Stemcelldoc's Weblog

January 26, 2014

Effect of Amide Local Anesthetics on Stem Cell Viability: Patient BEWARE !

At the Centeno-Schultz Clinic ongoing research and publication is a cornerstone of the practice.

Multiple articles have been published in peer-reviewed journals.

A new article just published examined the effect of amide type local anesthetics on human mesenchymal stem cell viability and adhesion.

Why?

cell death

Local anesthetic are commonly utilized in joint and injections.  Local anesthetics combined with high dose steroids are commonly injected into the joint.  The local anesthetic provides numbing which gives the patient several hours of pain relief.

Do the injected local anesthetics affect stem cells?

Four amide local anesthetics were examined in varying concentrations:  ropivacaine, lidocaine, bupivacaine and mepivacine.

Each anesthetic in different concentrations was incubated with human mesenchymal stem cells for 40 minutes, 120 minutes and 360 minutes and 24 hours.  Cell viability was assessed at each time point.

Conclusions

Extended treatment with local anesthetics for 24 hours or more had signficant impact on both stem cell viability and adhesion.

Stem cells treated with lidocaine, bupivacaine and mepivacine resulted in cell death via apopotosis after brief exposures.

Amide local anesthetics induce stem cells apoptosis(cell death) in a time and dose dependent manner.

Bottom Line

Patient beware!  Know that injected local anesthetics can negatively impact your repair cells.  If you medical provider wants to inject your joint ask why and with what acknowledging that your repair cells and cartilage are at risk of damage.

November 11, 2012

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!

October 4, 2012

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

September 9, 2012

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 surgerySurgery 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.

May 30, 2012

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.

April 30, 2012

Ankle Anterior Draw Sign: Assessing the stability of the Anterior Talofibular Ligament

Stability is a central theme at the Centeno-Schultz Clinic as discussed in Ortho 2.0.

The anterior talofibular ligament provides critical lateral support to the ankle and has been discussed in prior blogs.

Stability of the anterior talofibular ligament is evaluated by the anterior draw sign whereby the distal part of the leg is stabilized with one hand while the other hand cups the heel.  An anterior pull is applied to the heel attempting to move the talus forward from beneath the tibia.

The anterior drawer test has demonstrated high accuracy in the determination of lateral ankle instability and in the diagnosis of a ligament rupture.

Stem cell therapy is an alternative to traditional ankle surgery and a clinical case has been previously discussed.

At the Centeno-Schultz Clinic the anterior drawer sign can be performed under MSK ultrasound which can distinguish a partial from a complete tear.  The patient is place in the prone position with the foot hanging off the exam table in plantar flexion.  The forefoot is then pulled forward while the tibia is stabilized.  If the ATF is torn the gap between the talus and the tibia/fibula will widen when anterior force is applied which is depicted below.

April 1, 2012

Stem Cell Success in Ballet Dancer with Ankle Instability

Ankle instability can mean the end of a career or passion.

Micro motion in the ankle can led to additional injuries and accelerate the degenerative process as discussed in Ortho 2.0.

Stem cell treatments are an alternative to ankle surgery.  CK is a case in point.

CK is active equestrian and ballet dancer who sustained a severe ankle sprain who presented to the Centeno-Schultz with a 4 month history of ankle instability and pain. Her  symptoms were progressive in  nature , exclusively located over the lateral aspect of the ankle and refractory to conservative care.  MRI was signficant for complete rupture of the anterior talofibular ligament and Grade 2 sprain of the calcaeofibular ligament.

The importance of the anterior talofibular and calcaneal fibular ligament has been discussed in a prior blog.

CK underwent ultrasound  guided injections of both prolotherapy and  Regenexx PL and SCP with significant improvement.  Initial MRI of ankle noted a complete rupture of ATF whereas followup studies demonstrated  a thick and wavy ATF ligament.  Pre and post MRI images will be posted at a later time.    Most importantly CK avoided a surgery and is back to her passions: dancing and riding.   Congratulations!!

March 30, 2012

Ankle Pain: Tarsal Tunnel Syndrome

At the Centeno-Schultz Clinic we acknowledge that there are many causes of ankle pain.

