The Top 5 Reasons Why An Injection May NOT Work For You
/1) The injection missed the spot: We take a lot of pride in using ultrasound guidance for all of our injections. This tremendously improves accuracy, making an injection much more likely to be effective. However, this is a skill set we have honed for 10 years and is still not considered the standard of care in orthopedics. Therefore, many injections by very good clinicians are still given without ultrasound, and unfortunately, the target is often missed. Even missing by a few millimeters can decrease the effectiveness. Medical studies have demonstrated that some of the most commonly given injections in orthopedics without guidance are inaccurate anywhere from 10% to 70% of the time.
2) Steroids don’t help everything: Steroids are great anti-inflammatories but do not reverse damage. They may help in some cases of arthritis, and if so, often are temporary, providing weeks to months of benefit. In addition, in many cases of tendon problems such as tendonosis (degeneration or tendon tearing), inflammation is not the primary source of pain and thus, the steroid injections are unlikely to help for any significant period of time.
3) The pathology is too great to see benefit from an injection: For example, in some cases of severe arthritis, no injection is going to help to a significant degree. A prime example would be severe hip osteoarthritis where total hip arthroplasty (hip replacement) is usually far more effective than any type of injection. There are some ligament and tendon tears that are full thickness, and no injection will get the job done. Thus once again, surgical treatment would be the top recommendation, with an ACL tear being a prime example.
4) After the injection, you do not treat the injected area the correct way: We are very specific in our “dos” and “don’ts” after an injection. For example, after the majority of our steroid/cortisone injections, we recommend a minimum of 5 to 7 days of rest of the affected area. So, if you have a knee joint injection you are not going for a power walk, playing golf, or doing heavy yardwork for 5 to 7 days after the injection. Those who return to rigorous activity too soon often do not see the expected benefit after certain injections. After more complex injections like platelet-rich plasma (PRP), we generally have very specific restrictions and recommendations in our aftercare protocol. For example, after a lateral elbow PRP injection, we typically hold patients out of golf or tennis for 2 to 3 months to allow for healing of the tendon.
5) Lack of experience by the clinician providing the injection: There are many small nuances when it comes to giving a successful injection, including needle length, the right dosing of the injected solution, whether guidance is used effectively or not, how quickly the material is injected, the correct volume of the injected solution and patient positioning during the injection. Those clinicians who have fine-tuned their skill set over years to decades have developed an ability to make the right choices when it comes to these decisions, thus putting the injection in a position to be successful.
Injections are some of the most effective tools in the treatment of musculoskeletal conditions. They can be used to reduce pain, improve function, improve quality of life, serve as diagnostic tools, and in some cases, can promote healing of damaged tissue and/or decrease the deterioration of certain types of tissue such as cartilage within the joint. Therefore, choose your clinician wisely when it comes to injections and utilize someone who has an expertise in this field of medicine.
F. Clarke Holmes, M.D.
Impact Sports Medicine and Orthopedics
It’s Time To Start Treating Your Arthritic Knee Like Your Car
/“Orthopedic Maintenance”…that’s a term you may start to hear, especially in our practice. For years, patients have been led to believe that in the case of their arthritis, there’s “nothing you can do about it” until you want or choose to have a replacement. Also, our medical system has been developed to be reactive instead of proactive, especially again in the setting of arthritis. So, let me ask you this, do you only take your car to the mechanic when you have a problem? If the answer is yes, then you are on the fast track to either a needing a new car or paying your mechanic a pretty penny for all the repairs your car will need! If you are a wise car owner, then you take your car in at regular intervals for the oil change, fluid additions, tire rotation, alignment, brake maintenance and various inspections. So I then ask, should you be doing the same for your arthritic knee? The answer is a resounding “Yes!”
So, what does orthopedic maintenance look like? In very general terms, it means that if your body has aches, pains or dysfunction, then it’s wise to jump on these earlier than later, avoiding the temptation to ignore symptoms, and think, “I’m just getting old.” This translates to seeing your orthopedic/sports medicine physician to confirm a diagnosis and discuss treatment and prevention strategies. Let’s focus on one of the most effective forms of non-operative treatment for knee osteoarthritis: injections
1) Steroid (cortisone) injections are great for acute pain, when it’s important to reduce symptoms and swelling quickly. Steroids are really a more “reactive” treatment, such as when a patient needs to feel better quickly for a major life event (a trip, visit with the grandkids, have to feel better for work, etc.) but can be proactive for a patient trying to stave off a knee replacement or is not a good candidate for knee replacement. For example, the elderly patient whose risk of knee replacement outweighs the benefit, planning two steroid injections a year for his/her symptomatic knee arthritis may allow the patient to feel less pain, move better, be at lower risk for a fall and have a greater quality of life.
2) Hyaluronic Acid/Viscosupplement injections (brand names include Orthovisc, Gelsyn, Euflexxa, etc.) have a long track record of excellent safety and provide symptomatic relief in approximately 75% of patients for 4-12 months. They probably work as anti-inflammatories and lubricants for the knee, replenishing the hyaluronic acid in the arthritic knee that is depleted or less effective. These are probably more beneficial for those with mild to moderate arthritis as opposed to more severe cases. There are essentially no side effects except for mild injection-site soreness in some. Most insurance companies will authorize this 3-4 injection series every 6 months, so planning on about two series a year is a very proactive strategy. These are what we often term as the “oil change” injections.
3) Orthobiologic injections are really your “game-changer” injections. These have been used in orthopedics for 15 years and in our practice for over 10 years. Platelet-Rich Plasma (PRP) is the most commonly used orthobiologic injection. Insurance companies and even some medical providers still like to consider these as “experimental” or unproven treatments for osteoarthritis, yet there are now 39 randomized, controlled trials (studies) that demonstrate that PRP is effective in the treatment of knee osteoarthritis. PRP is derived from your own blood, as we obtain blood from an arm vein, spin this in a centrifuge, remove the majority of red and white blood cells, and concentrate the platelets which are rich in your own growth factors. These growth factors module inflammation, reduce pain, improve function, and most likely have a beneficial effect on the cartilage within the joint. This is how they are “game-changers.” They very likely stop or slow the progression of arthritis by stabilizing the cartilage and potentially improving the quality of the cartilage.
We typically start with two PRP injections 2-6 weeks apart and expect, on the average, 6-12 months of symptomatic benefit. Repeating these at regular intervals is likely the best plan of action in order to see continued, long-term benefits. PRP injections are here to stay, and how we continue to apply them in the treatment of osteoarthritis will continue to evolve.
