“Blood” (PRP) Versus “Gel” (Hyaluronic Acid) Injections: How to Choose
/The two most popular and common injections we offer patients for knee osteoarthritis are platelet-rich plasma (PRP), utilizing a patient’s own blood, and hyaluronic acid injections, commonly known as the gel, rooster comb, or viscosupplement injections.
Let’s compare the two and discuss pros and cons of each:
Both would be considered “natural“ injections with PRP obviously coming from your own blood and hyaluronic acid is a substance already in your joint, but depleted in joints that have osteoarthritis.
We often describe PRP as that big 100,000 mile service you do on your car, and hyaluronic injections are more like the oil change. Thus, PRP is more comprehensive.
PRP Injections
PROS
-most effective long-term injection we offer patients. Benefits typically seen for 6–24 months, and then PRP can then be safely repeated when necessary.
-very likely disease–modifying, meaning we are stopping or slowing the deterioration of cartilage in the knee. These give patients the greatest opportunity to either delay or avoid knee replacement.
-other than weight loss, probably the best long-term medical and financial nonsurgical investment in the health of your knee.
CONS
-not covered by insurance. See our blog regarding this here
-works gradually, with greatest benefit likely seen 4-6 months after the injections.
-anti-inflammatories of any type as well as blood thinners need to be stopped before and after the PRP procedure for a specific period of time.
Hyaluronic acid Injections
PROS
-authorized by most insurance plans, meaning the cost of these is fully covered, partially covered, or can be applied towards your deductible.
-excellent safety profile.
-the majority of patients see a benefit, often for 4 to 12 months.
-like PRP, injections are not particularly painful when given into the knee joint under ultrasound guidance and only require a few days of rest afterwards.
CONS
-may have an indirect benefit on the long-term health of the knee joint, but are not considered “disease–modifying” like PRP.
-benefits of pain and swelling reduction along with functional improvements do not last as long as PRP.
-although they work a bit more rapidly than PRP injections, typically it takes 6 to 8 weeks after the final injection to see the greatest benefit.
-most brands require a series of 3–4 total injections, given one per week.
Want to know more about PRP?
Learn about the key details of PRP here
How is PRP simple and not-so-simple? Read here
As always, let us know if we can be of assistance to you!
F. Clarke Holmes, M.D.
PRP For Knee Pain: Almost A No-Brainer
/Knee pain is often caused by a meniscus tear, osteoarthritis, patellar tendinopathy, low-grade ACL or MCL sprain or some combination of these.
Don’t want surgery, don’t need surgery or already had surgery with a less than satisfactory outcome?
Platelet rich plasma (PRP) has been a star in the world of orthopedics, particularly as it pertains to knee conditions.
Once considered experimental, this innovative, minimally-invasive treatment using your own blood and concentrated growth factors is now is becoming a standard-of-care treatment for many knee conditions.
Over 45 studies have demonstrated clinically significant benefit in the treatment of knee osteoarthritis (OA). The overwhelming majority of studies demonstrate that PRP is more effective in the long-term when compared to steroid or hyaluronic acid injections for knee OA.
Want something safe, natural, effective, and a disease-modifying intervention that will relieve pain, improve function, provide stability and/or healing for tissues that can be done in the office? Then PRP can be a great option for you.
I've been giving ultrasound-guided PRP injections for 15 years. I’ve spent countless hours on the educational process, training and fine-tuning of techniques to make this a excellent option for our patients. I’ve been a patient myself, receiving PRP for shoulder and knee conditions and I've experienced the success firsthand.
Want to know more about PRP?
Learn about the key details of PRP here
How is PRP simple and not-so-simple? Read here
If you think you may be a candidate or want to discuss further, then
come see us. We are always happy to help!
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.
When It Comes to Osteoarthritis, PRP is the Winner!
/Although platelet-rich plasma (PRP) injections remain innovative and the science behind and techniques when using them are evolving, they are trending towards the injection of choice, especially in the case of osteoarthritis. Once considered “experimental,” there are now at least 45 studies validating the success of PRP in the treatment of knee osteoarthritis. So simply put, why would you choose PRP over a steroid injection or hyaluronic acid for knee osteoarthritis?
