Stemcelldoc's Weblog

November 22, 2012

Lateral Elbow Pain: Posterior Interosseous Nerve Compression

At the Centeno-Schultz Clinic we acknowledge that lateral elbow pain can be debilitating and impact daily function.

Not all lateral elbow pain is lateral epicondylitis as illustrated by a recent patient seen in clinic.

Joey is a 17 y/o hocky player with 1 year history of lateral elbow pain which was constant, progressive in nature and aggravated with rotation of his palm upward (supination).  He has undergone PT, trial of NSAID’s, heat, ice and 2 steroid injections without relief.  High dose steroids have signficant side effect both on tissue and stem cell function.

Joey had compression of posterior interosseus nerve which was confirmed by MSK ultrasound.  Treatment options include US guided Regenexx PL/SCP injections and possible hydrodissection.   A patient’s testimonial illustrates the potential of treating nerve injuries with ulrasound guided platelet therapy.

The posterior interosseous nerve (PIN) is nerve in the forearm. 

Posterior Interosseous Nerve

It is the continuation of the deep branch of the radial nerve.  It passes thru supinator muscle in its course from anterior to the posterior surface of the forearm. The PIN may become entrapped at the tendinous border of the supinator known as Aracade of Froshse. Posterior interosseous neuropathy is purely a motor syndrome resulting in finger drop, and radial wrist deviation on extension.  

Other causes of PIN dysfunction include trauma, synovitis, tumors, and iatrogenic injuries.


Pain with resisted supination of the forearm.

Pain with resisted extension of extension of middle finger.

Tenderness over lateral epicondyle and distally over the aracade of Froshe. 

Other causes of lateral elbow pain which warrant consideration include:

C7 radiculopathy

Lateral epicondylitis

Extensor tendon rupture

July 22, 2011

Treatment of Lateral Elbow Pain with PRP

Pain on the outside aspect of the elbow is referred to as lateral epicondylitis or tennis elbow.  It can be quite disabling affecting both the quality of life and range of motion.

Lateral epicondylitis is caused by irritation of the common extensor tendons as they insert onto the bony surface of the elbow.

PRP (platelet rich plasma) has become increasing popular as non surgical treatment in common orthopedic conditions.

Has it been used in the treatment of elbow pain?


Peerbooms demonstrated PRP to be more effective than steroids in the treatment of lateral elbow pain.  100 patients were randomly assigned treatment with either PRP or steroids.  At one year 73% of patients treated with PRP reported significant improvement vs 49% in the steroid group.

Steroid use has been associated with significant side effects including ligament and cartilage compromise and cell death (apoptosis).

At the Centeno-Schultz Clinic advanced cell treatments including PRP are used in the treatment of lateral elbow pain and other common orthopedic conditions including meniscus tears, supraspinatus tears,  osteoarthritis of hip, knee and anklesMSK ultrasound and or x-ray is used in injections to ensure accurate placement of platelets.

March 3, 2011

Steroids and Cell Death: Apoptosis


Apoptosis is the process of programmed cell death.  The process is controlled by a variety of factors both within and outside of  cells.  High dose steroids have been demonstrated to create cell death in muscles, bones, cartilage and ligaments.  High dose steroids are commonly used to treat a variety of painful conditions which include rotator cuff tears, lateral epicondylitis, patellar and Achilles tendonitis, pes anersine bursitis,  lumbar facet dysfunction and sciatica.

At the Centeno-Schultz Clinic we acknowledge the negative effect of  high dose steroids.  Our aim is to identify the source of a patient’s pain and provide a therapy which will attempt to repair the damaged tissue.  Our treatments are not aimed at advancing the degenerative process or triggering apoptosis.  Accordingly we use only very small doses of steroids when necesary and have a large number of regenerative therapies which promote healing: prolotherapy, platelet rich plasma (PRP), Regenexx SCP, Regenexx AD and Regenexx SD.

January 10, 2011

Shoulder Pain and Ultrasound Guided Injections

Platelet rich plasma, prolotherapy and autologous stem cells are non-surgical treatments for shoulder pain.  Clinical success is dependent upon selecting the appropriate treatment option and placing the solution into the targeted site.

