Inject Or Not To Inject? That's the Question...

We have all been there before, that pain that will not go away.  It seems to wake you up at night, hurts when you take that first step, maybe even seems to catch your breath.  That's when you call me, or at least someone like me. (Or if your my family member or friend, you text in a panic :)  It is human nature to want a pill, cream, or patch to take the hurt away.  None of us are immune, and if you are in my family you tend to get hurt a little more often!

Many times I have seen a patients in a similar situation and they too want the aching or stabbing to stop in their given joint.  The topic of steroid injections comes up often in this scenario. Where steroid injections can be helpful in reducing pain, they should also be approached as an infrequent or one time treatment.  Steroids are not a benign medication and should not be treated like they are a Flintstones vitamin.  Unfortunately, I do see some people who have had many injections over the course of their lives into the same area.  This is not necessarily the best practice when it comes to our joints.

Using my uncle as an example: he had terrible arthritis of his knees.  He had limped around for years in pain, failed injections. therapy, and knee scopes.  If he had chosen to get steroid injections every 3-6 months in his knees for years he would have only treated his symptoms.  Instead he treated the problem and got both knees replaced and is very happy.  Having one or two steroid injections get you through an injury maybe helpful. However, for someone with a chronic arthritic problem, continued injections do not addressing their underlying problems.

Also, studies have shown that repeated steroid injections to the same area in a short amount of time can be destructive to the tissues.  Detrimental Effect of Repeated and Single Subacromial Corticosteroid Injections on the Intact and Injured Rotator Cuff, in the American Journal of Sports Medicine tests one and three steroid injections in the shoulders of rats.  The researchers had rats with both non injured shoulders and some with rotator cuff tears. Then they either gave them saline injections, one steroid injection, or three steroid injections over 3 weeks. The rotator cuffs were then tested for failure.  The single injection rats took 17% less load to cause the cuffs to fail then the saline group, and the triple injection took 32% less load to fail.1  Also, they found the bone volume was decreased in the triple injection group and the stiffness of the cuff tissue decreased by 50% in the triple injection group.1   What does it all mean?  Multiple injections can cause damage to the tissues within the joint. 
  
I wish I could tell you that everything that made you feel better was good for you.  But that just in not true, or responsible.  Steroid injections have a great place in orthopedics and medicine but often get overused because people want a quick fix.  Remember to look for a solution to the problem if possible.  As with everything there are always gray areas and it is best to discuss this with your provider individually.  


Sources:

1. Maman, E., Pritsch, T., & Morag, G. et al (2015, July 27). Detrimental Effect of Repeated and Single Subacromial Corticosteroid Injections on the Intact of Injured Rotator Cuff: A Biomechanical and Imaging Study in Rats. The American Journal of Sports Medicine, 44(1), 177-182. 

Stem Cell Answers

Lately I have had patients asking me about stem cell injections for arthritis, newly popular treatment for a variety of aliments. Stem cells are immature cells that have not yet "differentiated" or formed into their final cell type.  This makes them very useful in regenerative medicine and also controversial.

Stem cells can be found in many tissues through out the body including bone marrow, fat, muscle, and brain tissue. 1  Stem cells can also be harvested from human embryos. This particular topic is very controversial and not on our agenda for today.  So lets just stick to what we call "adult" stem cells, or those harvested from grown humans.  The beauty of an undifferentiated stem cell is in its future.  Much like a young college co-ed, it doesn't know what exactly it will be when it grows up, but the world is often its oyster.

Kelly Hotchkiss, student, VCU Department of Biomedical Engineering, School of Engineering Hotchkiss’ image shows human mesenchymal stem cells that present a spread pattern of attachment after being prepared on a glass surface." 2

Depending on what tissue the stem cell is harvested from will determine what cell lines it could potentially form.  For example, in orthopedics we love to use the bone marrow because it contains a stem cell known as the mesenchymal cell (MSC).1  This cell line has the potential to turn into bone and cartilage.1  Other cell lines in bone marrow have potential to turn into other blood cells, etc.  This is useful in certain cancer treatments when patients are in need of more healthy cells/blood.  Also, once implanted it is thought that the cell is actually influenced by the cells around it to differentiate into the same type of tissue.1  A kind of scientific peer pressure if you will!

