Joint Preservation Blog

January 5, 2010

Steroids and Apoptosis

Filed under: Uncategorized — Tags: , , , , , , , — D @ 6:08 pm

Apoptosis means pre-programmed cell death.  High dose steroids (corticosteroids which are commonly used to decrease swelling) have been implicated in causing this condition.  When I first heard about this issue from chiropractors and physical therapists years ago, I though it was an alternative medicine marketing tactic.  However, as I read more, it became clear that these negative effects of steroids on muscles, bones, cartilage, and ligament were quite real.  I have summarized those here:

Cartilage

Muscle

-Bone

-Ligament

November 3, 2009

An upper back problem that looks like it’s abdominal pain…

Filed under: Uncategorized — Tags: , , , , — D @ 1:16 pm

abdomen_muscles

Jimmy was a teenage baseball player with a history of severe abdominal pain.  I think his case illustrates how many M.D.’s have lost our ability to structurally diagnose patients with chronic pain.  Since he had high abdominal pain below the ribs, he had the million dollar GI work-up for his abdominal pain.  He was ultimately placed on very high dose narcotics and other drugs by a local Childern’s hospital.  When he first came to our clinic, his pain was across the top of his stomach and he couldn’t sleep more than 1-2 hours a night.  He wasn’t eating well and had given up baseball (his passion).  What was striking on initial exam was that if this patient had an internal organ problem, you wouldn’t expect his upper abdomen to be tender, right along the rib cage.  When these lower ribs were followed to his upper back, he had muscle spasms in this area as well.  Since nobody had ever found anything wrong with little Jimmy’s internal organs, it was a safe bet that he had a lower thoracic problem leading to pain in the ribs, which masqueraded as a stomach problem.  Further exam in Jimmy’s case showed that the abdominal muscles had significant trigger points and the area that attached to the ribs had a significant enthesopathy (swelling at the tendons that attach to bone, due to excessive pulling on the attachment by tight muscles).  Our plan was to begin injecting the lower ribs with prolotherapy solution to allow these abdominal muscle attachments to heal and to get rid of trigger points in the abdominal and upper back muscles using an IMS technique.  Within 12 weeks (Jimmy had suffered for two years), Jimmy was back to playing baseball and without pain.  He went off all meds and at one year follow-up, he’s still off meds and without pain.  His case is a good example of how a simple musculosketal pain problem can be misdiagnosed, cost a bunch of money in expensive diagnostic work-up, and if undiagnosed and without proper treatment, would have led to a teenager addicted to narcotics.

April 18, 2009

Can stem cells fix a knee?

pix-knee1

Cartilage is funny stuff.  It’s a shock absorber and filled with cells, so it’s alive.  For a long time, we doctors believed is was so much inert filler so we developed a surgical culture of trimming it and cutting it out.  This was called debridement.  The problem is that arthoscopic surgery for knee pain doesn’t work.  The reason, cutting out living cells turns out to be a bad idea.  So the next step is actually trying to fix cartilage.  We have demonstrated on MRI that using the patient’s own stem cells can help the appearance of knee cartilage (as seen on high resolution MRI) as well as the pain reported by patients.  The secret appears to be taking the patient’s own stem cells and growing them to bigger numbers.  The FDA has taken a strange position on all of this, but doctors and patients have other ideas.  In the meantime, fixing cartilage with stem cells seems like a better idea than cutting it out.

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 13, 2009

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

Prolite Thumb Support

Filed under: thumb — Tags: , , , , , , , — D @ 3:14 pm
prolite thumb support

prolite thumb support

 

As a doctor, thumb braces such as the “Prolite Thumb Support” can help provide an additional sense of stability.  However, have you ever wondered if your thumb arthritis could be fixed without surgery by repairing the painful joint?  Is this possible?  New advances in using the patient’s own stem cells mean that a simple injection might help the thumb without the need for invasive surgeries.  Since a video is worth a few thousand words, here are some for more information.  The link above has more information as well.

