Conditions We Treat

Knee Osteoarthritis

Osteoarthritis is the most common form of arthritis in the knee and occurs as the cartilage within the joint gradually wears away. It is a degenerative type of arthritis that occurs most often in people 50 years of age and older, but may occur in younger people, too. As the cartilage wears away, it becomes frayed and rough, and the protective space between the bones decreases. This can result in bone rubbing on bone and produces painful bone spurs.

What Are the symptoms of Knee Osteoarthritis?

Osteoarthritis develops gradually and worsens over time. The first symptom may be pain, which can get worse with exercise and stop during periods of rest. Morning stiffness may occur but often dispels during the day as the knee warms up. As osteoarthritis gets worse, the knees lose their ability to bend and general movement and flexibility will become limited. They become tender, and a grating sensation may be felt during movement.

How Is Knee Osteoarthritis treated?

Treatment goals are to control pain and prevent joint destruction. The type of treatment depends on lifestyle and the progressive degree of Osteoarthritis.

Treatment 

Treatment options for osteoarthritis of the knee include: 

· Weight loss

· Non-steroidal anti-inflammatory drugs

· Physical therapy and exercise

· Knee replacement surgery as a last resort

Additional information on PRP for Knee Osteoarthritis

Does Intra Articular Platelet Rich Plasma Injection Improve Function, Pain and Quality of Life in Patients with Osteoarthritis of the Knee? A Randomized Clinical Trial Orthop Rev (Pavia). 2014 Aug 8; 6(3): 5405.Published online 2014 Sep 18. doi: 10.4081/or.2014.5405 

Results obtained from this study proved that intra-articular PRP knee injection can be effective in the reduction of pain and stiffness with improvements to the patient’s quality of life in comparison to the control group in the short term.

In a recent 2013 study published in The American Journal of Sports Medicine, it was shown that PRP, or platelet-rich plasma, is effective in alleviating or improving the pain from arthritis of the knee. In this study, two different doses of PRP were given to patients and then compared to a saline injection

Another study published in 2017 looked at a meta-analysis, meaning a comparison of multiple studies evaluating the same outcomes. The total number of patients was 1423. PRP significantly reduces the pain and improves the knee function.

Conclusion: Intra-articular PRP injections seem to be more efficacious in the treatment of Knee Osteoarthritis in terms of pain relief and self-reported function improvement at three, six and 12 months follow-ups, compared with other injections, including saline placebo, cortisone and HA (Joint lubricant injection).

Can PRP Prevent Arthritis from Worsening? Brian Halpern, MD; Salma Chaudhury, MD, Ph.D., MRC; Scott A. Rodeo, MD; Catherine Hayter, MD; Eric Bogner, MD; Hollis G. Potter, MD; Joseph Nguyen, MPHDisclosures Clin J Sports Med. 2013;23(3):238-239.

This study found that in using PRP, pain scores decreased significantly, whereas functional and clinical scores increased at six months and one year from the baseline. Qualitative MRIs demonstrated no change per compartment in at least 73% of cases at one year.

Conclusion: The conclusion of this study shows that PRP injections may slow the progression of Osteoarthritis. PRP injections may help to preserve the cartilage that is left within the knee before a complete loss. PRP injections appear to improve the quality of life of those suffering from Osteoarthritis and may offer a solution to immediate surgical action. That being said, PRP injections have NOT been shown to reverse or cure arthritis. Many, more research studies are needed. Stay tuned.

Knee Osteoarthritis Injection Choices: Platelet- Rich Plasma (PRP) Versus Hyaluronic Acid (A one-year randomized clinical trial).

This study suggests that PRP injections are more effective than hyaluronic injections in reducing symptoms and improving the quality of life in patients suffering from Osteoarthritis. This suggests a therapeutic option for select patients with Knee Osteoarthritis who have not responded to conventional treatment.  

Shoulder Anatomy

The shoulder is a ball-and-socket joint made up of three bones: the humerus (upper arm bone), the scapula (shoulder blade), and the clavicle (collarbone). The head of the upper arm bone fits into a rounded socket in the shoulder blade called the glenoid. A combination of muscles and tendons called the rotator cuff keeps the arm bone centered in the shoulder socket. These tissues cover the head of the upper arm bone and attach it to the shoulder blade.

Common causes of shoulder pain

·  Tendon inflammation (bursitis or tendinitis)  

·  tendon tear(partial or complete)

·  Frozen shoulder

·  Instability

·  Arthritis

·  Fracture (broken bone)

Other less common causes of shoulder pain are tumors, infection, and nerve-related problems.

