Joint Preservation Blog

July 14, 2011

Knee Pain Top of Kneecap

Filed under: knee — Tags: — D @ 10:59 pm

knee pain top of kneecap

Knee pain at the top of the knee cap (knee pain top of kneecap) can be caused by an alignment problem, cartilage injury, patellar tendon issues, or trigger points in the quadriceps muscle. The knee cap fits into a groove in the end of the femur (thigh bone). When the muscle that controls the knee cap (quadriceps) pulls on one side of the knee cap more than the other, the knee cap can get out of alignment. This is discussed further in our book on new approaches to orthopedic problems and stem cells. As the knee cap travels through it’s groove, the cartilage on the back of the knee cap and on the femur help to make the knee cap glide smoothly. When this cartilage gets injured or has been worn away through arthritis, knee pain at the top of the knee cap can be the result. The knee cap lives in a tendon (the end of the quadriceps muscle) that anchors itself to the leg bone (tibia). This whole mechanism (muscle, knee cap, and tendon) move the leg bone forward when you kick, run, or walk. When the muscle has areas that are shut down due to nerve issues in the back, the tendon can be pulled on too much, leading to pain at the top of the knee cap. In addition, the tendon can become injured by trauma such as kicking into turf. Finally, the quadriceps muscle itself may be the problem. The muscle can develop trigger points (as discussed above) which can cause pain and weakness in the muscle. These trigger points can refer knee pain to the top of the knee cap. If you have any of the problems causing knee pain at the top of the kneecap, what can you do? If the knee cap isn’t well aligned, there are many types of physical therapy that can help that alignment (see our book on new biologic orthopedic techniques). Taping the knee cap may help in addition to these special exercises. If you have a cartilage injury or arthritis causing this knee pain, investigate whether stem cell injection options may help your pain. If the tendon is the problem we’ve had excellent results with platelet rich plasma or stem cell plasma injections into the tendon under imaging guidance. Also consider what biomechanical problems might be causing too much pressure on the knee cap tendon. Finally, if the quadriceps muscle is the cause, IMS trigger point needling works well. In summary, knee pain at the top of the knee cap has a few causes, all of which are treatable.

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February 12, 2009

Bone Marrow Nucleated Cell Concentrate (BMAC): Is it Concentrated Enough?

 

bmac machine

bmac machine

 

In 2005-2006 we mixed up BMAC in our cell biology lab.  It was easy to create from a marrow aspirate.  We performed some basic MRI studies with pre and post 3.0T high field studies and ran outcome questionnaires for knee and hip arthritis patients.  We were unimpressed by the results and because of this experience moved on to culture expanded mesenchymal stem cells.  

 

BMAC has become popular of late. In this procedure, a physician takes a bone marrow aspirate, places it in a specially designed centrifuge and pulls out a concentrate of bone marrow nucleated cells. This has been billed as a stem cell concentrate, but the stem cells that are concentrated in reasonable numbers tend to be CD34+ heme progenitors (stem cells that make new blood) and not MSC’s (Mesenchymal Stem Cells). Since MSC’s are the MVP of the adult stem cell mix available in a bone marrow concentrate, their concentration is very important to the success of such a treatment. A recent study on bedside bone marrow concentrate machines for MSC’s (BMAC) determined what concentrations were possible from a commercially available centrifuge unit. Using this study to calculate MSC numbers, a 60 ml bone marrow draw would produce 70,000-90,000 MSC’s. The Regenexx procedure yields after culture expansion are in the 5M-100M range. Based on this data, the Regenexx procedure produces approximately 100-1,000 times more cells than you can obtain with BMAC bedside systems. Based on this and other data, our best estimate is that the average micro fracture procedure would release 5-10 ml of un-concentrated marrow, so about 500-1,000 MSC’s into the defect site. Our own dosing data and the copious animal research would suggest that for appropriate cartilage, tendon, ligament, muscle repair the necessary MSC dose is in the millions range. Obtaining that amount of MSC’s from a BMAC system would require unacceptably high volumes of whole marrow from the patient. The conclusion, while very convienent, BMAC doesn’t have the right stuff.

For more information on different stem cell types, I’ve posted a video below:

January 22, 2009

ACL Laxity and Knee Braces

acl laxity and knee braces

A doctor discusses ACL Laxity and Knee Braces. The ACL is the duct tape in the knee that holds the big thigh bone (femur) to the leg bone (tibia). It stabilizes (along with the PCL) the knee in a front-back direction. A knee brace can be used to help the ACL. An ACL knee brace allows the knee to flex and extend while holding the thigh and leg bones in alignment. However,is there a better way than wearing a knee brace all the time? Knee surgeries to replace or reconstruct the ACL should only be performed (in my opinion) if the ACL is completely gone. if the ACL is just lax, an older method of treatment is prolotherapy. This is the injection of a substance to tighten the ligament. Reeves has shown that the ligament can be tightened in this way using monthly shots for about 6 months. Newer options already being performed in the US include seeding the patient’s own adult stem cells onto the ACL ligament to repair the damage. This only works if there are ACL fibers left to seed. Eventually, this same technique may be used to inject an ACL scaffold material into the knee with adult stem cells that can create a ligament. So if you have a stretched ACL and you’re using a knee brace for ACL laxity, investigate some of the injections that can help you loose the brace!