Primary care providers and dentists have done a great job integrating maintenance evaluations and treatments into a patient’s health regimen. Now, we should likely be doing the same in orthopedics, and the treatment of knee osteoarthritis is a great place to start, as this is the most common medical condition seen in our office today. It is a tremendous source of pain and disability for millions of Americans and contributes to the spending of billions of health care dollars. It’s time for orthopedic physicians and patients to join together to be proactive over reactive and realize that less-invasive preventative strategies are preferred over more-invasive and costly interventions.
As always, we here to help and strive to be your resource for these innovative maintenance strategies!
F. Clarke Holmes, M.D.
Impact Sports Medicine and Orthopedics
What Supplements Might Be Useful In Orthopedics?
/Many people prefer to try a natural approach when it comes to preventing conditions or treating symptoms by taking various vitamins and supplements. There are many options for supplements and vitamins out there, but are they really effective? Unfortunately, there is little education or research on these products.
Remember, the FDA does not regulate supplements and vitamins. Talk to your healthcare provider before beginning any supplements or vitamins. If you are pregnant or breastfeeding, discuss supplements and vitamins with your provider.
Here are a few common vitamins and supplements we discuss with our patients in orthopedics.
Turmeric
Known for its anti-inflammatory properties, turmeric is a great tool to help combat full body inflammation. We recommend a turmeric supplement that contains extract instead of ground root powder, 95% curcuminoids, curcumin, and bioperine (black pepper) to help with absorption. Daily dose recommendation is 500mg-2,000mg. Turmeric can slow blood clotting and should be avoided in those who take blood thinners, have bleeding disorders, anemia, gallbladder conditions, or pregnant. Caution should be used in those who take diabetes medication, as turmeric may make the effects of these medications stronger and therefore may result in hypoglycemia. Note: cooking occasionally with turmeric does not provide the amount needed to reach anti-inflammatory effects.
Glucosamine
Glucosamine is thought to increase cartilage and fluid around joints and/or help prevent cartilage breakdown, therefore, decreasing pain and improving function. Research studies’ results have shown conflicting information. Taking this does not reduce your risk of getting osteoarthritis. The recommended dose is 1,500mg daily. Do not take this supplement if you take warfarin (coumadin) as it increases the effects of warfarin, elevating your risk of serious bruising or bleeding. Do not take this supplement if you have personal or family history of glaucoma, are on cancer treatments, or have allergies to shellfish. Take caution if you have diabetes, as glucosamine has been shown to increase blood sugar levels and decrease the effectiveness of diabetic medications. Also, take caution if you are pregnant and/or breastfeeding, have asthma, glaucoma, hyperlipidemia (high cholesterol/triglycerides), and hypertension.
Chondroitin
Usually taken in combination with glucosamine, chondroitin sulfate is one of the building blocks of cartilage. Used to help decrease osteoarthritis pain and improve function. Recommended daily dose is 800-1,200mg. Do not take if you have prostate cancer or are pregnant/breastfeeding. Take caution in those with asthma. There is an increased risk of bleeding if taken with warfarin.
Hyaluronic Acid (HA)
HA’s action in orthopedics is to lubricate the joints and maintain normal joint cushioning to provide more support, resulting in decreased pain and increased functioning. In osteoarthritis and as we age, this substance becomes naturally depleted due to wear and tear. It comes in many different forms, but injections are the most widely used and most effective in sports medicine and orthopedics. We like to tell our patients to think of HA injections like an oil change for your knee; the oil is the HA substance and, your joints are the car. HA oral supplements have not shown to be effective for musculoskeletal use.
Vitamin D
Most people do not receive enough daily vitamin D from food and sun alone. Vitamin D has many benefits. From an orthopedic standpoint, vitamin D modulates inflammation, prevents involuntary muscle spasms, and cramps, and enhances calcium absorption into the bone which helps with bone growth and bone remodeling. Vitamin D plays a key role in helping prevent osteopenia and osteoporosis (thin and brittle bones). The recommended dose is 600-800 international units (IUs) daily, yet supplementing with 1000-2000 IUs of D3 is safe for most patients. Some patients are found to have vitamin D deficiencies with a blood test and will require higher dosing often for at least a month. Foods high in vitamin D include salmon, sardines, tuna, egg yolks, mushrooms, cow’s milk, soy milk, yogurt, orange juice, cheese, fortified cereal, and oatmeal.
Calcium
Calcium helps build and protect bones. A low calcium intake can result in fractures, osteopenia, and osteoporosis. Most people get enough calcium in their normal diet. The daily recommended amount of calcium needed is dependent on age.
1-3 years old: 700mg
4-8 years old: 1,000mg
9-18 years old: 1,300mg
19-50 years: 1,000mg,
51 years to 70 years: males 1,000mg and females 1,200mg
71 years and older: 1,200mg.
Who needs a calcium supplement? Those who are vegans, lactose intolerance, consume large amounts of protein or sodium, on long term steroid treatment, those who have inflammatory bowel disease and celiac disease, and those who do get enough calcium in the foods they eat. Overall, it is better to get the calcium your body needs through food instead of a supplement. There are some studies that have linked calcium supplements to heart disease, colon polyps, kidney stones, and heart attacks. Foods high in calcium: almonds, oranges, dried figs, soybeans, garbanzo beans, white beans, pinto beans, milk, yogurt, dark leafy green vegetables.
Ashwagandha
Ashwagandha helps in reducing anxiety and stress. On the label you want to look for root extract, as this is more potent that ground root powder. KSM-66 ashwagandha root extract has been studied in many clinical trials with positive outcomes. Daily dose recommended is between 500-1,500mg.
Potential side effects include gastrointestinal upset or headache. It can potentially lower blood pressure, lower blood sugar, and affect thyroid hormones, and in rare cases, have a negative effect on the liver. Women who are pregnant or breastfeeding should not take this.
Taylor Moore, FNP-C
Impact Sports Medicine and Orthopedics
What Shoes Should I Buy?
/Buying shoes is almost as complicated as finding the perfect home. There is an abundance of athletic and casual shoe options, but not many helpful suggestions about the best brands. When you do find a brand you like, many buyers get frustrated at which style to choose because there is never a clear-cut answer on what the difference is between all of the different types. Not only do shoes allow you to do activities you enjoy, but they can even decrease joint pain and orthopedic conditions. However, the opposite is also true. An improperly fit shoe that does not provide support, changes your biomechanics, or is too hyperflexible contributes to increased incidence of foot, ankle, knee, hip, and even spine symptoms. Unfortunately, there is not one shoe that is perfect for everyone, as everyone’s foot and gait style is unique.