Mesenchymal cells can be harvested from different areas of the body.  The characteristics of the cells may vary slightly depending on the harvest site, but the important factor is if the MSC can turn into a "chondrocyte" or cartilage cell.  For this reason many surgeons like to use bone marrow, intuitively one would think that MSC from bone would have a high potential to turn into bone and cartilage tissues.  Also these cell lines are the most studied forms, with experiments dating back to the 1960s.  More recently fat has been used as a donation site for stem cells.  Adipose (fat) tissue also contains mesenchymal cells and as one article put it, "adipose is an abundant and easily accessible source." 3  So essentially we have A LOT more fat to choose from as a society, why not use it!

Bone marrow is usually harvested from the hip in the operating room under anesthesia.  Adipose tissue can be taken from several areas including the stomach, love handles, and buttocks.  Once harvested it is treated to remove excess cells and spun down using a machine called a centrifuge to get MSCs.  The cells are then re-implanted into the knee (for example) in the area of the cartilage defect.  Post operative protocols are varied depending on surgeon but may include non-weight baring for a period of time, braces, and physical therapy.

Centrifuge

These procedures are still new and considered experimental by insurance companies.  This makes them cost more money out of pocket unfortunately.  Where there is exciting research being done on the topic the results vary from paper to paper and I would consider the jury still out on some of the overall conclusions.  Before undergoing these injections make sure you have a conversation with your provider and understand exactly what to expect.

   

         
Sources:

1.  http://stemcells.nih.gov/info/basics/Pages/Default.aspx

2. https://news.vcu.edu/article/Small_wonders_The_microscopic_images_currently_on_display_at

3. Koh, Y. G., MD, Kwon, O. R., MD, & Kim, Y. S., MD. (2014). Second look arthroscopic evaluation of cartilage lesions after mesenchymal stem cell implantation in osteoarthritic knees. The American Journal of Sports Medicine, 42(7), 1628-1637. Retrieved April 12, 2016, from www.sagepub.com/journalsPermissions.nav.

So You've Decided to Have a Total Knee...

This will be a follow up piece on my segment from October 2015 "Total Knee Arthroplasty--Why So Spooky?"  If you have not looked at it I recommend taking a peek to get some general background on knee arthritis and surgery selection.

Ok so you have decided to take the plunge and sign up for a total knee arthroplasty (TKA).  What happens next?  First, I recommend making a list of questions about the procedure and follow up care and scheduling an appointment with your surgeon.  During this appointment you can become more comfortable with the surgery schedule as well as short and long term expectations.

Day of surgery questions to consider:  Where will the operation take place?  We perform TKA surgery in both an outpatient setting at the surgery center, and inpatient at the hospital.  A person's health, age, insurance, type of surgery, and preference all go into making the decision of outpatient vs inpatient surgery.  Is there an information class?  Many hospitals and total joint centers offer classes preoperatively to educate patients on how to prepare for surgery and what to expect the day of surgery. (For more information on Missouri Baptist's class click Here.)  Do I need surgical clearance?  Most total knee patients will need some form of clearance from at least their primary care physician.  Often depending on health conditions patients may need to visit cardiologists, pulmonologists, other doctors, and even have tests run before being cleared for surgery.

Example of Post Operative Total Knee Arthroplasty Components

Short term expectations to consider: How long will you stay in the hospital/surgery center?  This depends on your choice of having one knee replaced or having both done at the same time.  Also your health will depend on how long you stay in the hospital.  Often stays average 1-3 days.  Will you have home health?  Many of our patients have the assistance of home health and home physical therapy for a few weeks.   This will vary depending on surgeon preference and patient ability.  Will you be on a blood thinner?  Studies show that there is an increased risk of blood clots the first few weeks after a replacement type surgery.  Your surgeon will likely place you on a type of medication to thin your blood and prevent clots for 2-4 weeks.  Also he/she may include leg stockings or leg pumping devices to increase blood flow for a period of time.  Where will you go to physical therapy?  This is important.  You want to make sure that the therapist you work with has experience with joint replacements.

