Joint Preservation Blog

October 1, 2010

Pudendal Nerve Entrapment and Pelvic Ligament Problems

Filed under: Back/Lumbar, ligament/tendon — D @ 8:03 pm


RD is a middle-aged ex-fireman who injured his hip and sacro-iliac joint in a fall. We treated his pain with SI joint injections and epidurals, but recently he began to talk about sexual dysfunction. He consulted multiple specialists without any answers. He finally asked me if it could be due to his back. His MRI showed no severe issues that could cause sexual dysfunction, so we began looking for other sources. In particular, he was very tender over the sacrospinous ligament, which travels from the bottom of the tailbone (sacrum) to the bottom part of the pelvic bone. Once I looked it up, it became clear that the pudendal nerve (that supplies the penis) travels under this ligament (ligament in red above, star shape at site where nerve gets entrapped). It was worth a shot (literally) as he had no other options and cutting the ligament would destabilize his pelvis and SI joint complex. Under ultrasound guidance we localized his sacrospinous ligament and injected a small amount of anti-inflammatory. When I saw him two weeks later, his sexual dysfunction was gone, meaning that it’s likely the nerve was getting entrapped. While this may be a rare problem, the solution in this one patient was simple.

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

Does ibuprofen inhibit ligament repair?

As a doctor, I get asked allot, “Does ibruprofen inhibit ligament repair?“. In short, likely. We know from the medical research that Ibuprofen belongs to a drug class (NSAID’s) that inhibits the cyclo-oxengenase pathway of inflammation (COX) and that this can inhibit bone healing. We also know from animal models that injecting NSAID’s into a joint can cause arthritis. We also know that NSAID’s can negatively impact adult mesenchymal stem cells that are key in the ligament healing process. The upshot, Ibuprofen and NSAID drugs like Alleve, Motrin, Celebrex, and others likely impair healing of bones, ligaments, tendons, and other musculoskeletal tissues by impairing adult stem cells in their normal role of tissue repair. The upshot, based on the circumstantial evidence, taking NSAID’s after a ligament injury is likely a bad idea.

January 19, 2009

Torn Shoulder Rotator Cuff

Ruth is like many of our patients with a torn shoulder rotator cuff. She’s a health care professional (nurse) who has had the RIGHT rotator cuff treated twice with traditional roator cuff repair surgery. The several month recovery was difficult, the blue pillow immobilization meant that she couldn’t work as an ER nurse. Because of the muscle atrophy (this means that the sutures from the surgery can hurt local muscle cells, causing them to atrophy and die off) she likely experienced with the first RIGHT sided rotator cuff surgery, she had a retear of the same rotator cuff a few years later. The second time she was again off work for several months and unable to earn her salary. Based on her outcome with her first and second surgeries on the RIGHT, when the LEFT rotator cuff tore (while she was transferring a patient as a nurse), she went searching to see if non-surgical alternatives were available. We treated the LEFT by using her MRI to plan our x-ray guided injections of her own mesenchymal stem cells into the tear. It’s should be noted that this time, she remained working and fully active during the procedures. She has had three injections into her torn shoulder rotator cuff with excellent relief of pain and return of full range of motion. Rather than the doctor continuing to tell what happened, best to let the patient tell her own story:

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 11, 2009

Shoulder Ligament Injuries

Ligament Tear Symptoms

Ligament Tear Symptoms

MY OWN TORN SHOULDER LIGAMENT TREATMENT: As a very young young doctor many years ago, I thought I knew how to ride a motorcycle (or a donor cycle as my mother called it) and ended up with my right shoulder finding the road. This began my first-hand education of my own shoulder ligament injury. First, an anatomy lesson on shoulder ligaments simplified for non-physicians. The most commonly torn shoulder ligaments in a “separated shoulder” are those that hold the collar bone (clavicle) and top of the shoulder blade (acromion) together. There is an actual joint here, known as the “AC” joint or acromio-clavicular joint. When you injure this joint and the ligaments that hold this top shoulder joint together, it can be a grade 1 (just stretched ligaments, but the joint is still together), grade 2 (stretched ligaments that allow the joint to come apart a bit, but are still intact), or a grade 3 (completely torn-up ligaments that no longer hold the joint together or connect). If you have a grade 3 torn ligament in your shoulder, you’ll know it by the huge step off (often 1/2-1 inch) between the collar bone and the acromion (top of shoulder). If you have a grade 3, then the only long-term solution is to either leave it alone or have an orthopedic surgeon perform a shoulder repair using cadaver ligaments, a tendon graft, or similar to bring it back together. The grade 1’s and 2’s are really the focus of this post. What to do if this continues to pop, click, get sore, and generally hurt? How do you heal these torn ligaments in the shoulder? After a few years of not being able to go back to weight lifting, I tried prolotherapy on mine, and it worked reasonaly well (not a complete fix, but better). This is where the doctor injects substances that cause a brief inflammatory healing reaction in the ligaments. What would I do if I injured it today and it wasn’t getting better, no doubt I’d try some of the adult stem cell procedures where we can take your own stem cells and inject them into the ligaments to reapir the damage. In addition, if you have a partial rotator cuff tear (not uncommon), the same can be done to heal that as well. I have posted videos at the end of this discussion on a shoulder rotator cuff tear and ankle ligaments healed this way. What would I stay away from? The knife and shoulder ligament surgery! For a grade 1 and grade 2 shoulder ligament injury, in my opinion, there is no rationale for surgical repair, given these other treatment options. There are various links above for more information. Why do you want to get the ligaments fixed in some way? because if you don’t, the AC joint will develop arthritis and start pressing on the rotator cuff muscles leading to a chronic shoulder problem that will need surgery one day.

My shoulder? No perfect, but since I went back to lift very heavy weights as a weight lifter, you can guess it’s much much better than it was prior to treatment. I have never had surgery and am doing fine some 20 years after the injury.

January 4, 2009

Ligament Tear Symptoms

Ligament Tear Symptoms

Ligament Tear Symptoms

What are ligament tear symptoms? Think of ligaments as the duct tape that holds your bones and joints together. What happens when the duct tape gets stretched or gets torn? In this case, the duct tape (your ligaments) don’t hold the joint together, allowing for too much movement. While the area of the ligament tear can hurt and swell, once that initial several weeks of healing is over, if the duct tape hasn’t mended completely, the joint can be left unstable (read moving around too much). This instability can cause popping, clicking, and/or further swelling and pain in the joint. Over a few months to years, this can cause arthritis to develop much more quickly. How do you fix this ligament issue? Surgery is a possibility, but a bit more traumatic than the repair needs to be in most instances. A newer method is injecting your own stem cells into the ligament to get it to heal. The ligament grades above show that grade 1 and 2 are when the ligament is stretched or partially torn, grade 3 is completely torn. This stem cell treatment works best in grades 1 and 2. If you have a grade 3 tear, then surgery may be the only answer at this point.

January 2, 2009

Torn Tendon in Foot

Torn Tendon in Foot. Tendons are the cords that attach muscles to bone. In the foot, there are many tendons broken down into a couple of categories based on how they move the foot. These are tendons that plantar flex (foot pointed down), dorsiflex (toes and foot moving up), pronate and/or invert (bottom of foot points to other foot), and supinate and/or evert (bottom of foot points to the outside). A tear in a foot tendon is usually due to either an injury or overuse. For example, a tear in the tibialis anterior tendon can be due to too much force on the tendon as it tries to keep the foot from slapping on the ground. This type of tear is also usually caused by weakness in the tibialis anterior muscle (front of the shin) from a chronic low back pinched nerve. This muscle helps us control the foot as we walk. As the muscle gets weaker, the tendon gets beaten up trying to keep the foot from slapping while walking. In addition, the extensor hallicus longus (EHL) can get worn out trying to help the weak tibialis anterior muscle. Fixing a torn tendon in the foot can sometimes involve surgery, but newer non-surgical methods are much more promising. The newer treatments for torn tendons involve injecting the patient’s own stem cells into the tendon so that they can repair the damage. This is a full activity or a minimal downtime procedure, unlike surgery.

Achilles Tendon Support Socks

The Achilles tendon can be weakened by injury or being overloaded.  Support socks for the Achilles tendon will add compression around the tendon which may allow it to feel like it has greater support.   In essence, this pressure gives the tendon more structure.  Look for support socks that place pressure on the tendon (the heel cord) without causing pain.  The need for support in the Achilles tendon is usually from a partialtear or chronically frayed tissue in the tendon.  Another way to treat this without surgery or bracing is to use the patients own stem cells to repair the tendon.  These are cells taken from the patient, grown in the lab, and then injected into the tendon so that they can orchestrate a healing response.  With this type of Achilles tendon repair therapy, the need for Achilles tendon support socks can be eliminated.  This type of Achilles tendon treatment is new to the US and holds great promise for making the tendon stronger.

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