Ortho 2.o discusses the key concepts in evaluating  the ankle:  Stabilization, Articulation, Neurological and Alignment.

Tarsal tunnel syndrome (TTS)  is an entrapment of the tibial nerve  on the medial side of the ankle and is characterized by numbness and pain in the toes and sole of the foot.

The tibial nerve, artery and tendons of the flexors travel as a bundle through the tarsal tunnel.  the tarsal tunnel is delineated by bone on the inside and the flexor retinaculum on the outside.  In the tarsal tunnel the tibial nerve divides into three different segment:. calcaneal, medial and lateral. 

Anything that creates pressure in the Tarsal Tunnel can cause TTS. Common causes include cysts, bone spurs, varicose veins, ganglia, inflammation of tendons or swelling from trauma.

Symptoms include burning pain, tingling or numbness typically worse after prolonged standing.

Tarsal tunnel syndrome is diagnosed by clinical examination and based on findings such as area of sensory disturbance and positive Tinel sign over the tarsal tunnel.

Ultrasound imaging is utilized at the Centeno-Schultz Clinic for both diagnostic evaluations and therapeutic injections of prolotherapy and platelet derived growth factors.  Below is short axis  ultrasound image of the tarsal tunnel and tibial nerve.

Legend:  Abdh:  abductor hallucis muscle,

curved arrow:  tibial nerve,

fhl: flexor hallucis  longus tendon,

ST: sustentaculum tali,

straight open arrows:  flexor digitorum longus tendon,

void arrowhead:  tibial artery,

white arrow heads:  posterior tibial veins.

March 26, 2012

Ankle Sprains: Calcaneal Fibular Ligament

An ankle sprain, more commonly called “rolling your ankle,” is a stretch or tear in one or more ankle ligaments. It most commonly involves the anterior talofibular ligament and the calcaneal fibular ligament.  The former has been discussed in a previous blog.

At the Centeno-Schultz Clinic stability is a key concept in the treatment of orthopedic injuries.  Stability is one of  many critical concepts discussed in Ortho 2.0.  Joint instability can lead to injury, acceleration of cartilage and meniscus degeneration and an alternation in bio mechanics.

The calcaneal fibular ligament  is a narrow cord that connects the distal tip of fibula with posterior and lateral aspect of the calcaneus.

Inversion sprain is the most common injury whereby the  ankle is inverted and ligament are stretched or torn.

The  primary function of the calcaneal fibular ligament is to stablize sub-talar joint and limit inversion.

At the Centeno-Schultz Clinic the talar tilt test is  to evaluate talar instability.  The talar tilt test is defined as the angle produced by the tibial plafond and the dome of the talus in response to forceful inversion of the hindfoot.

The calcaneus and talus are grasped as a unit and tilted into inversion. The tibia is held stable with the ankle in neutral dorsiflexion.

Risk factors for an ankle sprain include:  weak muscles/tendons, weak or lax ligaments and poor ankle flexibility.

March 25, 2012

Anterior Talofibular Ligament: Ankle Stability

At the Centeno-Schultz Clinic stability is a key concept in the treatment of orthopedic injuries.  Stability is one of  many critical concepts discussed in Ortho 2.0.  Joint instability can lead to injury, acceleration of cartilage and meniscus degeneration and an alternation in bio mechanics.

The anterior talofibular ligament (ATF)  is a key lateral ligament in the  ankle.  Ligaments are dense fibrous tissue that connect one bone to another.  Treatment options for ligament laxity include prolotherapy, platelet derived growth factors and autologous stem cell therapy.

The anterior talofibular ligament has the following characteristics:

It connects anterior fibula to neck of talus.

In dorsiflexion, its fibers are oriented 75 deg to the floor

In plantar flexion, its fibers approach vertical orientation.

The ATF ligament prevents the foot from sliding forward in relation to the shin

It is the weakest of the ankle ligaments and it’s because of this it is the one that is most commonly injured.

The  anterior drawer and talar tilt tests are common tests used at the Centeno-Schultz Clinic to evaluate lateral ligament laxity.

Below is an ultrasound image of the ATF.  F=fibula and T=Talus.  The arrows identify the  anterior talofibular ligament.

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