Ultrasound has become the standard of care at the Centeno-Schultz Clinic.  Ultrasound does not involve exposure to x-rays and provides a rich image of the bone, muscles, tendons and ligaments. It also allows for a dynamic evaluation whereby the patient is able to go through the activities that cause them pain.  This is not the case with MRI’s given that they require a patient to remain completely still.  MRI’s provide a static image of the shoulder which may not be helpful in some cases of impingement.

This last weekend Ron Hanson M.D. was an instructor at a highly respected shoulder ultrasound course.

We are very pleased to have Ron’s gifted clinical and ultrasound skills here in Denver/Boulder area at the Centeno-Schultz Clinic.

September 16, 2010

Elbow Pain: Accurate Diagnosis and Treatment

Pain on the outside of the elbow which is referred to as lateral epicondylitis can be disabling.  Typically seen in 30-60 year olds, patients complain of point tenderness over the outside aspect of the  elbow ( lateral epicondyle) aggravated by gripping and activities that extend the wrist.

The pain is thought to arise from degenerative changes in the muscles that attach to lateral epicondyle called the extensor muscles.  These muscles allow the arm to extend(bent backward) .

The diagnosis is made by clinical signs and symptoms.  A common diagnostic test is the Cozen test. Conservative treatment includes PT, NSAIDs, heat, ice and rest.  Injection of cortisone has been demonstrated to be no different than placebo.  Complications from repeated steroid injections include fat atrophy and potential weaking of the tendon.

Not all lateral elbow pain is lateral epicondylitis. 

LF  presented with a 5 month history of lateral elbow pain after tripping over her dog and striking her elbow on her granite countertop.  Conservative therapy had failed and her physician had referred her for PRP injection.  At the Centeno-Schultz Clinic therapeutic injections are performed with either x-ray or ultrasound to confirm accurate placement. LF’s ultrasound exam was significant for tendosis (tendosis) of the extensor muscles which are commonly associated with lateral epicondylitis.  More important was the significant tendosis and partial muscle tear of the triceps muscle (not typically seen with lateral epiconduylitis).  Identifying this second site of injury was cardinal as it represented another source of pain which needed to be treated for maximal clinical outcome.  At the Centeno-Schultz Clinic  an accurate diagnosis and appropriate placement of regenerative therapies whether it be stem cell therapy, prolotherapy, APC or PRP injections  is our standard.

May 31, 2010

Essential Differences in PRP Therapies

Platelet rich plasma (PRP) therapy is the use of a patient’s own platelets to accelerate healing.  It is termed rich because the platelets are concentrated, typically 5-10x above the concentration that is circulating in your blood.

PRP therapy has been used for a number of different indications  including wound healing in surgery,tendinitis, cardiac care and dental health.

Platelet-rich plasma (PRP) therapy made headlines following the Super Bowl, when it was revealed that Pittsburgh Steelers Hines Ward and Troy Polamalu had undergone PRP injections in the days leading up to the game.

Are all PRP therapies the same?


There are distinct differences in platelet rich plasma .

Most PRP is created by a bedside machine that creates a platelet concentrate by spinning (centrifuge) the blood thereby separating the platelets from the other blood products.

A cell biologist in a laboratory, however,  is able to separate the platelet from other blood products and so much more.

A cell biologist can create PRP that is pure and free of any red or white blood cells.  A machine cannot.

A cell biologist can create PRP in a specific concentration for specific indications.  A machine cannot.

A cell biologist can make PRP that has a very high levels of specific, naturally occurring growth factors such as VGEF, vascular  growth endothelial factor.  A machine cannot.

At the  Centeno-Schultz Clinic we are not reliant on a machine.  Rather through the use of a state of the art lab with full-time cell biologists we are able to provide our patients with customized PRP therapies that are specifically designed for them.  This is the critical difference which translates to improved outcome.

January 14, 2010

Elbow Pain Now Addicted to Narcotics

55 year old patient presented with a 2 year history of left elbow pain which was constant in duration, 8/10 in severity, progressive in nature, localized on the lateral (outside) aspect of elbow without any radiations.  Patient drives a city bus and sustained a slip and fall injury in which he struck his left elbow. He denied any neck or arm pain.  Treatment to date had included massage, x-rays, cortisone injections into the joint and oral narcotics.  Narcotics were started “since other therapies had failed”.  Patient had a known addictive personality and was a recovering alcoholic. He was using up to 8 Vicodin /day as prescribed.

On physical examination he had extreme tenderness over the outside aspect of the elbow (lateral epicondyle) and multiple tender points along the extensor muscles in his forearm. His neurologic exam was normal.

