Our Approach to Knee Injections

Joint injections and musculoskeletal (MSK) injections are increasingly common in Calgary and indeed, across North America.  At both Elite Sport Performance as well as our private Knee Clinic, we utilize various injections when clinically indicated.  Joint and musculoskeletal injections can be done either blind or with the benefit of image guidance.  Various studies purport that blind injections into a joint have an accuracy of somewhere around 63% to 75%, while image-guided joint injections enjoy an accuracy of between 95% and 99%.  Unsurprisingly then, the popularity of image-guided joint injections is increasing.  There are still some ‘old-school’ physicians who claim to be able to do a blind injection with a high degree of accuracy, but the statistics do not support this approach.

 

When performing an image guided injection, the practitioner has the option of using a diagnostic ultrasound or a much more expensive piece of equipment called a fluoroscope.  A fluoroscope is effectively a live x-ray exposing the patient to a not-insignificant degree of radiation.  Diagnostic ultrasound, on the other hand, is non-irradiating.  With respect to fluoroscope-guided procedures, a small amount of dye is typically injected so that the physician can confirm that the needle placement is correct.  This is in part necessary because the fluoroscope does not show in great detail the soft tissues in the area in question.  Diagnostic ultrasound, on the other hand, does not require any dye injection and shows in considerable detail the soft tissues surrounding the target to the injective.

 

There is another less palatable reason for a doctor to use a fluoroscope for image guidance rather than a diagnostic ultrasound, and that is the ability to bill Alberta Health Services for a ‘surgical procedure’ for even the most basic injection.  This billing code allows the physician to bill Alberta Health Services over $600 for simply turning on the fluoroscope when a much less expensive, less dangerous ultrasound option exists.  Diagnostic ultrasound procedures are billed at a dramatically lower rate to Alberta Health and can also be utilized within a truly private clinic.  Compounding the disparity between these two procedures is the timeliness with which they can be done.  Image-guided joint injection by a physician using a fluoroscope currently is accompanied by a wait of weeks to months within the city of Calgary.  The same image-guided joint injection using a diagnostic ultrasound can often be done within one or two days.  This represents a significant cost-savings of time for a patient looking to have a procedure done sooner rather than later.  This timeliness, along with the different ethical approach in billing Alberta Health Services so much money for a simple procedure, is why there is quite a difference in pricing for certain injections within the city.

 

Ultimately, it is the patient’s prerogative which route they choose to take,  but consider asking the clinic which method of image guidance they use and ask yourself if costing the public system more than $600 extra really represents good value for you, your family, or your community.  Paying a little bit extra to have the procedure done privately in a timely fashion, using a non-irradiating guidance such as diagnostic ultrasound, can allow you to feel better both physically and morally.  For more information regarding this topic or to learn more about any of the injections that we offer within our clinic, please reach out at (403) 689-9889 or reception@kneeclinic.ca.

Low Back Pain and Disability

Did you know that low back pain causes more disability than any other condition globally? As such, the development, or ‘pathogenesis’, of low back pain has long been investigated by research groups and programs. Most recently, the esteemed Drs. Injeyan, Injeyan, and Triano compared differences in inflammatory markers in the blood between asymptomatic individuals, and patients with non-specific acute or chronic low back pain. While there are limitations to every study, their results highlighted a distinct increase in pro-inflammatory mediators and a marked decrease in anti-inflammatory mediators in both groups of symptomatic patients when compared to asymptomatic individuals. Interestingly, a separate group in 2016 looked at the various effects of spinal manipulation and found that this technique may in fact activate naturally-produced anti-inflammatory mediators.