-Safer and more natural
-Longer-lasting relief of pain with often 6 months to 2 years of benefit for knee OA
-Most likely PRP is disease-modifying, meaning it is slowing the deterioration of cartilage in your knee
How about a study or two demonstrating these points made above:
PRP and Knee OA- Article 1
PRP and Knee OA- Article 2
Want to know more? Here are a couple of our previous blogs on the topic:
https://www.impactsportsnashville.com/blog/2024/2/16/7826kg4vvyebmp8bt2aph72i704hmc
https://www.impactsportsnashville.com/blog/2023/6/17/insurance-companies-say-prp-is-experimentalwe-sigh
As always, we are here to help! Let us know if we can be of assistance to you.
F. Clarke Holmes, M.D.
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
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.
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.
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
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.
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.
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.
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.
Three Roadblocks to Your Health: Time, Fear and Money
/
Time: we’re all so busy, at least we think we are. Let’s be real, going to see the doctor does take time. Driving, parking, filling out forms, waiting, talking, testing and deciding. The average visit from start to finish. meaning door-to-door is in the range of 2 to 3 hours. Yet, that 2 to 3 hours could be the difference in you getting a diagnosis, relieving anxiety, feeling better, promoting better function and doing something that can help your body long-term. Are you willing to binge watch a show for 2 to 3 hours? Are you willing to go to dinner for 2 to 3 hours? Are you willing to surf social media and watch videos for 2 to 3 hours? Are you willing to go to the mall for 2 to 3 hours? Are you willing to go to the gym for 2 to 3 hours? If the answer to these questions is “yes,” then you definitely have time for a doctor’s visit.
Fear: so many patients skip that doctor’s visit because of fear of a frightening diagnosis, a recommendation that surgery is necessary or because of potential expenses that come with that visit and subsequent treatment. Here’s the good news: often that fear fades away once you get into the doctor’s office and actually are able to learn why you have certain symptoms and then are able to develop a plan of action. I’ve seen it for decades, as many patients, even when given news that they did not want to hear, find a sense of relief. Frequently though, we are able to provide good news and reassurance, calming the patient’s fears. In a nutshell, fear of the unknown is often much greater than the fear of the known. More good news here… 95% of patients that present to our office do not require surgery!
Money: sometimes the most expensive course of medical treatment is the one that was developed late in the game. Meaning, if a patient would have sought treatment earlier, a much less expensive plan of action could have been developed. There is no greater investment than the one in your health. We are all willing to spend money on trips, hobbies, clothes, restaurants, cars, etc. While all these can have value, they don’t hold a candle when compared to your health. So, make sure that you are budgeting enough money to pay for your necessary healthcare. Finally, when making financial decisions about your health, attempt to think long-term, not just short-term.
As always, let us know if we can be of assistance to you!
F. Clarke Holmes, M.D.
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.
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.
TENex for TENnis Elbow
/At times, tennis elbow, also known as lateral epicondylitis, can be so stubborn that an advanced procedure is needed to overcome this condition. There are two basic types of surgeries used to treat this condition. The first and by far our favorite is a percutaneous tenotomy under ultrasound guidance, commonly referred to as the Tenex procedure. The other is an open release of the tendon which involves cutting the tendon off the bone. Let’s briefly highlight the differences between the two:
Anesthesia
Tenex: Local-lidocaine injection only
Open: General- patient is put to sleep
Incision Size
Tenex: 1/4 inch
Open: 1-2 inches
Trauma To Tissue
Tenex: Minimal
Open: Moderate
Infection Risk
Tenex: Minimal
Open: Mild
Sutures/Stitches
Tenex: None
Open: 1-2 layers required
Recovery Time
Tenex: 2-6 months
Open: 4-12 months
Success Rate
Tenex: 90-95%
Open: 75-90%
Are we biased towards the Tenex? You better believe it! Look at those comparisons above. In our mind, it’s an obvious choice: the Tenex procedure is the better overall option. Why do more physicians not perform the Tenex procedure? Because you are required to have proficiency in musculoskeletal ultrasound to perform this procedure. Not many physicians have taken the time and made the investment in ultrasound-guided procedures, so they tend to revert to the more traditional, sometimes higher-risk and less successful options.