So here are a few tips to decrease the frustration when it comes to shoe-shopping.
1. Try all footwear on in-person.
2. Place two fingers on the sole of the toe. If you can fold it onto itself or side to side easily, the shoe is probably too hyperflexible and will likely not provide enough support and shock absorption. We call this the “Holmes Rule.”
3. Check the tread wear on your shoes. If the tread is worn, it is time to go shopping for new shoes. Evaluate where the tread is most worn. If on the outside of the forefoot (near the toes), then you are likely supinating. If towards the inside (closer to the big toe area), then you are likely pronating.
4. Try to go to a shoe store that can identify the best shoe match for you based on your foot shape, the way you walk or run, and your activity. We recommend Fleet Feet, Team Nashville, or Nashville Running Company if you live in the Nashville area.
5. Remember, a manufactured shoe may not fit your needs perfectly. Over-the-counter or custom orthotics/inserts can help your foot to achieve normal realignment and promote proper foot mechanics. Having an appropriate orthotic/insert that is interchangeable amongst all your shoes can decrease foot, knee, hip, and even back pain! We have specific orthotic specialists that work with our practice.
6. A good quality shoe will begin at $75. Be careful buying shoes that are highly- discounted.
Recommended shoe brands:
BRANDS
Asics
Brooks
Hoka
On Cloud
Saucony
New Balance
Karhu
Altra
Mizuno
WIDE TOE BOX
Hoka
Mizuno
Altra
Brooks
Asics
New Balance
CASUAL SHOE
Clarks
Merrell
Johnston & Murphy (XC4 Technology)
Vionic
WALKING/RUNNING
Brooks
Hoka
Asics
New Balance
Mizuno
On Cloud
Karhu
Alta
AGILITY ACTIVITIES
Brooks
Asics
New Balance
Nike
HIKING **
Merrell
Keen
Hoka
Saucony
Altra
Salomon
(**specific hiking versions of these brands)
This is not a complete list of recommended shoes for each category, but a compilation of recommendations based on research and patient feedback.
SHOES FOR SPECIFIC SPORTS: follow sport-specific recommendations for shoe wear
Taylor Moore, FNP-C
Impact Sports Medicine and Orthopedics
What is a Nurse Practitioner?
/I have had the pleasure to meet and take care of many of our awesome patients since I joined Impact Sports Medicine in August 2020. However, questions still occasionally arise about what my role is at Impact.
What is a Nurse Practitioner?
You may hear the following interchangeable terms: Nurse Practitioner, NP, Mid-level, Advanced Practice Registered Nurse (APRN). Nurse Practitioners are trained to assess patient needs, order and interpret imaging and laboratory tests, diagnose conditions, formulate and prescribe treatment plans, and provide patient education. There are many different Nurse Practitioner Specialty degrees. You commonly see NPs in inpatient and outpatient settings, primary care, and specialist offices, occupational health, the health department, and more!
Are a Nurse Practitioner and a Nurse the same thing?
No, these are not the same roles and have different scopes of practice. A nurse assists providers and has an associates or bachelors degree, whereas an NP requires at least a masters degree and special training through an NP educational program.
Nurse Practitioners function as a provider just like a Medical Doctor (M.D.). In Tennessee, all Nurse Practitioners are required to be under the supervision of a Medical Doctor.
What is the difference between a Nurse Practitioner (NP) and a Physician Assistant (PA)?
These two roles function very similarly with tiny nuances. Both are considered mid-level roles. A Nurse Practitioner is required to be a Registered Nurse (RN) before advancing their training to become an NP.
What is my role at Impact Sports Medicine and Orthopedics?
I see patients independently of, and at times along side, Dr Holmes. This means I can assess and examine patients, interpret imaging and labs, prescribe medications, diagnose conditions, provide treatment plans, perform ultrasound guided injections, and provide education to patients. Overall, think of me as a provider extension of Dr. Holmes.
What else do I want you to know about me as an NP?
Although you will see me independently, Dr. Holmes and I work as a team. This means I discuss patient cases and my decisions with him, and always have him review x-ray and MRI images as well. I want patients to know he is involved in their care, even if you don’t see him directly. Yet, have confidence that I will deliver safe, compassionate, and competent care to get our patients better! I work with my patients as a team to devise decisions that are tailored to each individual, their conditions, and their needs.
Hopefully this provides more clarity on what a Nurse Practitioner is and my role at Impact Sports Medicine and Orthopedics. Looking forward to providing care to y’all in the future!
Taylor Moore, FNP-C
Instagram: @taylormoore_nashvillenp
Facebook: Taylor Moore, FNP-C
Here are 4 reasons why some people DON'T want to see an orthopedic doctor (and why they should re-think that decision!):
/1) "I was told I have arthritis, and there's nothing that can be done for it."....more than ever, we have numerous tools in the toolbox to treat symptomatic arthritis and also, means to prevent arthritis from progressing.
2) "I consulted with Dr. Google and got all the information I need to treat this problem."...Dr. Google can not listen to you, examine you, interpret your x-rays, evaluate an ultrasound, prescribe medications, perform a helpful procedure, demonstrate/supervise a rehab program, etc. We like Dr. Google. He's a wealth of information, but he has too many limitations to give you what you really may need.
3) "I already saw my primary care physician for this problem and he/she has started treating me."...We love PCPs and strongly endorse their role in the healthcare setting. We think every patient should have one. However, there is no substitute for specialist care. Don't you want to work with a physician that treats your problem on a daily basis?
4) "I don't want to be told I have to have surgery."...90-95% of the problems we encounter in our practice do not require surgery. Even our surgical peers that we really trust are conservative in their care and only operate on our patients when the condition will have a better outcome with surgical intervention. If we can't get you to the point where you need to be, then we will have partners that very likely will be able to do so.
We are here to help you!
F. Clarke Holmes, M.D.
5 Reasons to Either Have or Avoid a Steroid/Cortisone Injection
/Steroid, often called “cortisone,” injections have been used in orthopedics and other specialties for several decades as potent anti-inflammatories. In recent years, they’ve become more controversial, as medical studies have validated that they likely have negative effects on our bodies and actually worsen certain conditions in the long-term. However, steroid injections still have some positive utility, and careful discussion with each patient must be undertaken to determine whether a steroid injection may be more beneficial or more harmful in each unique situation. Let’s explore those situations:
A Steroid Injection Can Be Particularly Beneficial in These Situations:
1) Adhesive Capsulitis- most commonly seen in middle-age women, this highly-inflammatory condition causing shoulder pain and stiffness often responds beautifully to an ultrasound-guided injection into the glenohumeral joint.