Inflammation and Diet

Did you know that localized inflammation in response to musculoskeletal injury is not only natural, but is essential to promote healing?  Damaged cells release chemicals within the inflammation which signals the body to initiate the repair process.  While some level of local inflammation is necessary, uncontrolled or persistent inflammation can cause more harm than benefit, resulting in additional tissue damage and prolonged recovery.  Substantial evidence now suggests that what we eat can influence the inflammatory response to both acute and chronic conditions.  Both pro-inflammatory and anti-inflammatory foods have been shown to affect the inflammatory response of the immune system to injury.  Limiting consumption of pro-inflammatory foods such as saturated and trans fats, refined sugars and carbohydrates, and processed foods, and increasing consumption of anti-inflammatory foods such as omega-3 fatty acids, colourful fruits and vegetables, olive and flax seed oils, and nuts, may not only help keep the inflammatory response in check, but may also protect healthy cells from inflammation caused damage.

 

References:

Minihane, A., et al. (2015). Low-grade inflammation, diet composition and health: current research evidence and its translation. British Journal of Nutrition114(7), 999-1012.Tidball, J. (2005). Inflammatory processes in muscle injury and repair. American Journal of Physiology-Regulatory, Integrative and Comparative Physiology288(2), R345-R353.

Inflammation and OA

Osteoarthritis (OA) was previously considered non-inflammatory. It is now well recognized that inflammatory mediators are produced and can be measured in joint fluids of patients with OA. This inflammation is a major risk factor in cartilage loss, pain, swelling, and stiffness. When management and treatment of OA consists of anti-inflammatory components, patients can improve their function and decrease pain levels. Platelet-rich plasma (PRP) is a cell therapy, that uses one’s own blood through joint injections, to reduce inflammation. Platelets are a high source of concentrated growth factors and inflammatory mediators. Platelets in PRP release many types of anti-inflammatory proteins that signal cells that lead to suppression of inflammation in OA.

 

Goldring and Otero. Inflammation in Osteoarthritis. Curr Opin Rheumatol. 2011; 23

Xie et al. Biology of platelet-rich plasma and its clinical application in cartilage repair. Arthritis Res Ther. 2014; 16

What is Cupping and why does Michael Phelps swear by it?

What is Cupping?

Cupping is a therapy in which glass jars or cups are suctioned onto the skins surface with negative pressure. Traditionally, cupping has been used in Chinese medicine for 1000s of years to open up meridian pathways to allow Qi to flow through. When Qi flows freely throughout the body one enjoys good physical, mental and emotional wellbeing.

Cupping uses suction and negative pressure to drain excess fluids, stimulate the parasympathetic nervous system (relaxation) and increase blood flow to muscles and skin. It can be used along Meridians and acupuncture points to clear colds and flus and stimulate specific organs, it can also be used along fascial lines across the body to specifically treat fascia and muscles

Why treat fascia? Fascia is connective tissue (has an appearance like a spider web) that covers everything within our bodies – muscles, bone, nerve, organs etc. – it is the 3D glue that holds everything together.  It is what allows our muscles to slide/glide efficiently.  A fascial dysfunction can restrict range of motion, decrease blood flow to an area, and cause pain and toxin build up.

Cupping is different than most manual therapy in that the majority of other techniques use compression, whereas Cupping decompresses (lifts, separates and stretches) tissue to release adhesions and break down existing scar tissue, relax muscle spasms, and decrease trigger point pain. It has also been shown to decrease tissue changes (scar tissue formation) and inflammation following trauma.

What are the marks left by cupping?

The circular marks left behind from a treatment are not bruises and are rarely sensitive to the touch. They are static blood, lymph, cellular debris and toxins being released from deeper tissue layers. Marks can vary in pattern and color and can last anywhere from 3 days to 2 weeks.

So who can benefit from Cupping?

The short answer is anyone, but especially those with joint or muscle pain/tension, headaches, frequent colds or flu that are not getting the relief they need from regular massage therapy. Cupping is historically very effective in treating chronic overuse injuries such as bursitis, tendonitis and other myofascial pain syndromes such as runner’s knee, tennis elbow, and low back pain.

 

Platelet Rich Plasma (PRP): How does it work?

