Successful ACL Repair With Stem Cell Therapy

At the Centeno Schultz Clinic we have previously discussed treatment of anterior cruciate ligament (ACL) dysfunction.    Anterior cruciate tears have been successfully treated with stem cell therapy.

Below is another successful case of ACL repair utilizing stem cell therapy.  BT is an 18 y/o college football player who sustained an acute anterior ligament tear.  He declined surgical repair and underwent Regenexx SD with placement of his own stem cells into the ACL in November 2012.  Three months post injection a repeat MRI was performed at the same imaging center.  Below are the pre and post images of the ACL along with the MRI reports.

The ACL in the pre-procedure MRI is irregular and disorganized with a visible tear.  After Regenexx treatment the ACL fibers are uniform and well-organized.  The postprocedure MRI formal report notes ”previously described anterior cruciate ligament tear appears to have resolved”.

This corresponds to BT’s clinical presentation who describes no pain or swelling.  Regenexx SD enabled BT to avoid a major surgery and extensive rehabilitation.  A new option is now available for ACL dysfunction.

Platelet Rich Plasma vs Hyaluronic Acid Comparison for Knee Osteoarthritis

At the Centeno-Schultz Clinic we acknowledge that knee pain can be debilitating and severely impact an active life style.

Stem cell treatment is an alternative to traditional knee surgery.

Hyaluronic acid (HA) is a thick liquid that helps lubricate the joints and is used routinely in the treatment of knee osteoarthritis.  Different brands of hyaluronan are available and include Euflexxa, Hyalgan and Orthovisc.

Platelet rich plasma is a concentration of a patient’s own platelets which can be used in treat degenerative knee disorders.  Many professional athletics have undergone PRP injections including, Hinds Ward and TigerWoods.

Is PRP better than HA for knee osteoarthritis?

 Cerza et al recently published such a study.   120 patients with knee osteoarthritis were divided into two equal groups and underwent weekly intra-artricular knee injections for 4 weeks.  One group received hyaluronic acid injections whereas the other group received platelet rich plasma.

Platelet rich plasma showed signficantly better clinical outcome compared to treatment with HA.  PRP was associated with a faster onset of relief that continued up to 24 weeks.  Unlike HA which had poor results with patients with advanced OA (LC 3) PRP showed no statistically signficant difference with varying severity of osteoarhtritis.

In 2013 when you doctor recommends a hyaluronic acid injection for your knee pain ask about the superior PRP alternative.

Posterior Cruciate Injection: Accurate Placement

At the Centeno-Schultz Clinic stability is critical as evidenced in our SANS approach: Stability, Articulation, Neurologic and Symmetry.  Joint stability is essential for optimal clinical outcomes.

Accurate needle placement is equally important and is accomplished through direct visualization either by MSK ultrasound or x-ray or both.

The posterior cruciate ligament is large ligament in the knee that provides restraining force to straight posterior translation of the tibia relative to femur.  It originates from  anterolateral aspect of the medial femoral condyle and attached onto the posterior tibia.
VM is a 32 y/o snowboarder seen in clinic today with knee instability and pain.  MRI was significant for partial tearing of the PCL and swelling at its tibial insertion.

Below is an x-ray image of the PCL injection.   A posterior approach was utilized.  The femoral nerve and vasculature was identified by MSK ultrasound.  Thereafter a 25 gauge need was advanced into the PCL at the tibial attachment.  A small amount of contrast was injected with filling of the PCL.

Patient hopes to return to riding soon and we are expecting snow this weekend.

Shoulder injuries and Yoga: Things to know

During my New Year’s day practice I noted the absence of a favorite instructor.  She had suffered a shoulder injury last week. 

Injuries to the rotator cuff, labrum and shoulder ligaments can occur in yoga.  Upward-facing dog and downward dog are particularly stressful on the shoulder and can lead to inury.

I was surprised to learn that she had received a cortisone injection especially given the risks associated with steroids.

In 2013 the Centeno-Schultz Clinic provides some health guidelines for patients.

1) Know the source of your pain.  It is not enough to simply look at the MRI or x-ray.

2) Use diagnostic studies and physical examination to identity injuries.  Studies include but are not limited to x-ray, MSK ultrasound, MRI and CT.

3) All injections need to be performed with guidance.  At the Centeno-Schultz Clinic all injections are performed with either MSK ultrasound or x-ray.  This ensures accurate needle placement and best clinical outcomes. 

4) Avoid high dose steroids given their risks.

5) Consider regenerative therapies including platelets, prolotherapy and stem cells therapy.