Bursitis

Bursae are small, fluid-filled sacs located in joints throughout the body, including the shoulder. They act as cushions between bones and the overlying soft tissues, reducing friction between the gliding muscles and the bone.

Excessive use of the shoulder can lead to inflammation and swelling of the bursa between the rotator cuff and the shoulder blade's acromion, resulting in a condition known as subacromial bursitis.

Bursitis often occurs along with rotator cuff tendinitis. The pain and inflammation can make daily activities like combing your hair or getting dressed difficult.

Tendinitis

Shoulder tendinitis comes in two types:

1. Chronic tendinitis occurs due to repetitive wear and tear from aging.

2. Acute tendinitis can be caused by overhead activities during work or sports.

The four rotator cuff tendons and one of the two biceps tendons are the most commonly affected tendons in the shoulder.

Tendon Tears

Tendon tears can be caused by acute injury or degenerative changes due to aging, long-term overuse, or wear and tear. These tears can be partial or complete, either going through part of the tendon thickness or completely separating the tendon from where it attaches to the bone. Rotator cuff and biceps tendon injuries are among the most common of these injuries.

Shoulder Impingement

Shoulder impingement happens when the top of the shoulder blade (acromion) exerts pressure on the underlying soft tissues as the arm is raised away from the body. When the arm is lifted, the acromion rubs against the rotator cuff tendons and bursa, causing bursitis and tendinitis, which can result in pain and restricted movement.

Instability

Shoulder instability happens when the upper arm bone is forcefully pushed out of the shoulder socket. This typically occurs due to an injury. Dislocations can be partial, where the upper arm comes partially out of the socket (subluxation), or complete, where the ball comes all the way out of the socket. When the ligaments, tendons, and muscles around the shoulder become loose or torn, dislocations can happen repeatedly. Repeated dislocations, whether partial or complete, can cause pain and instability when raising or moving the arm away from the body and increase the risk of developing arthritis in the joint.

Arthritis

The most common type of shoulder arthritis is osteoarthritis (wear-and-tear arthritis). Symptoms such as pain and stiffness typically begin during middle age. Osteoarthritis develops slowly, and the pain it causes worsens over time.

Osteoarthritis may be related to sports, work injuries, or chronic wear and tear. Other types of arthritis can be linked to rotator cuff tears, infection, or an inflammation of the joint lining.

Tests

Common tests to diagnose shoulder issues:

·  X-rays: to check for bone injuries and arthritis.

·  Ultrasound Scan: to examine soft tissue for conditions like tendinitis and tears.

·  Magnetic resonance imaging (MRI): for more detailed information about soft tissue.

·  A computed tomography (CT) scan reveals details of the bones in the shoulder area.

Treatment

·  Activity Changes: Rest, modify activities, and undergo physical therapy to improve shoulder strength and flexibility.

Medications: Prescribed to reduce inflammation and pain. If medication is prescribed for pain relief, it should be taken only as directed.

·  Injections: Cortisone is used to relieve pain and inflammation. PRP (platelet-rich plasma) is used to promote healing and reduce pain. The injection preferably be performed with ultrasound guidance for increased accuracy and efficacy.

·  Surgery may be required to resolve certain shoulder problems such as large complete rotator cuff tears, end-stage arthritis, and recurrent dislocation. However, most patients with shoulder pain will respond to simple treatment methods like modifying activities, rest, physical therapy, medication and injections.

GTPS, or Greater Trochanter Pain Syndrome, is a common cause for lateral side hip pain. The source of the pain may have multiple causes including: 

• Bursitis: Greater trochanter bursitis is inflammation of the bursa covering the bony      portion of the hip, called the greater trochanter.
• Tendinitis: When the tendon attached to the greater trochanter bone becomes inflamed.
• Referred pain: When the original source of pain could be from the back or the hip joint itself.

Symptoms

The main symptom of GTPS is pain at the point of the hip. The pain usually extends to the outside of the thigh area. In the early stages, the pain is usually described as sharp and intense, only to become more of an ache that spreads across a larger area of the hip.

Typically, the pain is worse at night, when lying on the affected hip, or when getting up from a chair after being seated for an extended period. It may be worsened by prolonged walking, stair climbing, running, or squatting.

Risk factors

GTPS can affect anyone but is more common in women and middle-aged to elderly people.

