Intersection Syndrome: A cause of forearm pain

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

Intersection syndrome is a painful condition on the radial (thumb) side of the forearm when inflammation occurs at the intersection of the first and second extensor tendons. 

The first compartment is compromised of EPB (extensor pollicis brevis) and APL (abductor pollicis longus) whereas the second compartment includes ECRB and ECRL (extensor carpi radialis brevis and longus).

Presentation:  pain approximately 4 cm above the back of the wrist joint where the first and second compartment tendons cross.

 

Tendons are surrounded by a slippery sac called a tenosynovium which allows the tendons to glide.  Inflammation of the tenosynovium (tenosynovitis) impairs the tendons ability to glide and results in pain.

Etiology can be traumatic or due to repetitive wrist flexion and extension commonly seen in weightlifters ad rowers.

 Other causes of radial forearm pain include de Quervain tenosynovitis, thumb CMC arthritis, radial sensory nerve irritation and extensor pollicis longus (EPL) tendinitis.

In cases unresponsive to conservative therapy a guided injection under ultrasound is indicated.  At the Centeno-Schultz Clinic MSK US is utilized in joint, ligament and tendon injections.  Accuracy and visualization is critical for successful clinical results.  Below is an ultrasound image of the first and second compartment tendons crossing.  The white arrows identify the tendons of compartment 1 superficially crossing those of compartment 2.  This is the site of inflammation in intersection syndrome that results in radial side forearm pain.

Narcotics, Addiction and An Alternative in the Treatment of Pain

At the Centeno-Schultz Clinic we acknowledge that chronic pain can be devastating.  It impacts all facets of life and can lead to depression, inactivity and loss of connection.

Treatment options for chronic pain are extensive.

At the Centeno-Schultz Clinic we believe that identification of the pain generator is critical in the successful treatment of pain.   The pain generator is that tissue or structure that is responsible for the patient’s pain.  A thorough history and physical examination is starting point. Diagnostic tests may include  x-rays, MRI, MSK ultrasound, facet injections or selective nerve root blocks.  Once the source of the pain is identified a treatment plan can be established.  As discussed in Ortho 2.0 there are four critical elements : stability, articulation, neurologic and alignment.

Treatment options at the Centeno-Schultz Clinic include IMS,  prolotherapy, PRP and autologous stem cell therapy. 

Unfortunately narcotics have been used extensively in the treatment of chronic pain.  Narcotics do not identify the source of the pain but rather mask it.  Complications include addiction and death as discussed in medpage Today.

 Highlights of the article:

“The first decade of the 21st century has been a good one for makers of prescription painkillers as sales quadrupled from 1999 through 2010, but even in a growth industry OxyContin stands out — ringing up sales of nearly $3 billion a year.”

In 1998 Purdue Pharma’s marketing of OxyContin included a video in which 7 patients provided their glowing testimony on the benefits of oxycontin. 

10 years later two of the seven patients died as active opioid abusers.

A third became addicted, suffered greatly, and quit after realizing she was headed for an overdose.

Bottom Line:  Narcotics are not the answer.  Identify the pain generator.

Exercise: A Key to Stem Cell Health

This last week in Grand Cayman we have performed a number of  Regenexx C procedures where culture expanded bone marrow derived stem cells are injected for the treatment of knee meniscus injuries and loss of cartilage in the knee, hip and ankle.  This is different from the Regenexx SD procedure that does not utilize culture expansion.  At the Centeno-Schutz Clinic in Colorado, Regenexx SD, AD and platelet therapies are provided as non surgical treatment options for common orthopedic conditions.

Caymanians and tourist alike engage in a number of water activities.  Deep water running and walking is quite popular.  Deep water exercises have signficant cardiovascular benefits which have been summarized.  This form of exercise also reduces the force exerted on a given joint.

Exercise along with diet is key in optimizing stem cell health.  Here are 10 steps to improve your stem cell health.

Lateral Hip Pain: Beyond Trochanteric Bursitis

At the Centeno-Schultz Clinic we understand that hip pain can be debilitating.  Hip pain can arise from osteoarthritis, avascular necrosis of the femoral head(AVN),  labral tears and fractures.  Stem cell treatments are an alternative to traditional hip surgery.

Trochanterteric bursitis is an inflammation of the bursa on the outside aspect of the hip bone (greater trochanter).  The bursa, a fluid filled sac lies between the insertion of the gluteus medius and gluteus minimus  muscles into the  greater trochanter.

Other causes of lateral hip pain include inflammation(tendinitis) and degeneration(tendonosis) of the tendons.  MSK ultrasound is an office based evaulation at the Centeno-Schultz Clinic that allows for accurate diagnosis and treatment.  Trochanteric bursitis can be distinguied by diagnostic ultrasound so that appropriate therapy can be understaken.  Therapies include prolotherapy, PRP and Regenexx platelet derived therapies.

Below is a illustration of the 4 surfaces on the greater trochanter and the insertions of the gluteus medius and mimimus tendons.

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.

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.