2) Early Phase of Tendonitis- if we catch tendonitis very early and when it’s primarily in the inflammatory stage (like tennis elbow or calcific rotator cuff tendonitis), a steroid injection can be very helpful in reducing pain and restoring function.
3) Diagnostic and Therapeutic- many times, we see a patient that has pain in an area, yet we can’t determine the exact source. Thus, we use a precisely-placed injection with ultrasound to see if the pain is relieved. If so, then we feel that we’ve located the source and can then customize a more effective treatment plan. We use this strategy often for hip pain.
4) A Patient Needs Rapid Relief- your knee is swollen and that bucket-list vacation that will require a lot of walking is fast-approaching. Your arthritic knee is in a flare, and we need to reduce pain and swelling within days, so that you can better enjoy that trip or upcoming event.
5) Gout and Pseudogout- these are highly-inflammatory conditions due to excessive urate or calcium deposits in a joint, respectively. A steroid injection can provide rapid relief from these conditions.
A Steroid Injection Should be Avoided in These Situations:
1) Chronic Tendonitis and Partial Tears- if you’ve had tennis or golfer’s elbow, rotator cuff issues or gluteal tendonitis for 3 months or greater, then your tendon likely has more degeneration and tearing than just inflammation. Steroid injections are far less likely to provide a long-term benefit in these situations.
2) Repetitively- unfortunately, many patients make it to our office after having had 3-5 steroid injections over the past 1-2 years for their chronic condition such as tennis elbow or plantar fasciitis. We know that steroid injections have a catabolic (causing further deterioration) effect on joints and soft tissues if used excessively.
3) Around Tendons at Risk for Rupture- the patellar tendon and Achilles tendon are two areas where we always avoid steroid injections. These tendons are prone to major tears, especially if exposed to injectable steroids.
4) Risk of Infection- if there is any suspicion for an infection in a joint or bursa, then steroid injections are a “no-go.” It’s better to aspirate the fluid and send for analysis first before considering a steroid.
5) Surgery in the Near Future- if a patient is considering having a joint replacement in the next 3 months, then steroid injections should be avoided due to the risk of infection during and shortly after the surgery.
We hope you find this information helpful when it comes to one of the most commonly proposed non-surgical treatment in orthopedics. As always, let us know if we can be of help to you!
-F. Clarke Holmes, M.D.
Impact Sports Medicine and Orthopedics
Will My Heel Pain Ever Go Away? I Need Help!
/In middle-age individuals, 90% of the time, heel pain is caused by plantar fasciitis. The plantar fascia is a soft-tissue band, technically a ligament, that supports the hindfoot and midfoot. It is quite prone to inflammation, degeneration and tearing. It is a stubborn problem to both endure and to treat, and commonly becomes a condition that last months to occasionally years. However, do not fear, we have solutions for you!
How Does it Present?
· Heel pain, often sharp, with the first few steps out of bed and after a long day on your feet
· Pain when rising from a seated position after prolonged sitting, such as in a car
· In endurance athletes, pain during and after exercise
· Tenderness on the bottom of the foot, specifically at the heel where the plantar fascia originates
Why Did I Get This?
· Age- middle-agers are prone to this, as they are very active, but their rate of tissue breakdown exceeds their body’s repair rate. This is why younger individuals do not typically get this problem. They have a faster healing rate.
· Poor footwear- shoes that are flimsy, too old or generally unsupportive contribute
· Weight- gaining weight or being overweight overloads the tissue at the lowest point of our body
· Too much activity/overuse- runners, walkers, and athletes repetitively load the plantar fascia, and at times, are in a situation of overuse or too much, too soon
· Poor biomechanics- tight or weak calf muscles, a high arch or flat foot or a foot that excessively pronates or supinates can all contribute
How Do I Treat It?
Patience is the key. Let’s repeat that….patience is the key. This condition often requires months of treatment. Recovery can be slow. The underlying risk factors listed above must be corrected. What works for one patient may not be the best treatment for another. Care must be individualized.
· Rest- yes, this is a dirty, four-letter word for many patients. Plantar fasciitis will NOT improve as long as one continues to run, walk or exercise to the same degree. Sometimes, activity modification will work- fewer miles, less frequent high-impact exercise and/or trying something lower impact such as biking or swimming
· Improve the footwear and minimize going barefoot- remember with shoes, you often get what you pay for. Don’t go cheap!
· Physical Therapy- helps most patients, can be curative for those with mild cases. Will not get the job done by itself for moderate to severe cases.
· Orthotics/Inserts- over-the-counter or custom. OTC ones are less expensive and worth a try for mild cases. Custom are more expensive but are more successful for most patients. Orthotics alone usually will not cure plantar fasciitis. Other treatments must be combined.
· Anti-inflammatory medications- helpful in mild cases caught early. Not helpful in more severe cases or in patients that have had the problem for months or longer.
· Cortisone injections- occasionally helpful, more often harmful. We rarely utilize these, as they don’t promote healing, only reduce inflammation and can increase the risk of further tearing of the fascia. NEVER get a series of 3 cortisone injections as recommended by some.
· Orthobiologic injections- very helpful for most. These are meant to “heal the heel!” Platelet-rich plasma injections introduce numerous growth factors to the area to improve the tissue environment and thus, are typically successful in promoting healing of the fascia while reducing pain and improving function. These are game-changing injections and ones we have provided under ultrasound-guidance successfully now for many years.
· Surgery- we favor a minimally-invasive procedure called the Tenex procedure. Tiny incision, local anesthesia only, no stitches required with minimal healthy tissue disruption. The “old-school” surgeries require larger incisions and involve “releasing”/cutting the fascia off the bone, are less successful, higher risk and have been abandoned by many orthopedic surgeons.
What to Avoid:
1) Stretching the bottom of the foot. An example is when you pull the toes back towards you. Most cases of PF involve inflammation and/or tearing of the fascia. Stretching damaged or inflamed tissue is often counterproductive
2) Pushing through the pain with exercise. If you have PF, you have to relatively rest, which may mean temporarily discontinuing running, walking, jumping, etc. or at least, reducing your distance or frequency of these activities.