Long term expectations to consider:  Should my therapist be doing that?  I hear a lot about how mean physical therapists are!  When it comes to total knee replacements 99% of the time they are doing exactly what they should.  Therapists are really trying to get range of motion back in the joint.  When I visit our patients in the hospital I always tell them that they have a 6 week window where range of motion is really essential.  Their knee is trying to scar around their new components and the more we can move the knee the more mobile the scar will become.  We all scar--that is inevitable, the more mobile the better.  The more motion the better.  This is why the PT is so hard on people the first 6-12 weeks after a knee replacement.  Often patients thank them later.  When will I get better?  In medicine we try to give estimates and averages based on our experience with past patients.  So on this question it is difficult with TKAs.  I will tell you that at 12 weeks post op most people have their motion back and are doing their day to day activities well but still need strength.  Patients will continue to see benefits and improvements from a TKA for the whole first year.

Before any surgery I encourage you to ask questions until you are comfortable with the procedure.  As providers we want our patients to be our partners in healthcare and understand why tests, exams, and procedures occur.  TKAs are a big undertaking but can have great success and provide much needed pain relief to those suffering from arthritis.  Feel free to ask questions! 


  

Spring Training-Pitch Counts Matter!

I now see that you like two things--controversy and sports.  I can't really argue with that logic, so let's continue our conversation with some spring training talk.  With warm weather comes baseball and softball spring workouts.  We see a lot of players getting ready for both high school and club teams in our practice and there are a few pitfalls I would like to help players avoid.

Pitch Counts Matter!!!!  Did everyone hear me? I know you are big and strong and can throw very hard.  Pitch counts matter.  I know you play softball and it's an underhand mechanism.  Pitch counts matter.  I know that you played for years and never got hurt so your child will be fine.  Pitch counts matter.  Both pitch counts and the appropriate amount of rest after a pitching appearance are vital in the prevention of elbow and shoulder injuries in youth throwers.  The American Sports Medicine Institute, headed by Dr. James Andrews, has been looking into the effects of pitching on injuries for years.  ASMI has made formal pitching recommendations which have been adopted by Little League Baseball. (Figure #1)  STOP Sports Injuries is a collaboration of several top organizations including the American Academy of Orthopedic Surgeons,  National Athletic Trainers' Association, and the American Medical Society for Sports Medicine. STOP has recommendations for several sports including pitch counts for both baseball and softball. (Figure #2) 

Figure #1

Figure #2

What exactly are we trying to prevent in our youth throwers?  Injuries including, shoulder labral tears (see my 1/5/16 blog on the labrum) growth plate injuries, and Ulnar collateral ligament injuries (AKA Tommy John) can all occur with overuse and poor mechanics.  The growth plate is the growth center in young bones.  The growth plate is the site of tendon attachments and is often vulnerable to injury.  The repetitive throwing motion can injure growth plates in either the shoulder or the elbow.  Awkward arm positions or poor "arm slots" while throwing cause impairment.  For this reason it is recommended that a pitcher master mechanics and a fastball before ever learning a curveball. (ASMI)  

Proper rest for athletes is essential not only with pitch counts, but also with rest throughout the year.  Taking a portion of the year off to relax the arm is imperative to the health the child.  Refraining from overhead activity for consecutive months throughout the year is recommended as well as playing additional sports.  When it comes down to it, it is logical--resting their arms helps them last longer.  It seems simple but in practice it proves to be difficult for many.  

Should My Child Play Just One Sport?

Let's start the year with a controversial topic shall we?! There is an on going out cry among many in the sports medicine community to stop young athletes from specializing in just one sport.  We are a country of bigger is better--when it comes to a Samsung TV I can't really argue. When it comes to training for Little League there is some room for debate.

Figure #1

Using baseball for example, we are seeing some disturbing trends over the last decade.   More Ulnar Collateral Ligament tears (Tommy John) are occurring in youth throwers. Figure #1 shows the percentage growth of UCL tears in youth and high school throwers according to the American Sports Medicine Institute.  Not only are there more tears we are seeing these in younger and younger players.  So why the trend?