Plantar Fasciitis Foot Brace

 

plantar fascia support brace

plantar fascia support brace

 

As a doctor, I have seen many patients have a difficult time understanding plantar fasciitis. Think of the plantar fascia as a piece of duct tape that travels along the bottom of your foot from your heel to the bottom of your toes.  It’s job is to support the normal arch in your foot, especially when you put weight on the foot.   As this piece of duct tape (plantar fascia) gets too much stress (due to extra weight on the person or too much force from changes in the way the foot moves), the heel area where it attaches can get easily overloaded and become painful.  A plantar fasciitis foot brace is therefore simple, it’s something that helps reduce the extra stress on the duct tape.  However, rather than bracing the plantar fascia, we often find that it’s much more effective to fix the problem.  How?  We strengthen the duct tape!  That can be as simple as taking the patients own adult stem cells and injecting them into the heel area under x-ray guidance (we numb the area first so it’s not uncomfortable).  This allows that heel anchor point to become much stronger and the pain to go away.  Click on the link about to learn more about this type of procedure.

January 10, 2009

athletic ankle supports

ankle-support

As a doctor with an ankle problem, who is athletic, the best ankle brace I’ve found is the Malleoloc.  However, if you have an ankle problem like I did, why not ditch the ankle supports?  There are now new treatments where they inject your own stem cells into the ankle ligament tears to heal the damage.  This way you avoid athletic ankle supports and surgery!  This procedure should allow you to get rid of the athletic ankle supports for good.  In this minor procedure, your own adult stem cells are grown to larger numbers.  These repair cells are then injected into your torn ankle ligaments.  After this cutting edge procedure, you can wear an athletic ankle support for a few weeks, but continue working out while the ligaments mend.  You get to ditch the athletic ankle supports after just a month.  Why do these injections instead of supports?  An unstable ankle eventually damages the cartilage in the ankle and leads to early arthritis.  So what’s a little ankle pain now, will be an arthritis problem in the future, unless you heal the ankle ligaments.

basketball ankle supports

ankle brace

ankle brace

As a doctor with an ankle problem, who plays basketball, the best ankle brace I’ve found is the Malleoloc.  However, if you have an ankle problem like I did, why not get rid of the brace?  There are now new treatments where the doctor injects your own stem cells into the ankle ligament tear to heal the damage.  This way you avoid braces and surgery!  This procedure should allow you to get rid of the basketball ankle supports for good.  In this procedure, your own adult mesenchymal stem cells are isolated and then grown to larger numbers.  These healing repair cells are then injected into your torn ankle ligaments.  After this cutting edge procedure, you can wear a basketball ankle support for a few weeks, but continue playing and working out while the ligaments heal.  Maximum healing is 6-12 weeks.  You can come out of the basketball ankle supports after just a month.  Why go through all of this?  An unstable ankle eventually damages the cartilage in the ankle and leads to early arthritis.  So what’s a mild pain in the ankle now, will be big arthritis in 20 years, unless you get the ankle ligaments fixed.

Mcdavid elastic ankle braces

 

mcdavid elastic ankle brace

mcdavid elastic ankle brace

 

 

As a doctor with an ankle problem, I like most of the Mcdavid elastic ankle braces that use both a hard shell component to add stability and elastic to allow movement.  However, if you have an ankle problem like mine, why not get rid of the brace?  New non-surgical treatments where the doctor injects your own stem cells into the ankle ligament tear to heal it should allow you to get rid of the Mcdavid elastic ankle brace for good.  In this procedure, your own adult mesenchymal stem cells are isolated and then grown to bigger numbers.  They are then injected under x-ray guidance into your torn ankle ligaments.  After this break-through procedure, you can wear a brace for a few weeks, but continue playing and working out while the ligaments heal.  Maximum healing is 6-12 weeks.  You can come out of the Mcdavid elastic ankle brace after just a month.  Why go through all of this?  An unstable ankle eventually damages the cartilage in the ankle and leads to early arthritis.  So what’s a pain in the ankle now, will be severe arthritis in 20 years, unless you get the ankle ligaments fixed.  Think of these ligaments as duct tape that holds your ankle bones together.  When that duct tape is torn, it needs to be fixed, not braced.

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