3) Skimping on shoes and/or orthotics. The old adage, “you get what you pay for…” applies here. Think of purchasing high-quality athletic and everyday shoes as well as orthotics (inserts) as an investment in your health and quality of life. At times, the more expensive orthotics are worth the extra cost.
In conclusion, heel pain affects a high percentage of middle-age individuals and can range from a nuisance problem to a disabling one. The key here is to seek care early and from someone who can customize a well-constructed treatment plan for you that has a variety of quality interventions. We are here to help!
The 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.
Five Mistakes to Avoid with Plantar Fasciitis
/Plantar Fasciitis is the most common cause of heel pain, most commonly seen in middle-age individuals. There are numerous treatment options, yet with our decades of experience in treating this problem, we’ve found many pitfalls, and thus, here’s a list of what NOT TO DO!
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.
4) Having multiple cortisone/steroid injections. It’s probably best to avoid steroid injections altogether for PF, yet a one-time steroid injection can occasionally be indicated for the patient that is miserable due to severe heel pain. Repetitive steroid injections often result in long-term worsening of this condition.
5) Not being patient. PF resolves in 95% of individuals with the proper customized treatment, yet it often is a 6 to 12-month process. Don’t give up on certain treatments too soon, as most interventions work gradually over weeks to months, including footwear changes, night splints, relative rest, physical therapy, orthotics and orthobiologic/regenerative injections.
If you are struggling with plantar fasciitis, then we are here to help!
Clarke Holmes, M.D.
I've Heard of Platelet-Rich Plasma (PRP) Injections. Am I a Candidate?
/Platelet-Rich Plasma injections have taken the orthopedic world by storm. Why is this? They are safe. They are natural. They can be done in the office in a short period of time. They may prevent surgery in some cases. They can be disease-altering, not just symptom-reducing. Most importantly, in many cases of tendon, ligament and joint problems, they are EFFECTIVE.
PRP injections involve drawing blood from a patient’s vein, typically in the arm. Then, the blood is centrifuged (spun) to separate out the red and white blood cells, while simultaneously concentrating your own platelets. Our platelets are known to have numerous growth factors that serve many beneficial roles in our musculoskeletal tissues. Just minutes later, this concentrated solution is then injected under ultrasound-guidance back into an area of damage, such as a partially torn tendon, the plantar fascia or an arthritic joint. We believe that these platelets help to modulate unhealthy inflammation that resides in damaged tissues. This helps over the long-term to reduce pain and subsequently, improve function. In some cases, damaged soft tissue can heal in the presence of these concentrated platelets. In other cases, the deterioration often seen in cases of osteoarthritis can be slowed or halted. Thus, there are some preventative benefits of PRP.
In our practice, the percentage of PRP injections is increasing, while the percentage of cortisone/steroid injections is dropping. Why? We want our patients to have “game-changing” treatments whenever possible. We want conditions to improve over the long-term. We want to stop that deterioration process and to promote healing when possible. Also, we know that in the case of steroid/cortisone injections, some patients feel so good, so quickly, that they are prone to re-injure themselves. Steroid injections also can be catabolic, meaning they contribute to the deterioration of tissue. Thus, short-term improvement, but long-term worsening with some steroid/cortisone injections.
Thus, here are some patient scenarios that demonstrate when PRP would be an excellent choice:
-A 50-year-old woman plays in a weekly tennis league. Her arthritic knee is painful and swollen, and she needs some long-term relief to keep playing the sport she loves. It’s a big part of her social life as well. We choose two leukocyte-poor (low white blood cells) injections 3-6 weeks apart to provide that relief and protect her knee from the “wear and tear” that comes from a high-impact sports like tennis. She will likely feel better within a few weeks of the injection and also likely will see a reduction of symptoms for 6 to 18 months.
-A 35-year-old runner tore his ACL at age 20 and had successful surgery. Now, he has mild osteoarthritis of the knee that is stiff in the morning, aches after long runs and occasionally swells. He is a another great candidate for PRP. PRP should help his keep inflammation down, reduce these aches and preserve the cartilage in his knee for years to come.
-A 65-year old woman has had 6 months of lateral hip pain after a trip to the beach with frequent walking. She can’t sleep on the side of her painful hip and going up stairs is difficult. We diagnose her with trochanteric bursitis and gluteal tendonosis Two CORTISONE injections at another office each helped for a few weeks, but the benefit was only temporary. An MRI confirms gluteus medius tendonosis, yet there is no large partial tear. We offer her a leukocyte-rich (higher white blood cells) PRP injection with the hope to overcome this condition, or at the very least, allow her to resume a walking program, climb stairs pain-free and lie on that hip while sleeping.
-A 42-year runner just can’t overcome her heel pain due to chronic plantar fasciitis, despite physical therapy, custom orthotics and one steroid injection. One leukoctye-rich PRP injection hopefully will do the trick. She will be in a boot for about 3 weeks after the injection, we’ll ask her to rest from running for at least 6 weeks.
-A 24-year-old recreational basketball player has patellar tendonopathy and pain every time he jumps and lands. Symptoms have been present for 6 months and despite physical therapy, a brace and NSAIDS, he is only 50% better. We offer him 1-2 PRP injections. We need to promote healing of that tendon. We want long-term reduction in symptoms and tissue improvement, so that he can continue to play basketball and with reduced risk of tearing the tendon. Plus, we never inject cortisone in or around certain tendons, including the patellar and Achilles tendons, due to the risk of tendon rupture.
-A 70-year-old has mild to moderate hip and knee osteoarthritis. He can play golf a couple days a week, but relies on frequent doses of ibuprofen after his golf games and on days he plays with his grandchildren. His hoping to avoid joint replacement in his lifetime and knows that long-term use of NSAIDs is not good for his blood pressure, stomach or kidneys. We offer him PRP as a great option, with an injection into the knee and hip joints on the same day. He then will return a month later for his 2nd set of injections. After that, we hope and expect that he will have less pain and better function for 6 to 18 months, while also lowering his chances of joint replacement in the intermediate future. These PRP injections can be safely repeated months to years later, if necessary.
These are everyday examples of how we customize our treatments for patients based on their symptoms, diagnosis and goals. Age of the patient can play a role, but one is never “too old” to have a PRP injection. When head-to-head studies compare PRP to steroid injections, PRP is declared the “winner” the large majority of the time. Thus, we know that for long-term benefits of many joint and tendon problems, PRP is the better choice.