Intuitively, one would think that we are seeing more injuries because children are spending more hours playing a sport.  A very interesting paper was just released in The American Journal of Sports Medicine in 2015 stating that the specialization of sport may in itself be harmful.  The title Sports-Specialized Intensive Training and the Risk of Injury in Young Athletes by Jaynathi, et al. was a case controlled study using youths age 7-18. 1

The children filled out surveys and were placed into groups depending on their level of specialization.  Low, moderate, and high specialization were determined by answering 3 questions:  "Can you pick a main sport?" "Did you quit other sports to focus on a main sport?" "Do you train > than 8 months a year?"  The athletes medical records were than analyzed for minor and major injuries, including overuse verses acute injuries. 1

Results showed as we would somewhat expect that injured athletes were older and spent more time in organized sports.  However, they also had higher specialization scores.  Also, youths with the serious overuse injuries were almost 2 times (1.90) more likely to be highly specialized compared with non-serious overuse injuries.  An interesting point from the study was that specialized athletes were not at more risk of getting acute injuries like ACL tears.  These are the accidents that just happen to our kids, the slips and falls.  However, the specialized kids are much more likely to experience the chronic severe stress fractures, spine injuries, and yes the UCL tear.

Me, my senior year of college. After having surgery on my own chronic shoulder injury.

One final thought on overuse in the specialized athlete comes from the authors Jayanthi and his counterparts at Loyola. "There is an increased risk of serious overuse injury for athletes who spend numerically more hours per week participating in sports versus their age in years."1   

Great resources exist for how to limit the impact of intensive sport on young athletes.

Multisport

• Stop sport injuries

Softball

• Coach Safely

Soccer

• Momsteam

Baseball

• Pitchsmart from MLB 
• ASMI 

Sources:
1. Jayanthi N, LaBella C, Fischer D, Pasulka J, Dugas L. Sports-Specialized Intensive Training and the Risk of Injury in Young Athletes: A Clinical Case-Control Study. The American Journal of Sports Medicine. 2015;43(4):794-801. doi:10.1177/0363546514567298.

2. http://www.asmi.org/research.php?page=research&section=UCL

What is the Labrum Anyway?

Many of our patients have heard the story of my college softball career.  I am not here to go into details about it, but I do like for patients to know that I have also had shoulder surgery.  A labral repair to be exact--and during my junior year of college softball no less.

Of all the structures in the shoulder, I think the labrum is most difficult to visualize.  We refer to the shoulder as a "ball and socket" joint.  Describing the humerus (upper arm bone) as the ball, and the glenoid of the scapula (shoulder blade) as the socket.  (Figure #1)  If one thinks about the ball of the humerus sitting like a golf ball on a tee, the labrum would be a ring around the tee to deepen it keeping the ball more stable.  If this system worked 100% of the time we would all be very happy and I would be out of a job.  Unfortunately injuries happen and force that humerus off the glenoid either partially or completely.

Injuries can include falls, pulling, pushing, repetitive injuries like throwing, impact directly to the shoulder, and motor vehicle accidents.  Events like falls may cause the shoulder to fully dislocate in that case there is often injury to the labrum.  Repetitive overhead throwing can pull on the top (superior) labrum where the biceps attaches.

Figure #1

The labrum is surgically described like the face of a clock with 12, 3, 6, and 9 o'clock positions.  Look at Figure #2.  The center picture shows the labrum looking straight on, at the 12 o'clock position you see a tendon attaching.  This is the biceps tendon and is an important      landmark for labral tears.  Labral tears involving the superior portion of the labrum and or the biceps are called SLAP tears.  There is an entire classification system for them, if you would like to see if check here.

Tears of the labrum do not heal. However, small tears may not feel as symptomatic and can stay stable for a period of time.  Larger tears should be repaired to prevent instability, pain and degeneration of the shoulder.  Surgery is an outpatient scope procedure that involves placing sutures through the torn labrum.  These sutures are then anchored to the bone.  Depending on your level of activity most people return to recreational activities around 4 months post operative and competitive sports closer to 6 months.

Figure #2

Speaking from experience, shoulder surgeries are not fun! But with diligent physical therapy and rehabilitation labral repair surgery can be a success.