The following risk factors have been associated with the development of GTPS:

• Repetitive stress and overuse of an injury: Running, stair climbing, bicycling, or standing for long periods of time.
• Hip injury
• Spine disease: This includes scoliosis, arthritis of the lumbar (lower) spine, and other spine related issues.
• Leg-length inequality: When one leg is significantly shorter than the other, it may affect the way you walk and can lead to irritation of a hip bursa.
• Rheumatoid  Arthritis: This makes the bursa more likely to become inflamed.
• Previous  surgery: Surgery around the hip or prosthetic implants in the hip can irritate the bursa and the tendons and cause bursitis.
• Bone spurs or calcium deposits: These can develop within the tendons that attach muscles to the trochanter. They can irritate the bursa, the tendon and cause inflammation.

Treatment

Many people with Hip Bursitis can experience relief non-surgically, with options such as: 

• Lifestyle  changes: Modified activity, non-steroidal anti-inflammatory medications,      assistive devices, and physical therapy. 
• Injections for the hip: When simpler treatment options do not produce the desired      results, injections into the affected area are generally more effective. The method of using ultrasound-guided injections ensures precision and accurate placement of the needle.
• Cortisone injection: This is the most traditional way of treating GTPS. Cortisone      injections provide a high dose of anti-inflammatory medication to the affected area. This treatment is associated with some risks, including a  ruptured tendon, which can lead to a flat foot, chronic pain, and a fat atrophy, decreasing the thickness of the fat pad in the hip.
• Platelet-rich plasma: PRP injections are a new treatment for GTPS. The treatment      involves spinning a blood sample in a centrifuge to concentrate the platelets and plasma together. The PRP that is isolated from your blood is then injected. Platelets produce essential growth factors that promote and accelerate healing without the potential side effects of the cortisone  injections. Comparing PRP to cortisone injection for GTPS shows that PRP is more effective than cortisone injections and provides extended pain relief.

Additional Information

Below is a summary of several studies comparing PRP treatments to cortisone injections.

1. Ultrasound-guided Platelet-rich Plasma Application Versus Corticosteroid Injections for the Treatment of Greater Trochanteric Pain Syndrome: A Prospective Controlled Randomized Comparative Clinical Study - Jan 2020

Twenty-four patients were randomized to undergo ultrasound-guided cortisone injections and ultrasound-guided PRP injections. After following up for 6 months, the author concludes that, “patients with GTPS present better and longer-lasting clinical results when treated with US-guided PRP injections compared to those with cortisone.”

Begkas D, Chatzopoulos ST, Touzopoulos P, Balanika A, Pastroudis A. Ultrasound-guided Platelet-rich Plasma Application Versus Corticosteroid Injections for the Treatment of Greater Trochanteric Pain Syndrome: A Prospective Controlled Randomized Comparative Clinical Study. Cureus. 2020;12(1):e6583. Published 2020 Jan 7. doi:10.7759/cureus.6583

2. Leucocyte-Rich Platelet-Rich Plasma Treatment of Gluteus Medius and Minimus Tendinopathy: A Double-Blind Randomized Controlled Trial With 2-Year Follow-up.

80 patients with GTPS randomized to either a single corticosteroid injection or a single PRP injection. The authors noticed that the improvement from a corticosteroid injection was maximal at six weeks and not maintained beyond 24 weeks. They also noticed that the improvement from a single PRP injection was sustained up to two years.

Fitzpatrick, Jane et al. “Leucocyte-Rich Platelet-Rich Plasma Treatment of Gluteus Medius and Minimus Tendinopathy: A Double-Blind Randomized Controlled Trial With 2-Year Follow-up.” The American journal of sports medicine vol. 47,5 (2019): 1130-1137. doi:10.1177/0363546519826969

3. Platelet-Rich Plasma Versus Surgery for the Management of Recalcitrant Greater Trochanteric Pain Syndrome: A Systematic Review

This study reviewed 185 patients who have had surgery for GTPS, and 94 patients who have undergone PRP. The authors concluded that both PRP and surgical intervention showed clinically significant improvements based on patient reported outcomes, however, PRP has less associated complications. PRP injections for GTPS provides an effective and safe alternative to surgery after failed physical therapy.

Surgical Treatment

Surgery is rarely needed for lateral hip pain. If the bursa remains inflamed and painful after all nonsurgical treatments have been tested, surgery can be performed to remove the bursa. 

Plantar Fasciitis and bone spurs

The plantar fascia is a long, thin ligament that lies directly beneath the skin on the bottom of your foot. It connects the heel to the front of your foot while supporting the arch. Plantar Fasciitis occurs when that strong band of tissue becomes irritated and inflamed. It is the most common cause of pain that occurs at the bottom of the heel, with the prevalence of Plantar Fasciitis being between 3.6% and 7% in the general population and 8% among runners. 