January 13, 2009

Steroid Shots

Steroid shots have become a mainstay of modern orthopedic medicine.  Relief from a cortisone shotis due to powerful anti-inflammatory effects of the corticosteroid medication.  You body uses this same chemical daily to modulate inflammation and help control tissue repair (generally to put the brakes on an inflammatory injury response).  In very low doses (about 1,000,000 times less than is used by most doctors) these natural steroids help to reduce swelling and help the joint produce growth factors like TGF-beta which can help heal local tissues.  However, in the high doses commonly used in orthopedics (milligrams or bout 1,000,000 times more than the nano-grams used naturally), steroids can be a big sledge hammer to the system, stamping out bad inflammation and good tissue repair with equal force.  A steroid shot for sciatica is common these days, as doctors often use these to decrease swelling around swollen nerve roots that lead to back and leg pain.  however, the same issues as above apply, the dose if often too high.  Our own experience with out own patients shows that relief from a cortison shot can be obtained with a low nono-gram dose approximately 1,000,000 times less than the commonly used milligram dose.  This also prevents many of the body wide side effects that can seen from high dose milligram cortisone shots, such as weight gain, changes in blood sugar, and moodiness.  Cortisone shots before surgery (the higher milligram dose) will generally reduce the effectivness of healing, as they tend to supress the healing immune system response including knocking down critical repair responses and adult stem cells.  Concerned about high milligram dose cortisone shots?  Alternatives treatments include prolotherapy and using your own stem cells to help heal a joint rather than just reducing the inflammation short term.

Cortisone Shot Flare

 

cortisone shot flare

cortisone shot flare

As a pain management doctor who performs procedures all day, I have seen Cortisone shot flares in the office.  Cortisone is a corticosteroid, which is a fancy way of saying that it’s a very strong anti-inflammatory which can bring down swelling.  Cortisone is actually an older brand name, newer brand names more commonly used today include Depomedrol and Celestone.  One of the biggest problems that we see in our office is that the commonly dose used of Cortisone is in the milligram range (thousandth of a gram).  While this may not sound like much, for orthopedic applications like sciatica, back pain, knee pain, shoulder pain, elbow pain, and other peripheral joints, this dose is about 100,000 to 1,000,000 times more than your body naturally uses to control swelling.  As an example, if the 50 nano-gram dose that your joint would use on it’s own to control inflammation is the height of a book of matches, the height of the usual dose used by most physicians to control swelling is the height of the Empire State Building.  Why? Unknown, as the science would support that the nano-gram (billionth of a gram) dose is good for the joint, while the milligram dose causes all natural repair function to cease.  This is why too many of these very high dose Cortisone shots can cause a joint to degrade.  Think of it as you can put in a finish nail with a sledgehammer (the milligram dose), but it isn’t pretty.   Steroid shots for sciatica are common, and we only use the giant milligram dose in certain circumstances where we need a huge effect to help the patient, otherwise we have moved to the lower doses.  So what’s the biggest cause of a Cortisone shot flare? While the high dose may be an issue, it’s usually the needle.  To inject joints, most syringes come loaded with a 20 gauge needle.  While this makes drawing up meds very fast and is great for pulling fluid out of a joint (aspirate), its way to large for putting cortisone into a joint.  A 27 gauge needle is a better choice and less likely to cause a cortisone shot flare.  So to avoid a Cortisone shot flare, make sure your doctor uses a smaller needle (25 or 27 gauge).  In addition, we find that cold spray on the skin can help patients tolerate the shot better.  In addition, having the doctor wiggle or put allot of pressure on the area to be injected can help reduce the sensation of the needle stick.  What if don’t want Cortisone?  Alternatives include prolotherapy and using your own stem cells to help heal a joint rather than just reducing the swelling short term.

January 8, 2009

Bone Stimulators

As a doctor, patients with a fracture that won’t heal can be in quite a pickle. There are many bone stimulators on the market including the Exogen, the Symphony bone growth stimulator, and the mbi bone growth stimulator. How does a bone stimulator work ? There are two main types, ultrasound based and an electrical bone stimulator. The ultrasound type works by emitting a pulsed low intensity ultrasound signal (PLIUS). This has been shown to stimulate mesenchymal stem cells which turn into osteoblasts which are cells that make new bone. An electrical bone growth stimulator works in much the same way. It’s usually worth using one of these units for 6-12 weeks. What if using a bone stimulator doesn’t work? Bone grafting is one option, but a big surgery. Is there another way? Yes, newer stem cell based injection methods can avoid the surgery and use your own stem cells to heal the fracture. I’ve posted two videos below on the subject:

electrical stimulation for fracture healing

As a doctor, one of the most difficult problems a patient can face is is a bone that won’t  heal.  One of the most miserable patients I can rememeber was a little old lady with a sacral fracture who at three months after her fracture couldn’t even go to physical therapy because the fracture wasn’t healing.  She had tried electrical stimulation for fracture healing, but this failed.  Other patients who come to mind are a thirty something smoker with an non-healing humerus fracture and a 60 something geologist with a leg fracture (tib-fib non-union).  They all had one thing in common, they could barely do anything.  What other options are there for these patients?  One option is as we’ve discussed, electrical stimulation for fracture healing.  There are also other types of fracture healing assist devices, including PLIUS or Pulsed Low Intensity Ultrasound.  These units can help, but what to do when they fail?  The issue is often a poor blood supply to the fracture.  As a result, surgeons traditionally try a bone graft with it’s own blood supply.  However, this is a very big surgery.  Is there another way to heal these fractures that won’t heal on their own?  Yes, recent research into adult stem cells have shown them capable of fracture repair.  How did we heal up the three fractures described above?  By injecting the patient’s own adult stem cells into the fracture lines (without bone graft surgery).  The little old lady?  Independent in 6 weeks with a healed scaral compression fracture.  The smoker?  Healed in 6 weeks and had full function of her arm.  The 60 some year old geologist with the tib-fib non-union?  Same.  All without surgery.  Below is a video that explains more:

January 6, 2009

Orthopedic Knee Surgery?

Orthopedic knee surgery no better than placebo surgery?  Two recent research articles have questioned whether orthopedic knee surgery is effective.  In fact, one study performed in 2002 showed orthopedic knee surgery was no better than sham surgery and the second published in 2008 showed orthopedic knee surgery no better than physical therapy and SynVisc shots.  Why?  The concept of arthroscopic surgery for the knee makes some sense.  Remove the offending parts and the knee will move more smoothly.  However, that seems to be the problem with orthopedic knee surgery, as removing parts of the meniscus or cartilage only make the knee get arthritis much more quickly.  In addition, another study has also questioned if meniscus tears are in fact a normal part of aging, showing that 60% of people with no knee pain had meniscus tears on MRI.  The video below explains some of this:

So wouldn’t it make more sense to put the cartilage back in or repair the meniscus by healing it? That’s the goal of new stem cell therapies for the knee:

To learn more about how to avoid orthopedic knee surgery…

January 3, 2009

Knee Replacement Surgery Recovery

Knee replacement surgery recovery is hard. As a doctor, I’ve seen everything from patients who can get back on their feet in weeks, to patients with months of severe pain requiring narcotics and ultimately poor outcomes (the knee area still hurts). Why? How can you tell who will do well and who will have a prolonged Knee replacement surgery recovery? After many years of seeing these patients, I think it comes down to why the knee hurts in the first place. Too often, the knee is diagnosed as the main pain generator, but much of the pain is really coming from somewhere else. For example, recent research has shown that while we see meniscus tears on MRI, they are often not the cause of knee pain. In addition, there is a mean serious complication rate from knee replacement surgery of 20%. This gets worse as the patient gets older, with severe consequences and complications (with protracted recovery) occurring in many more patients when they are over age 80. Even if the knee is the cause of the pain, you might consider trying non-surgical options before you pull the trigger on knee replacement. Many patients can get good results from SynVisc or other artificial joint lubricants. Some of my patients try prolotherapy. Even newer techniques are now available where the patient’s own stem cells are used to heal the problems in the knee. So one way to avoid a long Knee replacement surgery recovery watching re-runs of Oprah is to avoid the knee replacement altogether.

December 23, 2008

ACL Laxity and Knee Braces

ACL Laxity and Knee Braces.  The ACL is the inner duct tape (otherwise known as a ligament) that holds the knee together in a front-back direction.  This means that it prevents the lower shin bone (tibia) from moving forward on the thigh bone (femur). This ligament can be stretched or torn completely.  In these cases the joint is said to be “lax” and in need of either surgical repair, non-surgical repair, or knee bracing.  Bracing a knee with ACL Laxity involves stabilizing the femur and tibia in a front-back direction. However, there are pros and cons.   One of the problems is that bracing still allows some movement, which ultimately injuries the joint.  Up until now, there has been no way to repair a stretch injury to the ACL without surgery. However, the development of injection based therapy for partial ACL tears and laxity has been a big advancement beyond surgical grafts.  As an example, the Regenexx procedurenow allows doctors to inject the patient’s own stem cells onto the stretched ACL ligament and tighten that ligament back to it’s normal strength and length.  This development allows the patient to get rid of the brace all together.  Since there is no surgery needed, the recovery is much quicker and bracing is only used for a few weeks after the procedure if the laxity is severe.  This newer technique doesn’t work when there is no ACL left, but only if there are ACL fibers that can still be detected on MRI.  

As a physician who treats patients with these injuries, the best brace is the one that fits well.  For general fitting and measuring instructions, click here. Also, I often advise my patients to consider getting a slightly used brace.  Ebay can be a great place to to find a knee brace that will help with ACL laxity.

Below is a short video on the topic of repairing ligament tears by injecting your own stem cells.  While this shows an ankle ligament example, this could just as easily be a partial ACL tear.

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