We’ve performed more Tenex procedures in Middle Tennessee than any other physician. So, if you, a loved one or friend has tennis elbow, then come see us!
F. Clarke Holmes, M.D.
Bet You Didn't Know: Tennis Elbow
/Tennis Elbow, one of the most common conditions seen by an orthopedist, is one our favorite diagnoses to make. Why?…because we are almost always able to see complete resolution of the symptoms. Plus, we have numerous traditional and innovative tools in the toolbox to help our patients overcome this often stubborn and humbling condition. Here are some fast facts about tennis elbow you probably did not know:
-90% of those with tennis elbow, also known as lateral epicondylitis, do not play tennis. Weight-lifting, frequent typing, CrossFit, repetitive labor in one’s work or with household chores are frequent causes.
-Teenagers almost never get tennis elbow. Why? They have an amazing ability for their tendons to recover much faster and more efficiently than middle age and older individuals.
-Lateral epicondylitis is the medical term for tennis elbow and may be one of the more misnamed conditions in orthopedics. This implies there is inflammation of the bone on the outside of the elbow, but instead, this is a tendon problem.
Patients who receive cortisone/steroid injections are often better in the short term but worse in the long term. Our own experience and the medical literature validates this.
Neovascularization, essentially new blood for vessel formation, commonly occurs in advanced cases of tennis elbow. Increased blood flow seems like it would be a good thing for the tendon, but in reality, is a sign of more advanced tendon damage.
We believe that adjacent to those new blood vessels in the tendon are new nerves that are very hypersensitive and only make you feel pain. This is why many patients with advanced cases of tennis elbow complain of “burning” over the lateral elbow.
Platelet-rich plasma injections, now a commonly used and innovative treatment option for many orthopedic conditions, were first studied in the medical literature about 15 years ago in treating tennis elbow. PRP remains one of our advanced treatment options for tennis elbow.
One of our best treatment options for very stubborn cases of tennis elbow is the Tenex procedure. Not many people know about Tenex because we are one of the few physicians in middle Tennessee who have expertise in performing this procedure. We’ve done it for 11 years, and it involves a tiny incision, local anesthesia only, and use of a small needle-like device to excise the unhealthy part of the tendon. No stitches are required and only about two minutes of actual treatment time in the operating room. It carries a 95% success rate in our experience.
If you have pain on the outside of your elbow that is interfering with your quality of life, then come see us. We will have some great options for you!
F. Clarke Holmes, M.D.
Hamstring Strains- The All Too Common Injury
/Picture this….an explosive movement that involves hip flexion and knee extension. What could go wrong? Well, this is the mechanism of a hamstring strain or tear. The classic actions are jumping, kicking, or running. Occasionally, a pop will be felt. We see hamstring strains and tears in our practice often, and frequently, the patient is mistreating their hamstring pathology by the time they get to us. Because of this, we hope this blog will provide education on appropriate first-line treatment before and when you seek medical attention.
First, can anyone name the three hamstring muscles? The answer is: Biceps femoris, semitendinosus, and semimembranosus. What’s the common injury in Major League Baseball: you’re thinking a shoulder or elbow problem, right? Not so fast…a hamstring strain is the most common injury in baseball, and likely the NFL and Major League Soccer as well.
Hamstring strain/tear prevention: proper warm-up, dynamic stretching, adequate rest and recovery, and strengthening. Specifically, the quadriceps muscles tend to get a lot more attention than our hamstrings because they are “look good” muscles. However, neglecting the hamstrings and creating a muscle imbalance definitely increases one’s risks of a hamstring injury. Also in regards to prevention, when a hamstring starts to feel tight or crampy, then that’s a warning sign. It’s then wise to minimize those explosive activities that often lead to a major strain.
