Regenerative Healing

Regenerative Healing

Regenerative medicine, where the body regenerates or rebuilds itself, is a relatively new and rapidly evolving front in the field of interventional pain management. Although stem cell therapy has garnered much of the attention over the past several decades, multiple other regenerative medicine modalities also have caught the public’s attention.

  • Alpha-2-macroglobulin - concentrated from your blood, deactivates enzymes that destroy cartilage in joints
  • Exosomes - repairs damaged tissue, cartilage, and other tissue.
  • Stem cells (bone marrow or fat) - multiple uses
  • PRP (Platelet Rich Plasma) - multiple uses
  • Prolotherapy (with dextrose 50%)

Athlete & Injury Recovery

Athlete & Injury Recovery

Joint Injections

In our practice, all joints are injected under live fluoroscopy (x-ray) or ultrasound guidance. We feel it is safer to be able to prove that the medication is ending up in the joint space as opposed to just surrounding tissue. Most joint injections involve a local anesthetic (numbing medicine) and a long acting steroid. In some instances, we may trial Hyalgan a lubricating jelly that can be placed inside a joint instead of a steroid. For severe joint degeneration, we can discuss alpha-2-macroglobulin, exosomes, PRP or stem cell therapy to help rebuild the cartilage surface.

In addition to joint injections, we offer nerve blocks that help with pain from a joint. For a knee joint, for instance, we can perform a genicular nerve block. These nerves don't have any effect on muscle strength in your knee or leg

Knee Pain

Knee pain is a common problem that can originate in any of the bony structures compromising the knee joint (femur, tibia, fibula), the kneecap (patella), or the ligaments and cartilage (meniscus) of the knee. Knee pain can affect people of all ages, and home remedies can be helpful unless it becomes severe.

Knee pain can be divided into three major categories:

  • Acute injury: such as a broken bone (knee cap), torn ligament (such as ACL), or meniscal tear
  • If a tear is not complete, we may be able to help your body repair the injury without surgery
  • Fractures will often require a surgial consult
  • Medical conditions: Rheumatoid arthritis, Gout, infections
  • Chronic use/overuse conditions: osteoarthritis, patellar syndromes, tendinitis, and bursitis
  • Overuse during repetitive motions as are found during certain exercises (jogging, skiing) or work conditions (long periods of kneeling) can cause breakdown of cartilage and lead to pain.
  • These are mostly treated with injections, medications, and physical therapy.

We can treat most types of knee pain with a joint injection and genicular nerve blocks.

You can review recommendations from the AAOS clinical practice guidelines for osteoarthritis of the knee joint

Hip Pain

Pain may be felt in and around the hip joint and the cause for pain is multifactorial. The exact position of your hip pain suggests the probable cause or underlying condition causing pain.

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  • Pain felt inside the hip joint or your front of the hip or groin area is more likely to be because of the problems within the hip joint. It can also be referred pain from facet joints in your lumbar area.
  • Pain felt on the outer side of your hip, upper thigh or buttocks may be a result of the problems of the muscles, ligaments, tendons and soft tissues surrounding the hip joint.
  • Pain on the side of your hip may be caused by an inflamed greater trochanter bursa. Additionally, pain in the back of the hip or buttocks may be coming from the sacroiliac joint. These can be treated with injections.
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Shoulder Pain

Most often, shoulder pain can be traced to tenderness or soreness of the rotator-cuff tendons. The rotator cuff is the part of the shoulder that allows you to move your arms in a circular motion. It also helps to stabilize the shoulder joint also known as a gleno-humeral joint (HG joint).

In other cases, the subacromial bursa, or fluid sack, in your upper shoulder can become inflamed after a period of heavy lifting or other kind of physical activity involving repeated raising and lowering of the arms. This type of pain is worst when trying to lift your arm above your shoulder.