Platelet rich plasma, commonly called PRP, has been promoted widely as a potential treatment for helping injured musculoskeletal tissues to heal.  Platelet rich plasma contains high concentrations of several growth factors.   Platelet rich plasma has been used worldwide for multiple indications of knee pain, most commonly accelerate ligament healing or to augment tissue repair.  The mechanism of action of PRP is well understood, with ongoing research being done to further refine when and how PRP injections can be performed for maximal efficacy.  There are myriad ways in which PRP can help joint osteoarthritis, including the anabolic effects of the growth factors found within PRP.  There is a well-documented anti-inflammatory effect as well as cell proliferation and scaffolding to help create tissue remodeling.  PRP has also been found to improve tissue stiffness, making cartilage more resilient to future wear and tear.

The philosophy behind using platelet rich plasma to augment tissue healing is based upon growth factors that are present in an individual’s own blood.  Platelets naturally gravitate toward an injured area of the body and the alpha granules, which contain the growth factors, are released by the platelets.  For platelet rich plasma, blood is drawn from a patient and the platelets are spun down with a centrifuge to much higher levels than are normally seen in a person’s own blood.  These concentrated platelets are then injected into the injured or surgically repaired area.

Over the last few years, platelet rich plasma has emerged as an accessible and relatively inexpensive source of growth factors to treat musculoskeletal injuries.  PRP contains growth factors that are very important for musculoskeletal healing, such as TGF-beta, platelet-derived growth factor (PDGF) insulin-like growth factor (IGF-I) in fibroblast growth factor (FGF).  The growth factor concentration in platelets, coupled with the normal platelets that are present in blood, are sufficient to yield increases of measurable growth factors in the blood to help reduce knee pain.  Laboratory studies have confirmed that PRP has beneficial effects on ligament fibroblast migration and the differentiation and production of collagen.  This means that it assists with healing knee pain.  In addition to the effects of the growth factors directly on healing, platelet rich plasma has also been reported to enhance the gene expression of important healing factors.

The future of PRP is encouraging.  Using the patient’s own growth factors and platelets is cost effective and research does indicate that it facilitates repairs in both basic science and animal models.  While ongoing studies are still required, it is widely believed that the use of biologic agents to enhance healing is the next major breakthrough in sports medicine for treating knee pain.

(Source: Steadman Phillipon Research Institute via drrobertlaprademd.com website).

Inflammation- Understanding the Fire

Inflammation is a normal action of the immune system when it encounters injured tissue, infection, allergen or toxin. The whole point of inflammation is as a transient process whereby the immune system is stimulated to deal with an offending situation…a knee injury or virus for example. So in and of itself inflammation is not a bad thing yet can be if it’s left on for too long. That’s where lifestyle habits can come in. Eating foods that the body cannot digest well or might be sensitive to, not providing the body with the daily nutrition it needs to function properly, chronic stress, not getting enough sleep, repetitive movements at work or in sports, to start, all act as constant triggers of inflammation. Repeating even one of these triggers daily can maintain an inflammatory reaction in the body that effectively goes unchecked.

Ongoing inflammation doesn’t allow the body to fully heal itself or focus energy on day-to-day maintenance. If maintained long enough, a chronic inflammatory reaction will irritate the nervous system leading to chronic pain syndromes, contribute to hormone imbalances, worsen allergic reactions or make us more susceptible to infections. Sometimes we cannot get away from this reaction if we’ve sustained certain injuries or surgeries that damage our tissues yet for most if use, there’s much we can do to settle the fire of inflammation should we choose.

Do you really need a knee replacement?

Joint replacement surgery is a booming industry as our ageing population faces the degenerative processes that come with getting older.  Surgical techniques and hardware continue to improve, but wait times continue to worsen.  In the Calgary Health Region alone there are thousands of patients on the waiting list for hip or knee replacement, with wait times for a mere consult often over one year.  The reality is that only a small proportion of these people actually NEED a joint replacement.