Professional Athletes Taking Responsibility: Non surgical stem cell treatments

Average NFL career is 3.5 years.  An injury can end or significantly shorten a player’s career.  Surgery can also dramatically limit a player’s career.  Surgery all too often paints a patient into a corner form which they can not successfully rebound given the significant rehabilitation, down time, alternation of simple mechanics of the joint.

Jarvis Green, 2 time Super Bowl defense lineman knew first hand the limitations of surgery and its impact on his game.  After failed knee surgery and return of pain and restriction in range of motion he rejected surgery and opted for stem cell therapy utilizing the Regenexx C and SD procedure.

St Louis Cardinal’s Mark McCormick knows the limitations of surgery and acknowledges stem cells as an alternative to shoulder surgery.

Washington Redskins safety LaRon Landry suffered an Achilles tendon injury and has taken a similar path.   After undergoing team recommended PRP and shock wave therapy  Landry failed to fully recover.  The team  instructed him that” the best thing for me was to get open up and fully cut my Achilles and that’s a tough surgery as it takes a year and a half to heal”.  He rejected the extensive surgery and Redskins elected not to resign the defensive safety.  Ortho 2.0 discusses the importance of looking a stability, alignment and neurological function in treating an injury.

The list of professional athletes electing non-surgical stem cell treatments includes Tiger Woods,  Hines Ward,  Bartolo Colon and continues to grow.

Ortho Stem Cell Treatments: The Importance of Delivery

Stem cell therapy is a alternative to traditional orthopedic knee surgery.  Mesenchymal stem cells (MSC) can differentiate into cartilage, bone, tendon, ligament and disc.  Studies have demonstrated that the use of cultured expanded mesenchymal stem cells are both safe and effective in the treatment of knee osteoarthritis.

Does it matter how the stem cells are delivered to a targeted area?

In the case of soft tissue this is not a concern since the surrounding tissue will confine the spread of the stem cells to the targeted area.

In the case of a joint such as the knee the delivery of cells  is of critical significance. The key is that stem cell function through local attachment to the damaged site.  Animal studies have demonstrated that cells injected into a large joint often times have difficulty finding their way to the damaged area.

The key is delivering  stem cells directly into the damaged site.  Koga demonstrated this by comparing the results of blindly injecting stem cells into a joint vs dripping the cells directly into the damaged area.  The illustration below tells the story.  A defect in the cartilage was created and different methods of delivery were examined.  On the left there was minimal cartilage growth after the injection of saline.  In the middle there was minimal cartilage growth after blindly injecting stem cells into the joint. On the right where cells were injected directly into the area of damaged there was robust cartilage growth.  The new cartilage is purple in color.

Bottom Line:  The exact placement of stem cells within a joint is of critical importance.

At the Centeno-Schultz Clinic we utitlize x-ray and MSK ultrasound to guide bone marrow and platetlet derived stem cells into the  area of damaged tissue to maximize clinical outcomes.

Knee Replacement Complications

Stem cell therapy is an alternative to knee replacement.  Studies have documented the success and safety of using bone marrow derived cells in the treatment of knee osteoarthritis in patients who were candidates for knee replacement.  Many of the patients at the Centeno-Schultz Clinic are concerned about the risks of knee replacement.

Listed below are some of the risks which have been discussed in  previous blogs.

1)  44% of patient s/p knee replacement continue to have knee pain.

2)   1 in 10 patients who have a knee replacement suffer a serious complication.

3)    Blood clots and potential pulmonary embolism.

4)     Premature failure as noted in hip replacements.

5)      Alteration in gait, creation of new pain and degeneration when incorrect prosthesis size is utilized.

6)      1 in 10 continue to have knee cap (patella) pain.

7)      Post operative pain in patients s/p knee replacement may have pain originating from structures other than the knee

8)      Patients who smoke are at increased risk for complications and death.

9)      Association with wear particles.  Wear particles are microscopic pieces of metal, ceramic, or plastic that break off of from the knee replacement or hip prosthesis and irritate the local tissues and/or enter the bloodstream.

10)   Increase in serum metal ion levels.

11)   Increase risk of death after age 70  The odds of dying from the surgery are 4 times higher in patients aged 70-79 years old.

13)  Patella resurfacing does not improve outcome

Narcotic Risk: FDA issues public health advisory

The Centeno-Schultz Clinic acknowledges the dangers of utilizing narcotics in managing chronic spine pain.  These include addiction, tolerance requiring escalating doses. cognitive and behaviour changes and death.  The Centeno-Schultz Clinic offers comprehensive spine care including facet and epidural injectionsunder x-ray,  SI joint injections, prolotherapy and radiofrequency.  Stem cell therapy is an alternative to traditional spinal surgery.  Regenexx PL utilities platelet derived growth factors to enhance blood flow and reduce inflammation. Previous blogs have discussed the successful use of stem cells for spine pain.

Medication mix ups or mislabeled has potentially serious consequences.

Today the FDA has issued a warning that pills, tablets, or caplets of Percocet and eight other opioid products packaged by Novartis for Endo Pharmaceuticals may have been mixed up, with one drug being packaged as another.

Patients beware!