Joint Preservation Blog

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!

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 20, 2009

Rotator Cuff Pain Relief Therapy

 

rotator cuff pain relief therapy

rotator cuff pain relief therapy

So you’ve torn your rotator cuff, is there such a thing as rotator cuff pain relief therapy without surgery?  Yes.  First the simple stuff.  If you can’t lift your arm, then you’re likely too injured for this particular blog post (more to come).  However, if you just have pain on lifting, then this blog’s for you.  If you’re in this later category, the good news is that you likely have a partial rotator cuff tear, where the muscle is torn, but not through and through.  We frequently use treatment such as IMS to get rid of the muscle knots and help the pain.  This is where a tiny acupuncture needle is used to eliminate painful portions of the muscle (this is very different than traditional Chineese acupuncture where the muscles aren’t treated). In addition, massage therapy of the supraspinatus, infraspinatus, subscapularis, teres, or upper trapezius may help.  Finally, before you consider surgery, look at one of the newer injection based options to heal the tear with less down time.  For example, the patient’s own stem cells can now be injected into the rotator cuff tear under x-ray guidance, so that no surgery is required.  This gets rid of that big blue pillow immobilizer and the long recovery commonly associated with rotator cuff surgery.  You should give your rotator cuff tear a 4-6 weeks to heal and if it’s staying the same, time to get something done.  The big issue you want to avoid is muscle atrophy, so all of this should be performed with rotator cuff exercises.

January 19, 2009

Exercises that Stress the Rotator Cuff

The rotator cuff provides stability to the shoulder.  The most commonly injured muscle of the four muscles that make up the “rotator cuff” (Supraspinatus, Infraspinatus, Teres, Subscapularis) is the supraspinatus.  Exercises that stress the rotator cuff would focus on use of these four muscles more than other surrounding shoulder muscles (like the trapezius).  To stress the supraspinatus, the empty can maneuver is the best way to go.  Place your arm out to the side with the thumb down like you’re pouring out a can of soda.  The arm should be slightly forward.  If you move your arm up and down from the side of your body to just shoulder level, the muscle being stressed is the supraspinatus.  If this is painful and if when you place the thumb up much of the pain goes away, that’s a good indication that your supraspinatus muscle may be torn or injured.  If you can’t do this at all, it may be completely torn and retracted (not connected).  The infraspinatus and teres can be stressed by movements that externally roate the shoulder and arm (if you place your elbow at your side and start with your hand on your stomach and move it out to the side while keeping your elbow tucked in, that’s external rotation).  The subscapularis goes the other way, it brings the hand in with the elbow tucked into the side.  What if exercises won’t heal the problems?  You might consider some of the newer non-surgical methods that use injections of thepatient’s own stem cells to heal the rotator cuff tear.  The recovery times are much shorter and you can avoid the knife!

Nutrition to Heal Rotator Cuff Injury

Nutrition to heal a rotator cuff injury is all about the building blocks for repair and their helpers.  What are the building blocks?  Collagen and GAG’s (hyaluronic acid for instance) are good places to strat.  Foods that are rich in collogen include Jello.  Vitamins that help support collogen include vitamin C.  Other building blocks include glucosamine and chondrotin sulfate, although these are a bit more joint focused.  One of the big problems with rotator cuff repair is often there is limited blood supply to this area, so getting any nutrients to it can be tough.  Activity can help in this process.  Gentle rotator cuff exercises can help.  How do you know if it’s healed?  Take your arm and place it out to your side with the eblow extended and point your thumb to the ground.  This stresses the rotator cuff.  if you can’t do this or it hurts, then it’s not healed.  Is there a way to get it to heal without sugery, yes newer non-surgical procedures are available (click link).

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 14, 2009

Thumb Surgery

As a doctor, I see a lot of hand arthritis. With all of the Blackberry thumb and painful, and often disabling thumb joints out there, why don’t we see more thumb surgery? The reason is likely that the artificial joints in the hand seem to involve a long and often painful recovery with a lot of occupational therapy. Unlike a knee replacement, where you can still work with your hands, type, text, etc… a thumb joint replacement in your dominant hand means you’re totally out of commission in today’s modern hand-centered work force. As a result, we do see the occasional patients getting thumb surgery with a tendon (see Thumb Surgery Alternative post), but still the same issues above apply. Is there a way to avoid thumb surgery? Yes, we’ve had good experience with injecting the patent’s own adult stem cells into the joint. I’ve posted a patient testimonial below:

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.

What is a hip labrum?

hip labrum

hip labrum

Yesterday I posted on how to fix labral tears with stem cells, today I think it’s important again to show what the labrum is and what it does.  The picture above shows the hip socket where the hip bone (femur) would insert (ball of the femur would fit here in that socket, but the ball is removed here).  The labrum is represented by the red circle and the x’s.  This is the “lip” of the socket where the ball fits.  What does it do?  It helps to keep the ball in the socket .  The labrum becomes very important in doing this in activities with allot of travel for the hip joint like figure skating, bump skiing, horse back riding, hockey, etc…  If the labrum gets torn, movements where the hip is brought to extremes may allow the ball of the femur to move slightly out of the joint which can place extra stress on the other ligaments that help hold the joint together.  So in summary, the labrum is the lip around the socket that holds the ball in the socket

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