Medicine is not immune to the powers of marketing, and joint replacement surgery is no exception.  Knee and hip replacements are BIG business in the developed world, and family doctors are indoctrinated early on to refer directly to a surgeon whenever a patient presents with some knee or hip osteoarthritis.  The reality is that only some joints require replacement; the rest can be managed very well with conservative measures.  Reason would suggest that a patient with an osteoarthritic joint should start with the most conservative treatment options first, progressing on to more and more invasive options as needed, with total joint replacement as the final intervention once all others have failed.  Outlined below is a sample continuum that a patient can take on their journey through hip or knee osteoarthritis.

Get a weight bearing X-ray.

Proper positioning and select views in a weight bearing position can help to clarify exactly how much degenerative change has occurred to the joint in question.  Ask your doctor for weight bearing (standing) views to best ascertain the extent of wear.

Get a diagnostic ultrasound or and MRI.

An MRI is not always required, but it behooves the doctor and patient to get a clear picture not only of the boney deterioration of the joint but also the soft tissue and cartilage damage.  Remember that osteoarthritis (OA) is a degenerative joint process involving the soft tissues of the joint as well as the bone.  One does not exist in isolation from the other.

Correlate imaging findings with a thorough, hands-on clinical exam.

Too often I hear stories of doctors conducting a physical examination of a patient without ever putting their hands on the patient.  There is often a poor correlation between imaging findings and clinical symptoms, so it is vitally important to have a thorough, hands on examination of the joint in question to help complete the clinical picture.

Follow the clinical triad:

  1. Treat the actual problem
  2. Strengthen the area
  3. Avoid making it worse

Get stronger.

With increased strength comes increased stability, and instability within an arthritic joint is very often a considerable pain generator.  Beginning a strength program in an already painful joint can be agonizing, but there really is no alternative. Pushing through the first month of exercise-exacerbated pain will be worth it, and study after study suggest that resistance training and loading of an arthritic joint does not cause the joint to wear down faster, but rather helps to prolong the viability of that joint.

Get a custom unloader knee brace

One of the most effective, least invasive interventions that can be done is the use of a truly custom, unloading brace.  Made for both knee and hip osteoarthritis, a custom brace is often the single most effective intervention, and represents ‘the most bang for your buck’.  Custom knee braces in particular can offload the exact region of the knee that is most painful, allowing you to carry on with the activities that you are passionate about with considerably less discomfort.  By reducing the magnitude of impact on the arthritic joint with each step these braces also help to slow the rate of further progression.  They are lightweight, slim and can be worn under ‘most’ day to day clothing.  Custom unloader braces are often covered 100% by your private health insurance with a doctor’s prescription.

Consider a guided lubricant injection.

Viscosupplementation is the name for a type of hyaluronic acid injection that can serve to lubricate the internals of an osteoarthritic joint.  Brand names include Synvisc, Monovisc, Durolane, Cingal, Neovisc, Orthovisc, Synolis and others. Any of them can be beneficial in creating some hydraulic cushioning with the joint and defraying mechanical compressive load on to worn down cartilage.  These injections typically take about one month to begin working and can last for 10 – 12 months.  Some research suggests that repeating these injections once per year for three years (think of it as an annual oil change) can further slow the rate of wear of the joint.  These injections should be done under image guidance (ultrasound or fluoroscopy) to improve the accuracy of the injecting doctor.  Contraindications for viscosupplementation include very severe arthritis (it works best in mild to moderate OA), significant leg deformity (bow legged or knock kneed) and morbid obesity.

