knee pain

New Pain Treatment: Platelet Rich Plasma

/ Thomas Cohn, MD

Blood spinning PRPRecently, platelet rich plasma (PRP) has been making news as a treatment for hip bursitis after a presentation at the American Academy of Orthopedic Surgery annual meeting. PRP is blood that has been spun and has concentrated factors that stimulate tissue repair and growth. This concentrated solution can be injected back into the body in affected areas to improve healing in damaged tissue. New areas for use are being found regularly.

Initially, PRP was first used in trials for repair after a heart attack, but it has expanded into areas of tendon repair, nerve injury and bursitis. Most commonly it has been used in sports injuries, and for many of these patients it has been quite successful. Instead of just calming down inflammation like many medical treatments, PRP helps more intensely stimulate the body to repair the injury. The downside to this treatment is that it is still considered experimental and insurance rarely covers the cost which can be in the several thousand dollar range.

PRP for Tendonitis and Bursitis

The most common uses in pain management for platelet rich plasma is for shoulder, elbow, hip and knee pain especially related to tendinopathy, tenosynovitis and bursitis. Blood is taken from the patient and then spun in a centrifuge. The residual plasma is rich in a number of proteins and substances that promote healing in the body. The plasma then is injected with either ultrasound or X-ray guidance into the appropriate area, whether the shoulder, hip or by certain tendons to stimulate healing. A series of several injections may be necessary to fully promote healing.  Since it is an all natural product of the patient themselves, it is very safe, and may be very effective for the right conditions.

Tendonitis, bursitis, joint and ligament pain is always treated conservatively first. Rest, heat and ice, and physical therapy are the first lines of treatment. If the problems are not improving, medications like oral or topical anti-inflammatory drugs combined with exercises and therapy may also be effective. If those treatments do not help, corticosteroid injections may also be indicated and evaluation by a physical medicine pain specialist to guide treatment would be beneficial.

The medical literature at this time is showing that the use of platelet rich plasma may have many benefits in the treatment of some of these joint related conditions of pain and inflammation. PRP is not the first line of treatment; it is used when other courses have failed. Furthermore, insurance has not endorsed its use and the cost will most likely be the responsibility of the patient. As of now, the injections are mainly for athletes or people who can afford the treatment when other avenues have failed.

Does Glucosamine Work for Knee Pain?

/ Thomas Cohn, MD

Knee pain treatmentsA recent study in Arthritis and Rheumatology has cast new doubt on the use of glucosamine for knee pain. Glucosamine is a natural supplement that has been promoted for years to improve joint health. It is supposed to reduce pain and promote healthy cartilage in all joints. Knee joint pain has been one of the main claims for success over the past years.

The recent study reported that glucosamine had very little if any impact on any aspect of knee health. This study covered treatment over a 6-month time period.  It used medical exams and MRI scans at the beginning and end points as well as periodic X-ray films to objectively measure knee changes. Overall, pain and functional ability were not impacted by the use of glucosamine.

Knees and Age

Degenerative changes of the knees are common as we all get older. As we all age, the joints start showing signs of change including deterioration of the joint space and cartilage. Many of the activities we have done over time may worsen the problem. Sports, bending, twisting, kneeling, as well as being overweight may excessively stress the knee and lead to deterioration.

Treatment of the knees always starts conservatively. Most important is to ensure a patient doesn’t put unnecessary stress on their knees. One of the biggest culprits of knee issues is obesity, so weight control is essential. Keeping active helps facilitate blood flow to joints and maintains tissue health. Strengthening the muscles above the knee is also helpful.

Medication’s Role

The next level of intervention is medication. As noted above, natural supplements have not been found to be especially helpful when studied in a rigorous manner. Over the counter nonsteroidal anti-inflammatory drugs like ibuprofen and naproxen as well as acetaminophen may be helpful. If the above treatments are not helping, seeing a pain specialist for knee joint injections with steroids or viscosupplements may be worthwhile. Lastly, when all else fails, sometimes Orthopedic surgery may arthroscopically clean up the knee joint or at times, the knee is so deteriorated, joint replacement may be a good option.