In terms of radiographic diagnosis, x-rays are primarily only helpful to evaluate a patient for an avulsion fracture when the pain and strain is near the ischial tuberosity. These fractures are most common in skeletally immature patients such as younger teenagers with open growth plates. Musculoskeletal ultrasound, one of our areas of expertise, is a great and inexpensive way to visualize and grade hamstring strains in our office. Finally, an MRI is the most complete test to visualize a hamstring injury, but is not necessary in most patients and certainly the most expensive and time-consuming test.
Complete tears: If a complete tear is found, particularly proximally (at the origin at the “sit bone”), then surgical reconstruction is the typical treatment. I once knew someone who had liquid courage, (a.k.a., too much alcohol) on board and attempted to do the splits. He made it down into the splits but the explosiveness of the movement caused his hamstring to avulse off of the ischial tuberosity. He had to undergo surgery to reattach it. Needless to say, don’t try to do the splits, folks! Fortunately, complete tears are rare.
Strain/partial tear: This is most commonly the hamstring pathology we see. Hamstring injuries take a long time to heal. With proper treatment, this can be accelerated. The BIGGEST piece of advice I can give initially after the strain is DO NOT STRETCH the hamstring. It will commonly feel tight and feel like you need to stretch, but this will only strain the tendon and muscle belly further. Rest and activity modification are important steps in recovery. This even means to not lead up the stairs with the affected leg or bending at the waist, but instead with at your knees. Any activity that can tug on the hamstring, you should avoid. Other treatment options include thigh sleeve, steroid injection, physical therapy, and platelet-rich plasma (PRP) injections under the guidance of musculoskeletal ultrasound. PRP becomes a great option for proximal hamstring tendon problems that persist beyond a few months. We most commonly see this problem in long distance runners.
Recurrence: hamstring injuries are highly prone to recurrence. This is often due to a return to activity or sport too quickly and/or inadequate rehabilitation. This is why having an expert guide you in your recovery often decreases your risk of re-injury.
In a nutshell, if you have an acute or chronic hamstring injury, it’s best to seek medical attention as opposed to managing this yourself. Proper diagnosis, grading of the strain, discussion of treatment and prevention strategies along with a return-to-play/exercise plan is what we offer our patients.
As always, let us know if we can be of assistance to you!
Taylor Moore, NP and F. Clarke Holmes, M.D.
Tiger Woods and You...
/You or someone you know may have something in common with Tiger: plantar fasciitis. Tiger dropped out of the Masters golf tournament last weekend due to severe heel pain caused by plantar fasciitis. This all-too-common orthopedic condition afflicts a huge number of middle-aged Americans every year. The most common symptoms are heel pain when first getting out of bed, when barefoot or with prolonged walking, running or sports. Here are some key “Dos” and “Don’ts” when it comes to plantar fasciitis:
What To Do When You Have Plantar Fasciitis:
1) Seek medical attention early: We have many tools in the toolbox to treat this condition, but we first need to need to confirm the diagnosis, set-up a multi-faceted treatment plan, and guide you on your prognosis. Ultrasound, which can be done in our office, is by far the best imaging study to see the plantar fascia. This factors into our concept of PIO- Proactive Interventional Orthopedics.
2) Wear good footwear at ALL times: when in the house, in the yard, at the gym, at the pool, while shopping, going to that concert, socializing with friends and at church. Good footwear means very supportive, not too flexible, and not too cheap. Cheap unfortunately often means lower quality.
3) Consider inserts/orthotics for your shoes: over-the-counter can get the job done, but you’ll need some advice on how to choose these. A high-quality athletic shoe store or a visit to your sports medicine doctor can supply that information. However, custom orthotics prescribed by your physician may really be what you need. We are fortunate to have custom orthotic specialists that work directly with our practice.
4) Consider physical therapy as it’s beneficial for most patients: many cases of PF are related to biomechanical problems, meaning that your calves are too tight, your foot pronates or supinates, your foot muscles are weak or you are overweight. Physical therapy along with weight loss in some individuals can help correct these biomechanical problems.
5) Realize that 10-20% of cases of PF will need an advanced treatment: in our practice, our first-line innovative and advanced treatment for stubborn PF is a platelet-rich plasma injection. PRP uses your own blood and the concentrated growth factors we have produced to reduce inflammation and pain while stimulating a healing response. If this fails, then we move on to a minimally-invasive surgery called a percutaneous fasciotomy using the Tenex system.
