non-customized orthotics. You continue to walk, but three months later your heel pain is worse and you limp into the doctor’s office wondering what happened. Bottom line, you now have advanced plantar fasciitis. Unfortunately, the advice you’ve received from well-intentioned others has not been the best for you. Presenting to the doctor when the symptoms first developed would’ve given you a much better outcome, as an entirely different set of treatment options would have been suggested.

2. Your arthritic knee starts to hurt and you see a bit of swelling, but you decide to keep going to the gym, rubbing Biofreeze on it and you add in some heavy yardwork over several weekends, Ultimately, you can barely bend your very swollen knee, and you’re thinking about canceling that trip to see grandkids. Of course, we are here to help you, but we could’ve avoided this major flare if we would have proactively started some treatment as soon as your knee started to ache.

So we ask the question: are you going to be proactive or reactive? Not every little ache or pain that last hours to a few days should prompt a visit to the doctor. However, do not ignore symptoms and instead, do realize that early treatment usually provides better outcomes than waiting until symptoms rise to a moderate or severe level.

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.

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.

BEING PROACTIVE, NOT REACTIVE, WHEN IT COMES TO PLATELET RICH PLASMA (PRP) INJECTIONS

I am a 28 year-old nurse practitioner and former competitive athlete, and I am strongly considering getting platelet-rich plasma (PRP) injections for my knees. Why? For one, as a provider, I have witnessed many improved patient outcomes. Two, this procedure is safe, has relatively no side effects, and is minimally-invasive. Lastly, we are seeing that by being proactive with PRP versus reactive when symptoms are present shows even further benefit.

After many years of intense volleyball training, games, and working out without any downtime throughout the year, I developed bilateral knee pain. Although I have no x-ray evidence of osteoarthritis at this time, based on my symptoms, there is no doubt I have cartilage damage. Because of this, I feel that PRP injections, in addition to other conservative treatments I’ve used, will boost the longevity of my knees. 

PRP helps soft tissue, joint, and cartilage pathology. It is a great way to use your own body’s healing system to improve musculoskeletal problems, and there is minimal risk because it uses your own blood. 

What’s our process?

1. Obtain blood from a vein.

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

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

4. The PRP is then injected under ultrasound guidance in the targeted area.

When injecting the PRP solution to the targeted area, it creates an espresso shot-like effect for your body’s growth factors and repair cells to travel to this area. The main goal is to help repair the damaged area, decrease pain, and improve function. Keep in mind that this is a slow and methodical approach that can take up to 6 months to see maximum benefits. Sometimes more than one PRP injection is needed. How long does PRP last? It varies based on the severity of the patient’s condition, a patient’s activity level, and incorporation of other conservative treatments. Cost can vary per practice. We typical charge $800-$950 (*subject to change) depending on how many locations we are injecting and which centrifugation system we use. Keep in mind that PRP injections are NOT stem cell injections. 

My goal with this blog is to change the thought process that PRP injections should only be used reactively to treat orthopedic conditions and their accompanying symptoms to one instead that utilizes PRP in a proactive approach to slowly repair and stabilize conditions. 

So, why haven’t I had PRP injections in my knees already? Honestly, the only thing holding me back is my nervousness when it comes to needles. 

Interested to see if PRP injections would be helpful for you? We would love to have a consult with you to discuss these in detail! 

Taylor Moore, FNP

Impact Sports Medicine and Orthopedics