The world of orthobiologic injections such as PRP will only continue to expand as we strive to find more natural and less-invasive ways to treat a variety of orthopedic conditions. Dozens of medical studies each year continue to demonstrate that PRP injections are a safe, beneficial and cost-effective option for osteoarthritis, plantar fasciitis and many chronic tendon problems.
-Clarke Holmes, M.D.
My Elbow Really Hurts, and I Feel Like a Wimp!
/We hear this comment or one very similar to it on a frequent basis. Good ole’ tennis elbow, also know as lateral epicondylitis. Despite these names, this is not a problem limited to tennis players and does not typically involve the bone on the outside of the elbow named the lateral epicondyle. It is actually a tendon problem. The common extensor tendon on the outside of the elbow is highly involved in gripping, grabbing and lifting. When you shake someone’s hand, this tendon is under a lot of stress. When you lift the coffee mug with a handle, the positioning of your wrist transmits stress to this tendon. When you pull your sheets up to you when in bed, the position and action of the wrist and forearm send stress to this tendon. Finally, when this tendon is inflamed and/or partially torn, it HURTS! I mean, it really hurts. You are not a wimp for complaining about tennis elbow. Fortunately, this is one of my favorite conditions to treat. Why? For many reasons: we usually can cure this problem. Patients are so grateful to see this pain go away. Finally, it’s gratifying to see patients return to things they love to do after successful treatment such as tennis, golf, weight lifting, gardening and even typing!
Turning our attention to treatment options, there are traditional and innovative options. At Impact Sports Medicine and Orthopedics, we specialize in both types:
Traditional:
1) REST and changing the biomechanics- how and how much you lift, grip and grab
2) A wrist splint- yes, immobilizing the wrist and forearm unload the tendon far more than immobilizing the elbow
3) A cortisone injection- in our hands, 90% of patients experience relief with an ultrasound-guided injection. However, since tendon damage is often the cause of the stubborn pain, cortisone, at times, may only provide temporary benefit.
4) Physical Therapy- helpful in changing the biomechanical problems that led to the tendon damage. However, the benefit can be limited if tendon is partially torn.
Innovative:
1) The Tenex procedure- a true game-changing minimally-invasive procedure. This is our favorite option for those patients that have not improved with the traditional treatments. Local anesthesia only, a tiny incision, 2 minutes of tendon treatment with a small probe, no stitches, typically covered by insurance and a 90% success rate. How does that sound? We've loved this procedure for 7+ years.
2) Orthobiologic Injections- platelet-rich plasma (PRP) injections are very solid choices, isolating and concentrating the platelets from you own blood. This becomes a solution rich in human growth factors utilized to stimulate healing of the tendon.
3) Nitroglycerin patches- placed on the skin over the tendon, these are good choices for those patients needing something extra, but prefer a treatment that is non-invasive. These work by producing nitric oxide in the tissues, which then can be responsible for tendon healing.
In summary, we hate that you have "tennis elbow," but always appreciate the opportunity to treat you. It's our mission to make this common cause of elbow pain leave your life and never return! Let us know if we can help.
-F. Clarke Holmes, M.D.
Will Platelet-Rich Plasma (PRP) Injections Replace Cortisone?
/The answer to this question is simple: Yes, No and Maybe. Platelet-Rich Plasma injections have taken the orthopedic world by storm. Why is this? They are safe. They are natural. They can be done in the office in a short period of time. They may prevent surgery in some cases. They can be disease-altering, not just symptom-reducing. Most importantly, in many cases of tendon, ligament and joint problems, they are EFFECTIVE.
PRP injections involve drawing blood from a patient’s vein, typically in the arm. Then, the blood is centrifuged (spun) to separate out the red and white blood cells, while simultaneously concentrating your own platelets. Our platelets are known to have numerous growth factors that serve many beneficial roles in our musculoskeletal tissues. This concentrated solution is then injected under ultrasound-guidance back into an area of damage, such as a partially torn tendon, the plantar fascia or an arthritic joint. We believe that these platelets help to modulate unhealthy inflammation that resides in damaged tissues. This helps over the long-term to reduce pain and subsequently, improve function. In some cases, damaged soft tissue can heal in the presence of these concentrated platelets. In other cases, the deterioration often seen in cases of osteoarthritis can be slowed or halted. Thus, there are some preventative benefits of PRP.
Cortisone injections, known medically as steroids, have been around for decades. They simply are very strong anti-inflammatories. They can reduce pain and swelling within hours to days of an injection. However, they are known to have catabolic, or “breakdown” effects, meaning, numerous exposures to steroids can worsen the structure and strength of a soft tissue or joint. They also can produce short-term systemic side effects, including fluid retention, headache, insomnia, changes in emotions, skin flushing/redness and increases in blood sugar, particularly in diabetics. Cortisone injections are still used quite frequently to treat tendonitis, arthritis and disc problems in the spine.
Now, back to the question in the title. In our practice, we still use both types of injections. However, the percentage of PRP injections is increasing, while the percentage of cortisone is dropping. Why? We want our patients to have “game-changing” treatments whenever possible. We want conditions to improve over the long-term. We want to stop that deterioration process and to promote healing when possible. Also, we know that in the case of cortisone injections, some patients feel so good, so quickly, that they are prone to re-injure themselves. Thus, short-term improvement, but long-term worsening with some cortisone injections.
Thus, how do we choose what type of injection to recommend to a patient? Here are some examples:
-A 60-year-old woman will be traveling on a bucket-list trip to Italy in one week. Her arthritic knee is painful and swollen, and she needs some quick relief to really enjoy this trip. We choose a CORTISONE injection to provide that relief. She will likely feel better within a few days of the injection and will probably see a benefit for 1-3 months.
-A 35-year-old runner tore his ACL at age 20 and had successful surgery. Now, he has mild osteoarthritis of the knee that is stiff in the morning, aches after long runs and occasionally swells. He is a great candidate for PRP. PRP should help his keep inflammation down, reduce his aches and preserve his cartilage in his knee for years to come.
-A 65-year old woman has had 2 weeks of lateral hip pain after a trip to the beach with frequent walking. She can’t sleep on the side of her painful hip and going up stairs is difficult. We diagnose her with trochanteric bursitis and gluteal tendonitis. A CORTISONE injection here may do the trick. She has an acute inflammatory response and needs some relief to simply sleep better at night and handle her activities of daily living with less pain.