What Not To Do When You Have Plantar Fasciitis:
1) Stretch the bottom of the foot: many cases of PF involve tears in the plantar fascia. Although stretching the calf can help, stretching the bottom of the foot often irritates the fascia and can inhibit the healing process.
2) Buy expensive orthotics that are rigid or produced by an “orthotics store”: in our experience, these tend to be very uncomfortable for patients and unsuccessful in treating patients’ symptoms. Stick with an orthotics specialist recommended by an orthopedic/sports medicine physician.
3) Have multiple steroid/cortisone injections: although offered by some orthopedic doctors and podiatrists, we rarely offer these injections for PF and essentially never do more than one. Steoid injections can contribute to further tearing and often impede healing. Some patients feel better in the short term with steroid injections, but are worse in the long term.
4) Run/Walk through the pain: unfortunately, PF will just not get better if you keep doing the things that are causing the problem. So, a period of complete rest or relative rest will be necessary for PF to improve. Relative rest can mean dialing down your walking/running frequency or distance to the point that you stay below your pain threshold.
5) Become impatient: recovery from PF is often in the range of months, not days or weeks. So, once a treatment plan is in place, you’ll have to be patient. We often construct a Plan A, Plan B and Plan C. Each plan has 2-4 treatment entities within it and we insitute these for 1-2 months, judge their success and then move on to the next plan if we are not seeing the expected results.
In summary, plantar fasciitis is a condition that requires methodical treatment under the care of an experienced physician. Don’t just trust the advice from your non-medical friend, Dr. Google or YouTube. We are always here to help!
F. Clarke Holmes, M.D.
What is a Sports Medicine Provider, and Can I See One?
/You may be asking yourself what is a Sports Medicine provider? To be honest with you, I only found out the difference between sports medicine and general orthopedics in my last semester of Nurse Practitioner school. Because of this, I want to provide more insight into the differences so that you can be educated and empowered in choosing an orthopedic specialist that best fits your needs.
Sports Medicine is a specialty underneath the orthopedics umbrella. Just like you can see specialists who see only hips, shoulders and knees, foot and ankle, or the spine, you can see a sports medicine specialist. Dr. Clarke Holmes and I are Orthopedic Sports Medicine Providers. What might differentiate a sports medicine provider from a general or specialty orthopedist? Here are few key points:
1. One stop shop: Sports Medicine Providers see orthopedic conditions from the top of your head (concussions) to the tip of your toes, and everything in between
2. Conservative treatment options versus jumping right into surgery: Dr. Holmes and I will always be transparent with our patients if surgery is the best option, but why not try utilizing all the nonsurgical options first if surgery is not necessary?
3. We are experts in minimally-invasive procedures that can either prevent surgery or be an alternative to surgery: For example, Platelet Rich Plasma (PRP) injections are very successfully used for partial tendon tears and osteoarthritis of numerous joints. See our PRP blogs or check out our social media posts to learn more about PRP.
4. Improved accuracy of our injections by utilizing musculoskeletal (MSK) ultrasound guidance. Ultrasound is becoming a mainstay in the sports medicine world, and we’ve used MSK ultrasound for over a decade. We also use this daily to diagnose tendon tears, bursitis, joint swelling and ganglion cysts.
5. Holistic treatment: We care about the patient as a whole person and do not see them as just a body part, a diagnosis or a potential surgery. We develop a plan of action with the patient that considers what activities they like to do, their occupation, weight, nutrition, mental health and any other contributors to formulate an individualized treatment plan.
6. YOU DO NOT HAVE TO BE AN ATHLETE TO SEE A SPORTS MEDICINE PROVIDER. Yes, we experts in treating athletes ranging from the youth to the professional ranks, but we also treat those who do not consider themselves an athlete. In addition, we see patients of all ages and all activity levels. One of my favorite things to treat is arthritis, even in those who do not exercise and just want their pain to decrease and daily function/activities to improve.
Hopefully this has provided clarification on the differences between a sports medicine orthopedic specialist and a other types of orthopedists. As always, let us know if we can be a resource to you!