6) Know that surgery may limit your future treatment options and advance the underlying condition.

7) Evaluate stability, articulation, neurologic and symmetry for maximum clinical outcome.

Successful Stem Cell Treatment in Collegiate Field and Track Athlete: Update

Stem cell therapy is an alternative to traditional ankle surgery as discussed in a prior blog.

KW is a 21 y/o university track and field athlete whose ankle pain restricted her ability to compete.

At the Centeno-Schultz Clinic in 8/2011 she underwent Regenexx SD for cartilage loss in the tibial-talar joint(ankle).  In addition she underwent the following therapies:

- prolotherapy of the loose ankle ligaments

-Epidural injections of platelet derived growth factors:  Regenexx PL-disc.

-Injection of the loose spinal ligaments with Regenexx DDD.

KW recently emailed me with an update which she has allowed me to share.

 ”Hello Dr. Schultz,

It’s been a while since I have updated you on my progress and I felt that I had to share how well I have been doing.

I had my procedure done on my ankle last August. Until the past few months, I kept expecting something to go wrong or for my ankle to begin hurting again because it just felt too good to be true. However, I honestly can say that I believed I am healed and 100%. It took about 6 months post-injection for the pain and stiffness to stop, and since then I have been training to gain back my endurance and strength for running.
I am participating in weight lifting, hurdle drills and most importantly back to running 60+ miles a week with NO pain or stiffness in my ankle joint.

I feel so blessed to have had this opportunity…I am applying to medical school this coming year, and it was your compassion and high quality of patient care that has really pushed me to do so. This treatment and the concept of stem-cell is fascinating, and I anticipate future advances in medicine and treatments involving stem-cells. Thank you for helping me run again and for strengthening a passion of mine!”

Fantastic!

Posterior Knee Pain: Popliteus Tendonitis

At the Centeno–Schultz Clinic we acknowledge that knee pain can be disabling. Knee pain can arise as result of loss of cartilage, ligament instability, meniscus degeneration or tears, bursa inflammation and tendon irritation. Stem cell therapy is a non surgical treatment option for many types of knee pain. At the Centeno –Schultz Clinic other treatment options include IMS, prolotherapy, Regenexx SCP and RegenexxPL.

All knee treatments utilize guidance in the form of MSK US and or x-ray to insure accurate needle placement.

Popliteus tendonitis can be a cause of posterior lateral knee pain.

The popliteus muscle originates from the lateral femoral condyle and the posterior horn of the lateral meniscus. The popliteus tendon runs deep to the LCL and passes through the hiatus to attach to the posterior surface of the tibia.

The popliteus muscle unlocks the knee in the standing or walking position whereby it rotates the tibia inward, pulls the lateral meniscus backwards and flexes the leg upon the thigh.

Popliteus tendonitis is common among runners and typically presents as pain in the posterior aspect of the knee.

Below are images of the popliteus tendon.

Medial Foot Pain: Posterior Tibialis Tendon Dysfunction

At the Centeno-Schultz Clinic we acknowledge that foot pain can be disabling and affect your game.

Posterior tibialis tendon dysfunction is a common source of medial foot pain and instability. 

Stability is critical and is one of the four central components as discussed in Ortho 2.0.

Tendons connect muscle to bone.  The posterior tibial muscle originates in the lateral part of posterior surface of tibia and medial aspect of the fibula.  It runs down and behind the inside bump of the ankle (medial malleous) and attaches to the bottom of the foot.  The bulk of the tendon inserts on a prominence on the medial aspect of the navicular.  This prominence is called the navicular tubercle.

The posterior tibialis tendon is held in place by a thick fibrouse tissue, the flexor retinaculum.  The flexor retinaculum is the roof of the tarsal tunnel

The posterior tibialis muscles act to plantarflex the ankle and invert the foot. It is also medial ankle stabilizer.

Presentation:  primarily occurrs in women who are middle-aged or elderly.  Patients commonly complain of pain in the inside of the foot and ankle with  radiation into the arch of the foot.

On physical exam there is pain along the course of the tendon and often patients are unable to stand on their toes on the affected side.

Visualization is critical for effective clinical outcomes.  At the Centeno-Schultz Clinic MSK ultrasound is used both diagnostically as well as with tendon injections to ensure accurate placement of regenerative agents.  Prolotherapy, PRP and autologous stem cells are treatment options when conservative therapy has failed.

Below is an ultrasound image of the posterior tibialis tendon at the level of the medial malleous.