Consider Platelet Rich Plasma (PRP) injections

Platelet Rich Plasma is derived from a small fraction of your blood.  Drawn from your arm in the same fashion as having regular blood work done, the blood is spun in a special centrifuge to separate out the growth factors of your blood.  Reinjected into an arthritic joint twice over a six-week span, PRP can help to stimulate the development of new blood vessels and consequently allow for some new tissue regeneration.  With the exclusion of stem cell injections, PRP is the primary regenerative medicine that we have available to us in the management of joint osteoarthritis.  The benefits of PRP can often be felt after about six weeks, and can continue to have a positive effect on joint health for several years thereafter.  The injected joint is often sore for two to three days post injection, and it is important to know that you are not allowed to take anti-inflammatory medication for one week leading up to the procedure

Stay away from repeated cortisone injections

Cortisone (corticosteroid) injections are a very effective way to diminish inflammation within a joint.  The problem is that osteoarthritis, despite its name, is not truly an inflammatory process.  Rather, osteoarthritis is degenerative joint disease, and while you may get some symptom relief from a single cortisone injection as it wipes out any residual inflammation that is present in the joint, it is not a clinically appropriate intervention to repeat.  Why put an anti-inflammatory into something that isn’t truly inflamed?

With any combination of the measures outlined above, patients can expect to have at least some improvement in their symptoms.  Sticking to the clinical triad (treat it, strengthen it, don’t make it worse) helps to keep patients focused on what’s important in the management of an arthritic joint, and will reduce the likelihood of truly needing a knee replacement.  In our clinic we hedge our bets by making the surgical referral on the assumption that it will take about one year to get to the surgeon.  During that year we work diligently with the patient using the interventions listed above.  Most of the time we are able to improve the patient’s symptoms and quality of life so much that they take themselves off the surgical list.  Check out our testimonials page to read some of the success stories.

Repetitive strain injuries: getting back to your activity

If you live an active lifestyle, chances are you’ve dealt with an injury at some point. You may have even heard this expression: repetitive strain injury.

Often, for athletes or those who enjoy leisure sports, the thing that keeps them out of the game is not a sudden injury. It’s an injury caused by consistent, repeated stress to the body’s muscles, tendons, nerves and other soft tissues.

“Repetitive strain injuries are among the most common problems we see,” says Dr. Dale Macdonald, Sport Specialist and Clinic Director at Elite Sport Performance in Calgary.
“People have a hard time not doing that physical activity they love.”

Macdonald understands that way of thinking. He and his colleagues in the clinic are all dedicated to their activities. He admits they can be a bit over-zealous at times, too. He notes, though, that doing something too long or too hard without adequate rest can easily sideline you from your favorite activity.

Here are the four most common repetitive strain injuries to watch out for. In each case, Elite Sport Performance Clinic can help.

Plantar fasciitis: “It hurts on the bottom of my foot and/or my heel.”

The plantar fascia is the thick connective tissue that supports the arch of the foot. It’s exposed to incredible impact every time we take a step, whether walking or running. Plantar fasciitis occurs when microscopic damage to the tissue causes inflammation of the plantar fascia and overlaying connective tissue sheath. Prolonged or repeated injury can create scar tissue as the body tries to ‘repair’ the injured area.

Achilles tendonitis: “It hurts at the back of my foot and just above my heel.”

The Achilles tendon connects the calf muscle to your heel. During the first stage of overuse, the Achilles tendon becomes inflamed. With prolonged, repeated stress, scar tissue can form, the tendon structure can change and the tendon can tear or rupture.

Patellar tendonitis: “It hurts below my knee.”

The patella is the kneecap covering the knee joint. Patellar tendonitis is an injury to the tendon that connects the kneecap to the shinbone. Symptoms include pain or aching in the front of the knee, and/or weakness or swelling in the area (during or after exercise). With Osgood-Schlatter’s disease, pain is closer to the shinbone. It’s not actually a disease, but an overuse injury and it’s very common in adolescents experiencing growth spurts. With Sinding-Larsen-Johannson syndrome, the pain or swelling is closer to the knee area.

IT band friction syndrome: “It hurts on the side of my knee or my outer thigh.”