-A 24-year-old recreational basketball player has patellar tendonopathy and pain every time he jumps and lands. Symptoms have been present for 6 months and despite physical therapy, a brace and NSAIDS, he is only 50% better. We offer him 1-2 PRP injections. We need to promote healing of that tendon. We want long-term reduction in symptoms and tissue improvement, so that he can continue to play basketball and with reduced risk of tearing the tendon. Plus, we never inject cortisone in or around certain tendons, including the patellar and Achilles tendons, due to the risk of tendon rupture.
-A 70-year-old has mild to moderate hip and knee osteoarthritis. He can play golf a couple days a week, but relies on frequent doses of ibuprofen after his golf games and on days he plays with his grandchildren. His hoping to avoid joint replacement in his lifetime and knows that long-term use of NSAIDs is not good for his blood pressure, stomach or kidneys. We offer him PRP as a great option, with an injection into the knee and hip joints on the same day. He then will return a month later for his 2nd set of injections. After that, we hope and expect that he will have less pain and better function for 6 to 24 months, while also lowering his chances of joint replacement in the intermediate future. These PRP injections can be safely repeated months to years later, if necessary.
These are everyday examples of how we customize our treatments for patients based on their symptoms, diagnosis and goals. Age of the patient can play a role, but one is never “too old” to have a PRP injection. When head-to-head studies compare PRP to steroid injections, PRP is declared the “winner” the large majority of the time. Thus, we know that for long-term benefits of many joint and tendon problems, PRP is the better choice.
In conclusion, cortisone/steroid injections are not going away any time soon. They still play a role in helping patients in select situations. However, the world of orthobiologic injections such as PRP will only continue to expand as we strive to find more natural and less-invasive ways to treat a variety of orthopedic conditions.
The 5 Biggest Mistakes Inexperienced Runners Make Leading to Injury
/1) Training for a ½ or full marathon when you’ve never run a 5K or 10K- because of variability of muscle types, bone density, running mechanics and the efficiency of oxygen consumption, not everybody was made to run long-distance races. Some great athletes are hardly capable of running 5 miles. Then, you have those individuals who can run a ½ marathon and barely train to do it. If a novice runner, see what your body is capable of first by training for and completing shorter races before attempting much longer runs.
2) Pushing through pain to get through a run- there’s fatigue, soreness, the muscle burn and then, there’s pain. Concerning pain includes sharp discomfort, pain that results in limping, constant pain and pain associated with swelling. Pain around a tendon or right over a bone is a warning sign. Don’t ignore the “check engine light” that comes on in your body. Learn to recognize the difference between the types of discomfort and seek medical attention when the concerning form of pain is present.
3) The wrong footwear- this can be shoes that are too old or the wrong type for your foot and particular gait pattern. It’s time for new shoes when there’s visible wear of the tread, especially in the forefoot area (the third of the foot closest to the toes). Shoes should be updated every 300-500 miles or every 9-12 months, whichever comes first. Also, seek a true “fitting” for your shoes. The right size, width and style (stability, neutral, zero drop, etc.) are important choices, and you should avoid choosing the latest “fad” shoe or the one that has the coolest design simply for the fashion statement. Find a quality running store that can help you with these choices.
4) Training with a partner of a different skill set- it’s generally best to train with someone of a similar skill set and set of goals. Many runners are competitive (whether they admit it or not!), and will push each other at times even on training runs. While this is not all bad, someone training for their first ½ marathon will likely struggle to keep up with someone that has run numerous long-distance races. What’s the net result? The inexperienced runner tries to keep up with the experienced runner in terms of speed, distance and mindset. This is a recipe for injury. If wanting to train with a partner, try to find one that is willing to follow a similar schedule and runs a similar pace.
5) Making up for lost time- sometimes a training schedule gets derailed. An illness, an injury or a life event knocks a runner off his/her training schedule for a couple of weeks. Race day is nearing, and thus, the runner tries to advance the training schedule by increasing the number of running days each week or jumping ahead and doing more miles or longer runs than what he/she should be doing. Example: it’s late in the training schedule for a ½ marathon, and the longest run you’ve done is 7 miles. You missed 2 weeks of training because of a sinus infection. You jump ahead on the schedule and do 10 miles on a Saturday. Now, your shin is throbbing. Shin splint or stress fracture? Either way, you’re done! No race for you. No running for weeks to months. What should you have done instead? Resumed your training schedule where you left off before the illness. Then, if not ready for this race, postpone and run another one. There are ½ marathons within a region almost every weekend, especially from the late winter until the late spring. Or, you could have still run the race, but adjusted your goals. Maybe you change your mindset to just finishing the race, even it meant walking part of race. The bottom line: skipping steps in your training often results in an increased risk of injury.
At Impact Sports Medicine, we would rather help you prevent an injury, but when one does occur, we are ready to help! Enjoy your running!
Tennis Elbow: The Most Misnamed Orthopedic Condition
/Fewer than 10% of patients that have tennis elbow actually play tennis. In addition, the medical term for this condition is "lateral epicondylitis." This also is misnamed. Why? The lateral epicondyle is the bony prominence on the outside of the elbow. This sometimes stubborn condition is not a bone problem, but a tendon problem, actually involving what we call the common extensor tendon. This also can be a very humbling condition. It can cause significant pain with some simple, everyday activities- lifting a coffee cup, shaking hands, pulling your bedsheets, just to name a few. Why you ask? Stress to this tendon is not only related to the weight of a lifted object, but also the arm and wrist position. Certain positions cause overloading of the damaged and/or inflamed tendon. Turning our attention to treatment options, there are traditional and innovative options. At Impact Sports Medicine, we actually specialize in both types:
Traditional:
1) REST and changing the biomechanics- how and how much you lift, grip and grab
2) A wrist splint- yes, immobilizing the wrist and forearm unload the tendon far more than immobilizing the elbow
3) A cortisone injection- in our hands, 90% of patients experience relief with an ultrasound-guided injection. However, since tendon damage is often the cause of the stubborn pain, cortisone, at times, may only provide temporary benefit.
4) Physical Therapy- helpful in changing the biomechanical problems that led to the tendon damage. However, the benefit can be limited if tendon is partially torn.
Innovative:
1) The Tenex procedure- a true game-changing minimally-invasive procedure. This is our favorite option for those patients that have not improved with the traditional treatments. Local anesthesia only, a tiny incision, 2 minutes of tendon treatment with a small probe, no stitches, covered by insurance and a 90% success rate. How does that sound? We've loved this procedure for 6+ years.