Lateral epicondylitis  is theorized to be an injury of repetitive microtrauma/overuse.

It is commonly caused by  commonly associated with playing tennis  and other racquet sports.

It can also be caused by sustained contraction of the extensor muscles in the forearm which result in excessive force on the tendon where it is attached on the bone.  Treatment is two-fold: relax the dysfunctional muscle and promote healing.  This is possible by IMS and prolotherapy.

Following regenerative therapy at the Centeno-Schultz Clinic, patient had reduction in his pain, increase in range of motion and elimination of all narcotics.

January 13, 2010

Effectiveness of Platelet Rich Plasma Injections

Regenerative medicine therapies include prolotherapy, platelet rich plasma injections and stem cells.

Platelet rich plasma (PRP) involves the use of platelet derived growth factors in the healing of tendon and muscle injuries.  The process includes collection of a patient’s blood with isolation and concentration of the platelets.  The concentrated platelets are then injected into the damaged tissue accelerating the healing process.

PRP therapy has made the headlines and utilized by many professional athletic teams.

Does it work?

According to Robert J. de Vos, M.D., in his recent publication in the Journal of American Medial Association, PRP injections did not significantly improve pain or activity level in patients with long-standing history of Achilles tendon irritation.  What this article did not discuss was the therapeutic effect of simply irritating the tendon (percutaneous tenotomy) which has been demonstrated to be effective.

Regenerative medicine has an increasing number of tools.  At the Centeno-Schultz Clinic it is our goal to utilize the appropriate regenerative therapy for the best possible clinical outcome.

October 26, 2009

Elbow Pain: Missing the Picture

Patient returned today after initial evaluation for lateral elbow pain.  She has a 5 year history of elbow pain, localized along the lateral aspect, constant in duration, progressive in nature without any radiations.  Pain was throbbing in character and aggravated by external rotation and her daily work responsibilities.  Therapies to date had included physical therapy, massage, chiropractic care, x-rays of elbow, evaluation by sports medicine physician, trial of anti-inflammatory medications and muscle relaxants. 

Physical examination demonstrated point tenderness along the lateral epicondyle and multiple trigger points in the extensor muscles.  Neurologic exam was normal.   Cervical spine had mild reduction in range of motion which was painful.  Specifically she had pain with extension and lateral rotation.

Lateral epicondyle 2

Given her poor response to conservative therapy, persistence of symptoms and neck pain and restriction motion, I was concerned that her pain was arising from a degenerate disc in her cervical spine.  That would make sense since the muscles in her arm which were painful receive their information from the C6 nerve.  If there is compression of the nerve root,  pain and muscle dysfunction can result.

Her cervical MRI demonstrated degeneration of the C5/6 disc and compression of the C6 nerve root.

A thorough examination is essential.  This is the standard at the Centeno-Schultz Clinic.  Regenerative options for this patient include prolotherapy, IMS, cervical injections with PRP and stem cell therapy.


October 9, 2009

Prolotherapy and Pelvic Pain

Filed under: American Stem Cell Therapy Association, Elbow, Shoulder — Tags: , — stemcelldoc @ 7:18 am

Saw a patient in clinic today who graciously has  allowed me to share her tale.

35 y/o female with 5 year history of pelvic pain which was constant induration, 5/10 in severity, localized at the level of her pubic bone with radiations into the left groin.

The pain was sharp in character, progressive in nature and not associated with any trauma.  It developed after the birth of her second child.  Pain prevented her from exercising, lifting and caring for her children and focusing on her work. 

Two continents, 12 doctors, CAT scans, MRIs, exploratory surgery, hernia repair, trial of muscle relaxants, narcotics, physical therapy had not afforded the patient any pain relief.

Physical examination was significant for acute tenderness directly over the pubis symphysis.

The pubic symphysis is a joint composed of cartilage which joins the two pelivc bones together.  It is rich in ligaments and tendons.

Prolotherapy is the injection of ligaments to initiate a healing response.  No steroids are used.

Three session of prolotherapy provided the patient with 80% reduction in her pain.  Intermittent x-ray was used to confirm accurate placment of both the needle and medication .  Prolotherapy has been effective treatment of many ligament disorders at the Centeno-Schultz Clinic  including elbow, knee, ankle and pelvic pain.

Prolotherapy of Pubis Symphysis ADF

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