Knee arthritis is very common, but any treatments are available. So far, natural supplements have not shown significant positive results. If the simple stuff is not working, your doctor can guide you through the other available options.

4 Common Causes of Knee Pain

/ Thomas Cohn, MD

knee pain treatmentThere are many causes of knee pain and treatment is dependent on determining the exact cause.  The knee has many components including multiple ligaments, tendons, cartilage, bursa, and bones. Because there are so many components, determining the problem is often difficult. Age and activity level can often be a clue to the existing problems.   Younger and more athletic people have injury type problems, while older people develop issues related to degeneration.  Below are four of the most common causes of knee pain:

  1. Osteoarthritis is the most common type of degeneration that occurs in the knee.  It is the progressive wear of the joint cartilage that occurs with age and use of the joint.  Read more about Osteoarthritis causes and treatment.
  2. Obesity worsens and stresses the joints even more as people age.  The knee becomes chronically swollen, and painful with activity. Treatment is symptomatic – keep the knee moving and strong, and use over the counter medications for the pain as necessary.  If you are obese, try to reduce your weight to relieve additional stress.  When the deterioration is severe, there are orthopedic surgeries that can help including knee replacement.
  3. Traumatic injuries to the knee include torn ligaments, meniscus tears, and tendonitis.  Bony injuries also occur to the patellar and the other bones of the joint area.  The anterior cruciate ligament is the most common ligament damaged in sports, caused when there is a sudden change in direction of the body. The side ligaments can also be injured in sports. These are usually treated conservatively.  The meniscus is part of the cartilage in the knee and is a shock absorber.  Injury to the meniscus occurs with twisting while weight bearing, and is fairly common in older active adults. Surgical repair is simple if conservative management is unsuccessful.
  4. Bursitis & Tendonitis. Brusitis is inflammation of small sacs of fluid that cushion ligaments and muscles around the knee. This condition often resolves with rest. Tendonitis commonly occurs to the patella tendons in runners, skiers, and cyclists. This condition is also best treated with rest.

Pain in the knees is relatively common.  Traumatic injuries often respond to conservative care.  If not resolving, evaluation by a physician is recommended to determine the cause and best treatment options.  Age related changes, such as osteoarthritis, are usually treated conservatively as long as possible.  If conditions worsen, physicians can prescribe stronger medications, special joint injections, and help determine when surgery may be beneficial.

6 Common Running Injuries & Pain Management Tips

/ Thomas Cohn, MD

running injuryRunning can be stressful to the body, causing injury and pain.  Areas of the body that are often affected by running include the low back, pelvis, hips, knees, ankle and foot joints, as well as the muscles, ligaments and tendons of the lower extremities.  Injuries happen for a number of reasons including overuse, body mechanics, training, and not allowing injuries that have occurred to heal adequately.  Running can be an excellent way to maintain fitness, but listen to your body, and try to use a degree of moderation.

Running Injuries

Listed below are 6 common running injuries and techniques to manage pain associated with each:

  1. Shin splints:  This is a pain along the front of the tibia.  This is thought to be a strain of the muscles attaching to the tibia.  It commonly occurs when increasing distance or frequency of running too fast.  Treatment is icing, rest, gentle stretching and anti-inflammatory medications.
  2. Runner’s knee:  This is pain under the kneecap due to irritation of the patellar cartilage.  It is a mechanical problem related to alignment and forces through the knee.  Up to 15% of runners may have this issue, and up to 40% of runners develop knee injuries.  Ice and anti-inflammatory medications for pain are reasonable, and muscle strengthening and the use of a soft knee brace with patella cut out can help. Knees are also prone to ligament sprains, which present as pain on the inside or outside of the knee, and also for tears of the meniscus, which presents as catching of the knee and internal knee pain.
  3. Stress fractures:  These are small cracks at the surface of the bone.  Common areas are the tibia and feet.  They are caused by the stress placed on the regions with the impact of running and occur most commonly with over training.  These absolutely need to be allowed to heal.  Stop running and stressing the area, when the pain is gone, then one can slowly resume activity.
  4. Ankle sprains:  The ankle is stabilized by ligaments, which allow normal motion.  Sprains are over stretching or tearing of these ligaments often by twisting or rolling the ankle.  Acutely icing the ankle, wrapping, and elevation will allow the injury to heal.  If pain continues or the ankle remains unstable and with activity, one frequently twists the ankle, then surgical repair may be necessary.
  5. Hamstring and Illio-tibial band syndromes:  These are the muscles on the side and back of the upper leg.  Pain in these areas is due to muscle strains.  Initially ice and rest are beneficial. Then, proper warm-up, stretching and training as well as post activity cool down can help treat and prevent this condition.
  6. Plantar fasciitis:  The plantar fascia is a tissue that extends from the heel to the toes along the bottom of the foot.  Pain is usually felt in the arch of the foot.  This tissue can easily be stressed by multiple impacts of the foot with running.  Running shoes with the proper support and alignment for the foot is important as well as whether one runs on pavement or softer surfaces such as dirt.  Icing, stretching the foot and anti-inflammatory medications are used in treatment. When more severe, splints at night and foot orthotics may be prescribed.

Maintaining aerobic fitness is a common goal of many people.  Running has become a favorite of many and for some almost an addiction.  Due to the intensity of this activity, injury is fairly common.  Most injuries can be treated simply, listen to your body, allow it to rest and heal.  When injuries are not healing, seek out good medical attention.

Other good sources of info on running injuries:

Osteoarthritis of the Knee – Treatment Options

/ Thomas Cohn, MD

osteoarthritis of the kneeEarlier this week, we discussed the signs and symptoms of osteoarthritis in the knee. Today we will further investigate this condition by discussing the treatment options for osteoarthritis.

Treatment of osteoarthritis of the knee includes a wide range of options, starting with lifestyle modifications, medications, and progressing to surgical management. 

Always start simple. Change starts with the individual and is not magical.  The most common first step is to lose excess weight so you are not stressing the joints.  Change the type of activity you are doing from high impact to low impact exercise. Go from jogging to cycling and swimming, or try an elliptical. Walking is always a good alternative as well.  Exercise maintains range of motion, flexibility, and health. Add in strengthening and function may also improve. 

Medication Management

Medication management is the next level of care. Having a physician involved in this level is beneficial to prevent negative side affects.  Natural substances you can take include:

  • A combination of glucosamine and chondroitin. These are natural substances found in joints. If taken orally they are supposed to promote normal joint health.  Scientific studies are mixed on whether they are truly helpful, but they rarely if ever would be harmful, if early in the disease, it may be worthwhile.
  • Fish oil. This can help with joint lubrication.

Prescription level medication starts with acetaminophen, to aspirin and anti-inflammatories, to steroids and injectable compounds.  Acetaminophen is only an analgesic and it treats pain.  Aspirin and ibufrophen or naproxen, are a class of medications known as nonsteroidal anti-inflammatory drugs (NSAIDs), and can treat pain and swelling.  These medications are stronger, may be taken orally and may be available as crèmes, but have many side affects and should be used with caution.  Skin preparations however are very safe and may be extremely helpful.

Corticosteroids are very powerful anti-inflammatory hormones, and sometimes on a limited basis orally or as injections can be helpful in controlling pain and swelling for long periods of time.  Lastly, viscosupplementation with injectable hyaluronic acid compounds is used to improve joint fluid production for periods of 3-6 months.

Surgical Options

End stage knee osteoarthritis can be treated surgically.  Orthopedic surgeons can do several things from cleaning up and removing damaged tissue in the joint arthroscopically when appropriate, to replacing the knee joint.  Surgical intervention is a consideration when the damage is severe, not responding to more conservative options, and otherwise when the patient is healthy enough to undergo surgery.

Osteoarthritis will occur eventually in all of us as we age.  The key to control degeneration is to maintain good health habits.  Keep your weight under control, excess weight will stress out your joints.  Exercise, this will keep everything moving, and maintain your strength.  Work with your doctor if more advanced treatments are needed.