Causes

The plantar fascia designed to absorb the high stresses and strains we place on our feet. Sometimes, however, too much pressure can damage or tear the tissue. The body's natural response to injury is inflammation, which results in the heel pain and stiffness of Plantar Fasciitis. 

Risk factors

In most cases, Plantar Fasciitis develops without a specific, identifiable reason. 

Factors that can make you more prone to the condition include:

· Repetitive impact activity (running/sports)

· New or increased activity 

· Obesity

· Very high arch

· Tighter calf muscles that make it difficult to flex your foot and bring your toes up toward your shin

Heel spurs

Heel spurs do not cause Plantar Fasciitis pain. Only one in 20 people (5% of the general population) with heel spur has foot pain.

Symptoms

· Pain on the bottom of the foot and near the heel.

· Pain with the first few steps after getting out of bed in the morning, or after a long period of rest, such as after a long car ride. The pain subsides after a few minutes of walking.

·  Pain after, but not during, exercise or activity.

Tests

Plantar Fasciitis is usually diagnosed by clinical examination. Tests are often ordered to make sure there are no other causes for the heel pain.

Treatment

Most patients with Plantar Fasciitis will notice improvements within ten months of starting simple treatment methods. Conservative management of Plantar Fasciitis includes:

· Resting

· Icing the foot

· Ankle and foot stretches,

· Avoiding prolonged standing

· Losing weight

· The use of proper sized footwear and orthotics

Nonsteroidal anti-inflammatory medication drugs such as ibuprofen, naproxen can also help to reduce pain and inflammation. Using the medication for more than one month should be reviewed with your family  doctor.

Injections for Plantar Fasciitis

When simpler treatment options do not produce the desired results, injections into the affected area may be more effective. Ultrasound-guided injections are the most accurate and most efficient way to heal Plantar Fasciitis. The method of using ultrasound-guided injections ensures precision and accurate placement of the needle, and pain management strategies are implemented to ensure the comfort of the patient. 

Cortisone injection: This is the traditional way of treating plantar fasciitis. The treatment involves injecting a high dose of anti-inflammatory medication into the affected area. Cortisone injections are associated with some risks, which include causing the plantar fascia to rupture, leading to a flat foot, chronic pain or a potential fat atrophy.

Platelet-rich plasma: PRP is a new treatment for Plantar Fasciitis. The treatment involves spinning a blood sample in a centrifuge to concentrate the platelets and plasma together. The PRP that is isolated from your blood is then injected into the affected area. Platelets produce essential growth factors that promote and accelerate healing. PRP does not have side effects of the cortisone injection.

Studies show PRP is more effective than cortisone injection and provides extended pain relief.

Additional information

1. Platelet-Rich Plasma Versus Corticosteroids for Plantar Fasciitis: A Systematic Review of Randomized Controlled Trials.
 

The author of this study reviewed nine other studies comparing 239 individuals who received PRP injections to 240 individuals who received Cortisone injections and their follow-up periods, including one, one-and-a-half, three, six, and 12 months.

He concluded that in patients with chronic plantar fasciitis, the current clinical evidence suggests that PRP may lead to a greater improvement in pain and functional outcome over cortisone injections.

 Eoghan T. Hurley, MB, BCh, MCh, Yoshiharu Shimozono, MD, Charles P. Hannon, MD, published April 27, 2020.
 

2. Platelet-rich plasma versus corticosteroid injection for plantar fasciitis: A comparative study.  Kowshik Jain a,∗, Philip N. Murphy b, Timothy M. Clougha

In this study, sixty patients were randomized to receive a Cortisone or PRP injection to treat plantar fasciitis. The study concludes that :

· PRP is as effective as Cortisone injections in achieving symptom relief at three and six months.

· The effect of PRP does not wear off with time.

· At 12 months, PRP is significantly more effective than cortisone injections.

· PRP is better and more durable than cortisone injections to treat plantar fasciitis.
 

The information below lists some of the studies which have proven PRP to be a more effective treatment option:

Mahindra et al., 2016. 

25 patients were given PRP injections, and 25 patients were given cortisone injections. One injection follow-up three months after the study concludes the PRP treated patients had superior results to the cortisone injections

Omar et al., 2018 

15 patients were injected with one PRP treatment and another 15 patients with one Cortisone treatment. Follow-up after one month concludes the PRP is more effective than cortisone.

Monto, 2014 

20 patients were injected with PRP and 20 patients with cortisone, one injection each. Follow-up after 24 months concluded that PRP is more effective than cortisone for treatment of plantar fasciitis.