Taylor Moore, NP
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.
TENex Gets a 10!
/Are you looking for permanent relief from tennis or golfer’s elbow? Are you tired of having elbow and forearm pain with lifting, gripping and grabbing, even with items like your phone or coffee mug? Are your workouts in the gym or tennis or golf severely hampered by these symptoms? Well, then look no further than the Tenex procedure. This is an innovative minimally invasive procedure developed 13 years ago in conjunction with the renowned Mayo Clinic. Dr. Holmes has performed more Tenex procedures than any other physician in middle Tennessee over the past 10 years.
The Tenex procedure, also termed a percutaneous tenotomy, is a great option for tennis or golfer’s elbow (also known as lateral or medial epicondylitis, respectively) that has not healed with rest and other possible treatments such as medications, physical therapy, injections, or bracing.
We go to the operating room, give the patient an injection of lidocaine only, a numbing agent. We get to avoid the sedation, cost and side effects of general anesthesia (getting put to sleep).
A tiny incision of about 1/4 inch is made. A small hand piece with a needle tip is inserted through the incision. Under ultrasound-guidance, this tip is inserted to the damaged part of the tendon and ultrasonic energy allows the tip to debride and remove the unhealthy portion of the tendon while leaving the healthy portion alone. Two minutes of treatment time or less and you are on the road to recovery.
No stitches required, just a few small steri-strips, followed by a small dressing and you are out the door, headed towards tendon healing, and eventually becoming pain-free.
Post-operatively, you wear a wrist splint for at least 2 weeks, and we restrict lifting for about 6 weeks. Our golfers, tennis players and weightlifters can usually gradually resume these activities at the 3-month mark. There is no “quick fix” for these conditions, yet Tenex offers a permanent solution to an often-stubborn problem.
We’ve done in the range of 500 of these procedures over the past 11 years with excellent results.
This procedure really beats the option of steroid injections, which often make the condition worse in the long term. The alternative to Tenex is a larger surgery requiring a 2-inch incision and a much longer recovery.
In our book, the Tenex procedure gets a rating of 10!
What Does "Being Proactive Over Reactive" Mean?
/Proactive Interventional Orthopedics (PIO)…a concept we will continue to promote. What does it mean in orthopedics to be proactive over reactive? Here are some examples and brief explanations:
Choose maintenance and more long-term injections over short-term steroid/cortisone injections: platelet-rich plasma (PRP) and hyaluronic acid injections often produce a more clinically significant and longer duration of benefit than steroid injections. For your knee and hip arthritis, tennis and golfer’s elbow and plantar fasciitis, just to name a few, choose these injections.
A course of physical therapy over exercises you simply found online: patient outcomes are generally better when you work with a physical therapist over Dr. Google or YouTube. We have fantastic relationships with physical therapists across Middle Tennessee and can work with you to find the best fit.
Regular use of supplements over prescription or over-the-counter medications: there’s a time and place for prescription meds when managing orthopedic conditions. However, for long-term management, we prefer options like curcumin/turmeric, collagen, and glucosamine/chondroitin. That being said, it’s always wise to consult with a physician before starting new supplements.
Don’t wait for your pain or disability to reach high levels before you seek treatment: orthopedic conditions treated early after the onset of symptoms and when pain and dysfunction are at a low level typically respond better to less-invasive treatments, and this early treatment can lower the risk of further damage to the joint or tissue.
Choose a specialist over a primary care physician for your orthopedics needs: PCPs work really hard and a do a great job to care for your overall health, but they do not necessarily have the expertise, the tools such as on-site imaging and advanced equipment or the time to dedicate to your orthopedic conditions.
Healthy eating patterns over a fad diet: weight loss is a vital part of the treatment plan when it comes to weight-bearing joint problems like hip and knee osteoarthritis. Through a variety of options, we can help you a structure a plan to gradually lose weight in a manner that the weight will stay off and through means that can be maintained for the long-term.
As always, let us know if we can help you overcome an injury, treat an orthopedic condition or find the pathway to greater wellness with an improved quality of life!