  • Pain on motion and at rest, referred to the insertion of the deltoid muscle, about 4-5 inches down the outer arm
  • Occasional regional loss of active movement
  • Local tenderness, typically located in the front (anterior) and upper (superior) aspects of the shoulder, or the upper third of the arm
  • Acute burning pain in shoulder as opposed to the intermittent dull pain of degenerative rotator cuff disease
  • Pain may be described as severe pain which may interrupt sleep and prevent active movement
  • Passive arm movement is often restricted in abduction only
  • Treated with a subacromial bursa steroid injection

Pain Reduction

Pain Reduction

How do we treat pain?

We start treatment by first reviewing your pain and what has already been tried. After a history and physical exam, we will come up with a mutually agreeable plan to tackle your pain.

*Please note that we DO NOT offer opioid management.

We use a combination of therapies to reduce or eliminate your pain and improve your functional status. This includes medications such as NSAID's, antidepressants, steroid injections, and referrals to chiropractic care and physical therapy, along with several regenerative injection options.

History Of PRP

In the early 2000s, the use of PRP expanded into orthopedics to augment healing in bone grafts and fractures. Success there encouraged its use in sports medicine for connective tissue repair. Mishra and Pavelko, associated with Stanford University, published the first human study supporting the use of PRP for chronic tendon problems in 2006. This study reported a 93% reduction in pain at two year follow up. Then, in 2008, Pittsburgh Steelers’ wide receiver, Hines Ward, received PRP for a knee medial collateral ligament sprain, and the Steelers went on to win SuperBowl XLII. Ward credited PRP for his ability to play in that game and his success with this treatment was discussed on national television.

Since then, other high profile athletes - such as Takashi Saito, closing pitcher for the L.A. Dodgers, and golfer Tiger Woods - credit PRP for helping them return to their sport. PRP continues to gain wider acceptance in the sports world with studies continuing to validate the use of PRP for ligament and tendon injuries, knee osteoarthritis, degenerative knee cartilage, chronic elbow tendonosis, muscle strain and tears, jumpers knee, plantar fasciitis and rotator cuff tendinopathy - albeit some skeptics and controversy remains.

Prolotherapy Versus PRP

The use of hyperosmolar dextrose (Prolotherapy) has been shown to increase platelet-derived growth factor expression and upregulate multiple mitogenic factors that may act as signaling mechanisms in tendon repair. An interesting study published in the January 2010 JAMA compared PRP versus saline injection (basically saline Prolotherapy) for chronic Achilles tendinopathy. Both groups improved “significantly” by Yellonel et al and the authors conclude there was no statistical difference between the improvement of both groups. Therefore, both PRP and Prolotherapy have been shown to stimulate natural healing and both can be effective and both should be considered in the treatment plan for connective tissue repair. However, PRP may be more appropriate in some cases. When PRP is used as a Prolotherapy “formula” for chronic or longstanding injuries, the PRP increases the initial healing factors and thereby the rate of healing. The Prolotherapy itself (irritation, needle microtrauma) is what is “tricking” the body into initiating repair at these long forgotten sites as well as the PRP, itself, which also acts as an “irritating solution.” This is especially important with chronic injuries, degeneration and severe tendonosis, where the body has stopped recognizing that area as “something to repair.” In these cases, PRP may be more appropriate, however this determination should be made by the physician on an individual basis. PRP can also be used preferentially over dextrose Prolotherapy in the case of a tendon sheath or muscle injury- areas occasionally but not typically treated with dextrose Prolotherapy where the focus is the fibroosseous junction (enthesis). It can also be used preferentially over dextrose Prolotherapy because of patient preference.

Safety Issues

The Prolotherapy, PRP therapy has low risk and few side effects. Concerns such as hyperplasia have been raised regarding the use of growth factors, however there have been no documented cases of carcinogenesis, hyperplasia, or tumor growth associated with the use of autologous PRP. PRP growth factors never enter the cell or its nucleus and act through the stimulation of external cell membrane receptors of adult mesenchymal stem cells, fibroblasts, endothelial cells, osteoblasts, and epidermal cells. This binding stimulates expression of a normal gene repair sequence, causing normal healing - only much faster. Therefore PRP has no ability to induce tumor formation. Also, because it is an autologous sample, the risk of allergy or infectious disease is considered negligible. Evidence also exists in studies that PRP may have an antibacterial effect.