Say et al., 2014

25 patients were injected with one PRP treatment and another 25 patients with one cortisone treatment. Follow-up after six months concluded that PRP is more effective than cortisone.

Shetty et al. 2014 

30 patients were injected with one PRP treatment and another 30 patients with one cortisone treatment. Follow-up after three months concluded that PRP is more effective.

Tiwari et al., 2013 

30 patients were injected with one PRP treatment and another 30 patients with one cortisone treatment. Follow-up after six months concluded that PRP injections are more effective than PRP.

Surgical Treatment

Surgery is considered only after 12 months of aggressive nonsurgical treatment. 

Lateral Epicondylitis, or Tennis Elbow, is a painful condition that occurs due to both overuse and degeneration of the tendons that are attached to the elbow. Tennis Elbow affects the extensor carpi radialis brevis (ECRB) tendon where it is attached to the lateral epicondyle; this tendon is one of the several tendons that work to extend the wrist. Most patients affected by tennis and golfer’s elbow are physically active individuals between the ages of 30 to 60 years old.

Symptoms

Symptoms of Lateral Epicondylitis tend to develop gradually over time, caused by both repetitive trauma and the natural aging process. Patients usually experience a point of localized pain that may also radiate down the back of the forearm. Gripping, grasping and especially lifting with an overhand grip aggravates the pain at the elbow and forearm. Though it may hurt to move the elbow, most patients retain a full range of motion. The diagnosis of tennis elbow is almost always made by a simple physical exam. Though usually unnecessary, your physician may order X-rays, MRIs, and other tests if there are atypical symptoms present.

Treatment

· Rest: The first step toward recovery is to give your arm proper rest. Sports or heavy work-related activities will need to be ceased for several weeks.

· Non-steroidal anti-inflammatory medicines: Drugs like aspirin or ibuprofen can help reduce pain and swelling.

· Physical therapy: Specific exercises are available to help strengthen the muscles in the forearm.  

· Brace: Using a brace centered over the back of your forearm may also help relieve symptoms of tennis elbow.  

· Steroid injections: Steroid injections, such as cortisone, are used to treat Tennis elbow.

· PRP: Platelet-rich plasma (PRP) is used for its effectiveness in treating a variety of tendon related injuries and inflammation. The treatment involves spinning a blood sample in a centrifuge to concentrate the platelets and plasma together. The PRP that is isolated from your blood is then injected into the plantar fascia. Platelets produce essential growth factors that promote and accelerate healing

Additional information

1. Clinical studies have evaluated the use of PRP in treating Lateral Epicondylitis for patients who have failed to respond to physical therapy. In reviewing 10 randomized controlled trials, most of the studies have proved the superiority of PRP over other treatment options that are currently available.

The author of this article concluded that : 

· PRP may provide longer continuous relief of symptoms for lateral epicondylitis than corticosteroid injection and, therefore, have a more sustainable treatment effect. 

· Patients who received PRP continued to report feeling relief for up to one year following their treatment, whereas the short-term benefits of corticosteroids began to wane after 12 weeks.

· The improvement within the group of patients who received PRP continued to be noted two years after the PRP injection. 

Summary and Recommendations: PRP is an effective treatment for lateral epicondylitis, with high-quality evidence demonstrating short-term and long-term efficacy.  

Adrian D.K. Le, MD, Lawrence Enweze, MD, Malcolm R. DeBaun, MD, Jason L. Dragoo,MD,  Platelets Rich Plasma

Clin Sports Med 38 (2019) 17–44

2. This study compared 116 patients treated with PRP to 114 treated with bupivacaine (local anesthetic). A success rate of 83.9% was noted in the PRP group versus 68.3% in control (bupivacaine) group at 24 weeks. No significant difference in the successful outcomes at 12 weeks; significant elbow tenderness reported in 29.1% of the PRP group versus 54.0% of the control group at 24 weeks. 

 Mishra et al.

3. This study compared 51 individuals treated with PRP to 49 individuals treated with corticosteroid injections and found a 77% successful outcome in the PRP group versus a 43% successful outcome in the corticosteroid group after two years.

Gosens et al.

4. This study compared 15 individuals treated with PRP to 5 individuals treated with bupivacaine (local anesthetic). The PRP group had a 93% reduction in pain at the final follow-up compared to their baseline. A 60% improvement was noted with PRP versus 16% improvement in the controls at eight weeks.

Mishra and Pavelko

5- studies confirm that PRP injection  can be as good as surgery. 

Coming soon.