FDL:  Flexor digitorum longus

PT:  Posterior tibialis

Peroneus Tendon Tear Successfully Treated with Prolotherapy

At the Centeno-Schultz Clinic we acknowledge that ankle pain can be disabling.  Ankle pain can arise from multiple sources which include ankle osteoarthritis, ligament laxity, tendon tears and  degenerative lumbar disorders.   Stem cell therapy is an alternative to ankle surgery.  Surgery is associated with risks and can often times accelerate the degeneration. 

JW is an active nurse who sustained an ankle injury while participating in Cross-Fit. Her pain was constant with weight-bearing, non progressive in nature, localized on the lateral aspect of the ankle with radiations into the little toe.  Physical examination was signficant for tenderness in the lateral ankle, laxity and multiple trigger points in calf and lumbar spine.

MRI was signficant for a partial tear in the peroneus brevus tendon and injury to the anterior talo-fibular ligament.

She declined surgical recommendations and opted to prolotherapy which is the injection of an irritant intended to initiate an inflammatory response and strengthen ligaments.

At the Centeno=Schultz Clinic prolotherapy is performed utilizing MSK ultrasound guidance which ensures accurate needle placement.  Treatment was targeted at both the peroneus tendon but also the other critical ankle ligaments.  Stability is a central element as discussed in Ortho 2.o.

Adjunct therapies included IMS, flexion/extension examination of the lumbar spine, deep water immersion exercises and low carbohydrate diet. Carbohydrate restriction and proper nutrition has been linked with improved stem cell numbers and function. 

After three prolotherapies, IMS treatment and 15 lb loss JW reports a 90% improvement and has resumed her running and cycling.

Great job Jennifer.

Plantar Fasciitis: New Treatment Options

At the Centeno-Schultz Clinic we acknowledge that heel pain can be disabling.

Plantar fasciitis is the most common cause of heel pain and is caused by the  inflammation  of the plantar fascia at its insertion on the medial process of the calcaneus ( heel bone).  The plantar fascia is the thick connective tissue which supports the arch on the bottom of the foot.  It runs from heel bone (calcaneus) forward to the heads of the metatarsal bones.  Repetitive microtrauma of the plantar fascia due to alterations in foot bio mechanics is thought to be major pathology.

Intense sharp heel pain with the first couple of steps in the morning is a common presentation.  Other diagnostic considerations include:

• Achilles tendon injuries

Lumbar radiculopathy

• Calcaneal stress fracture
• Calcaneal Bursitis
• Contusions
• Tarsal Tunnel Syndrome

In-0ffice MSK ultrasound at the Centeno-Schultz Clinic allows for radiation free method of visualizing the plantar fascia and diagnosing plantar fasciitis.

Treatment options for those who have not responded to rest and conservative therapy include IMS, ultrasound guided prolotherapy, PRP and percutaneous needle tenotomy. The latter is a non surgical procedure where under ultrasound guidance a small needle is placed into the fascia and small holes are created. A recent study by Vohra demonstrated greater than 80% improvement in 41 patients with chronic plantar fasciitis who underwent percutaneous needle tenotomy.  The ultrasound image below shows a needle directed into the plantar fascia in a patient with severe plantar fasciitis.

Anterior Hip Pain: Illiopsoas Tendinitis

At the Centeno-Schultz Clinic we acknowledge that hip pain can be disabling.

It may arise from osteoarthritis, avascular necrosis of the femoral head and femoral acetabular impingement syndrome.  Stem cell therapy is an alternative to traditional hip surgery.

Iliopsoas tendonitis can also cause hip pain which typically is anterior in location.  Tendinitis is inflammation of the tendon:  the rope-like tissue that connects muscle to bone.  Tendinitis is typically associated with an acute injury whereas tendinosis is chronic and associated with degeneration of the tendon.

Major causes include acute trauma and overuse from repetitive hip flexion.

The psoas and iliacus muscles originate from the lumbar spine and pelvis.  The muscles converge to form the iliopsoas muscle and insert onto the lesser trochanter.  The iliopsoas muscle functions as a hip flexor and external rotator of the femur.

Patients commonly present with anterior hip or groin pain.

Presentation may include shorten stride and anterior pelvic tilt.

Tenderness at the musculotendinous junction and insertion on tendon on the lesser trochanter is common.

The snapping hip sign or extension test is suggestive of iliopsoas injury.

At the Centeno-Schultz Clinic in-office ultrasound is an important diagnostic tool.  The noninvasive test typically demonstrates thickening of the tendon which is illustrated below.

Treatment options include prolotherapy, IMS, platelet derived growth factors and percutaneous needle tenotomy.