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.

Deltoid Ligament: Medial Ankle Pain

At the Centeno-Schultz Clinic stability is a central theme as outlined in Ortho 2.0.

The lateral ankle ligaments have been discussed in prior blog. Treatment of ankle sprains at the Centeno-Schultz Clinic includes a diagnostic MSK ultrasound where the ligaments visualized and their integrity assessed.  Treatment options for loose, partially torn or degenerative ligaments include prolotherapy, PRP and autolgous bone marrow derived stem cells.

A video discusses the use of stem cells as an alternative to ankle surgery.

15-20 % of all athletic injuries involve the ankle.  20-40% of ankle injuries will lead to chronic instability.

The deltoid ligament supports the medial side of the ankle joint and is composed of 3 principle ligaments.  They all attach at the medial malleolus.

Tibionavicular Ligament is the most anterior and inserts upon the navicular bone.

Tibiocalcaneal ligament is the middle ligament and inserts upon the sustentaculum tali of the calcaneus.

Posterior Tibiotalus are posterior fibers that connect to the talus.

An eversion sprain is a tear in the deltoid ligaments.  It occurs with excessive inward rotation and is often accompanied by a fracture of the fibula.

An ultrasound image of the tibiotalar  ligament is displayed below.

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.

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?

Yes!

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 ankles.  MSK ultrasound and or x-ray is used in injections to ensure accurate placement of platelets.

X-rays don’t not accurately identify source of pain

All too often degenerative changes on x-ray or MRI are identified as the source of pain.  At the Centeno-Schultz Clinic we acknowledge that pain can arise from many sources and that abnormalities on x-ray or MRI do not localize the source of pain.  There are patients with abnormal radiographic studies who have no pain and patients who have normal studies with debilitating pain.

Degnerative lumbar spine

This concept was validated in a recent study which examined the relationship between age/gender and prevalence of wrist arthritis.  The authors found the same variability that we see in the Centeno-Schultz Clinic:  “Patients with little radiographic evidence of arthritis may have many complaints while others with severe arthritis have very few if any.” 

Therapy based on radiographic abnormalities alone does not make sense.  The authors conclude: “a recommendation to operate on trapeziometacarpal (wrist) arthritis based upon radiographic criteria when the patient has adapted well to their illness would be questionable.” This makes particular sense given that arthritis is an inevitable part of aging.

After a complete evaluation potential pain generators are identified through ultrasound or x-ray guided diagnostic injections.  Therapies at the Centeno-Schultz Clinic include  platelet rich plasma, low dose cortisone, prolotherapy and autologous stem cell injections.



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.

Joint Stability: Essential for Success

Stability of a given joint is essential for the optimal function and maintenance of the joint.

Stability is determined by many factors which include the integrity of the ligaments.

Ligaments are thick connective tissue that connects bone to bone.   An example is the deltoid ligments in the ankle.

 

 Injury to ligaments due to either to acute or repeat trauma can compromise the  integrity and support provided by the ligament.  The consequences can include degenerative changes in the joint and pain.  This was clearly illustrated in a previous blog.

In the treatment of degenerative changes in a joint, it is essential that stability of the joint is evaluated and optimized.  It is not enough to use regenerative therapies on the joint such as PRP, prolotherapy or stem cell therapy.  For maximal clinical results, the joint and its stability must be addressed and optimized.  This is the standard of care at the Centeno-Schultz Clinic and Regenexx.

Steroids: Patients Beware

Steroids are commonly used to treat pain.  Common examples include cortisone injections into knees, elbows, hips and lumbar spine.

There is increasing concern by many authors about the side-effects of steroid injections.

Hossain demonstrated that steroids were capable of shutting down normal repair and maintenance functions in the joint.(Apoptosis) 

Nakazawa demonstrated that steroids can turn off the production of catilage.

Wong identified a correlation between steroid use and bone death. (avascular necrosis of the femoral head)

At the Centeno-Schultz Clinic we too are concerned and have changed our treatment protocols from large dose steroid injections to low dose.  Most steroid injections use 6 milligrams of steroid.  At Centeno-Schultz Clinic we use a very dilute concentration of steroid which is compounded for our clinic.  A nanogram is 1/1000 th of a milligram.  Steroid injections at Centeno-Schultz Clinic  are between 50 to 100 nanograms.  This dilute solution has positive effects on joint health by increasing the concentration of growth factors and stimulating stem cell production of cartilage.

Other options for the treatment of pain include prolotherapy, PRP and stem cell therapy.

X-Ray Guided Prolotherapy

Prolotherapy is the injection of a proliferative agent which triggers a natural healing response. 

It has been successful in the treatment of many disorders including neck, shoulder, knee and ankle pain.  Dr. Centeno recently published an article in The Journal of Prolotherapy in which he discusses the use of x-ray guidance with prolotherapy.  This ensures that the injection is in the correct place to maximize clinical results.  Dr. Centeno discusses the use of prolotherapy for  the treatment of neck, knee, sacroillac joint, ankle, ischial tuberosity and shoulder pain.  At the Centeno-Schultz Clinic x-ray guided prolotherapy is just one of the  therapies utilized in the successful treatment of pain.

regenexx.stemcelltherapy.regennes. regennes.regeness.

C-arm_fluoroscopy

Prolotherapy and Pelvic Pain

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.