2) Orthobiologic injections- platelet-rich plasma (PRP) injections are very solid choices, isolating and concentrating the platelets from you own blood. This becomes a solution rich in human growth factors utilized to stimulate healing of the tendon
3) Nitroglycerin patches- placed on the skin over the tendon, these are good choices for those patients needing something extra, but prefer a treatment that is non-invasive. These work by producing nitric oxide in the tissues, which then can be responsible for tendon healing.
In summary, we hate that you have "tennis elbow," but love the opportunity to treat you. It's our mission to make this common cause of elbow pain leave your life and never return! Let us know if we can help.
My Heel is Killing Me! What is This and How Do I Get Rid of It?
/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. Let’s quickly dive into this common cause of heel pain.
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. This condition may require a month or a year 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 more beneficial for most patients. Orthotics alone 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, occasionally 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 promote tissue regeneration. 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 most orthopedic surgeons
In conclusion, heel pain affects a high percentage of middle-age Americans 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!
"Regenerative" Injections- Let's Be Honest Here
/Concerned. Disappointed. Those are the first words that come to mind when I read or hear about another non-physician 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 doesn’t 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 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. They 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 10 years and only after taking a minimum of 6 courses on the subject. We are carefully studying the science and trends pertaining to regenerative injections and have provided these to our patients over the past 8 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.
The Top 3 Activities that Lead to Summer Injuries in Adults
/What are the top 3 activities that lead to summer injuries for adults?
1) Yard work- often a situation of doing too much at one time. Repetitive bending, lifting, pushing and trimming frequently lead to low back, neck, shoulder and elbow issues. Our advice- spread the work load among several family members and among several days. Instead of 4 hours of work on one day, divide the work load into 2-3 days. Get as close as you can to something you are lifting or trimming. Doing these with your arms further away from your body can overload the spine, joints and tendons.
2) Tennis and golf- these are great warm-weather sports, but lead to a elbow tendon and low back problems quite frequently. The same concept discussed above applies: avoid overuse situations. Play 9 holes instead of 18 on some days. If you are a middle-ager, don't expect to play 72 holes on a weekend and not feel some aches and pain. With tennis, consider playing with a 2-handed backhand. Play some doubles, not just singles, as this can decrease your reps, but lead to similar enjoyment of the game.
3) Running and power walking- many love just being outdoors for these fitness activities, while others are starting to train for 1/2 and full marathons in the fall. A couple of pieces of advice: if training for a race, follow a program/regimen. 12 weeks to train for a 1/2 marathon, 18 weeks for a full. To all: update your athletic shoes every 9-12 months or if any wear is present on the tread. Also, make sure your other shoes are supportive. Flimsy sandals and flip-flops lead to foot, ankle and knee problems, especially if these areas are already being stressed by other fitness activities. When it comes to summer shoes, to some degree, you get what you pay for. A quality pair of sandals or flip-flops will run you $50-$100.
Enjoy the summer!
The Top 5 Reasons to Have an Orthobiologic Injection
/Regenerative injections, also known as orthobiologic injections, include platelet-rich plasma (PRP), amniotic membrane and fluid, alpha-2 macroglobulin and mesenchymal stem cell (MSC)
1) Cortisone has not gotten the job done- corticosteroid injections are potent anti-inflammatories and can be effective in treating inflammatory conditions, but these have either zero or even a detrimental effect on healing. Most chronic tendon problems are not inflammatory, and thus, cortisone will provide minimal long-term benefit. Not all cases of arthritis are inflammatory either.
2) You are hoping to avoid surgery or you had surgery and are less than satisfied- we know that certain surgeries produce superior outcomes compared to nonsurgical treatment, particularly in younger and active individuals. Examples include ACL reconstruction after a full ACL tear and shoulder stabilizing procedures after multiple dislocations. However, there are numerous conditions that have equal or superior outcomes with nonsurgical treatment. These include small tears of the rotator cuff, hamstring, patellar and Achilles tendons; plantar fasciitis; degenerative meniscal tears; tennis and golfer’s elbow and mild to moderate osteoarthritis of the knee, hip, shoulder and basal thumb joint. These conditions are ideal candidates for regenerative injections, especially when traditional surgical and nonsurgical treatments are not producing major levels of benefit
3) Cost- no, insurance does not cover regenerative injections. However, these injections are designed to provide long-term or permanent benefit. The expected goals are months to years of reduction in pain, improvement in function, soft tissue healing and slowing or suspending joint degeneration, i.e., preventing osteoarthritis from getting worse. Thus, these injections have a very good chance of saving you money. These benefits translate into fewer physician’s visits, fewer trips to physical therapy (although we still see the value of PT), fewer medications and potentially, the elimination of the need for an expensive surgery.
4) You want a game-changing treatment, not one that just treats symptoms- regenerative injections are designed to change the environment of the area injected. Through the introduction of nutrients, growth factors and potentially stem cells, the goal of these injections is to not only make a patient feel and function better, but also to produce a healing response. This can mean tendon or ligament re-growth, cartilage regeneration and/or the reduction of unhealthy inflammation in the area of damage.
5) The medical literature- although insurance companies would like to paint orthobiologic injections as “experimental” and thus not pay for them, the truth is that there are now hundreds of studies that demonstrate a clinically significant benefit in the treatment of chronic tendon problems and osteoarthritis with regenerative injections. In fact, hot off the press, a prominent sports medicine journal just posted a detailed review of orthobiologic injections. The authors came to this conclusion: There was a total of 21 PRP (platelet-rich plasma) studies in the study. All PRP studies showed clinical improvement with PRP therapies in outcomes surveys measuring patient satisfaction, pain, and function…. The one PRP study that had a 2nd look arthroscopy reported increased cartilage regeneration with PRP. All 8 MSC (mesenchymal stem cell) studies with follow-up MRI and all 7 MSC studies with 2nd look arthroscopy showed improvement in cartilage regeneration in terms of coverage, fill of the defect, and/or firmness of the new cartilage.
Translation: patients are very satisfied with their outcomes after receiving these injections. Although we do not make guarantees about cartilage re-growth, improvement in the integrity of the cartilage after these injections is a possibility.
In conclusion, orthobiologic injections are rapidly entering and evolving within the world of orthopedic medicine. At this point, both their present and future look very bright. When considering a “regenerative” injection, seek the consultation of a medical doctor who has vast experience in researching and performing these procedures.
-Clarke Holmes, M.D.