The iliotibial (IT) band is the ligament that runs down the outside of the thigh from the hip to the shinbone. It primarily provides stabilization when running. IT band friction syndrome (sometimes called runner’s or jumper’s knee) occurs when the IT band rubs across the bony protuberance where it attaches to the knee. This friction causes irritation and swelling. The IT band can also be aggravated by muscle imbalance elsewhere in the body (weakness or tightness in other muscle groups) and poor pelvic muscle strength.

When to seek help

If a repetitive strain injury is caught early, healing can occur by avoiding or modifying an activity for a time. The problem, as Macdonald sees it, is that people may not stop their activity until the pain becomes unmanageable. That’s when they need to see a specialist.

“As a runner, when I am hurting, I just want to get going again,” Macdonald says. “But, pushing through an injury is not smart. If you want to return to an activity as quickly and safely as possible, you may need help getting there.”

Macdonald notes that repetitive strain injuries respond well to a number of different treatments.

For injuries in the early stages, treatment options include:

manual therapies such as Graston techniques or myofascial release techniques to break down scar tissue or overcome fascial restrictions and restore movement
active-release therapy, where soft tissues and muscles are massaged or put through a series of controlled movements
eccentric loading exercises, where a muscle is contracted and simultaneously lengthened

For stubborn or advanced injuries, treatment options may include:

shock wave therapy to reduce the size of the scar tissue
corticosteroid injection therapy to help minimize inflammation of connective tissue (but not scar tissue)
injection of platelet-rich plasma to encourage new tissue regeneration

In some cases, injury-specific treatments will be recommended, such as:

a custom orthotic that helps counter the pain of plantar fasciitis
exercises that focus on strengthening underlying muscle weakness or imbalances, like pelvis, hip flexor and abductor muscle strengthening when managing IT band friction syndrome

For active people – from runners to cyclists to golfers to yoga enthusiasts – Macdonald says there is always something that can be done for repetitive strain injuries. It’s a matter of seeing a specialist who can build a custom treatment plan that is matched to the patient’s body, the length of time they’ve had the injury and the type of activity they want to get back to.

The truth about stretching: it might not be doing what you think

For years, stretching has been promoted as beneficial for those with an active lifestyle. The trouble is, the touted benefits of stretching – lengthening and strengthening your muscles, and improving performance – aren’t supported by current research.

“As an avid runner, I was raised on the concept of stretching,” says Dr. Dale Macdonald, Sport Specialist and Clinic Director at Elite Sport Performance in Calgary. “Today, studies increasingly show that stretching is not beneficial in the ways we thought. In fact, stretching can actually cause harm.”

Macdonald points to three myths about stretching that may have you re-evaluating your fitness routine.

Myth #1: Stretching makes your muscles longer

One study tested muscle fibers before and after an eight- and 10-week intensive stretching program. Using biopsy tests measured under a scanning electron microscope, the result showed no gain in muscle length. The resting muscle fibers did not lengthen even a nanometer.

So why does it feel you ‘go further’ after stretching for weeks or months at a time? Macdonald says it’s not because the muscle is longer, but because the muscle is becoming numb.

Stretching desensitizes the nerve endings where the skin, muscle and connective tissues are being stretched. Over a period of time, pushing a stretch further makes it seem like you have a greater range of motion. In reality, you’re reaching the same end-range of motion but without that same sensation of pain.

Myth #2: Stretching muscles makes them stronger

Stretching can create miniscule amounts of strength. In laboratory tests, a muscle put on a jig and stretched for weeks at a time gained 2% to 3% in strength.

However, this is an incredibly small gain for the effort that goes into stretching. Couple that with the fact that stretching also desensitizes nerves and it’s clear: stretching isn’t worth it.

“That’s why I often disappoint my patients when I tell them yoga is not, in fact, a strength-building exercise,” Macdonald says. “Yoga has its benefits, but greatly improved muscle strength is not one of them.”

If it’s strength you are after, Macdonald suggests trying weight-bearing or resistance exercises instead.

Myth #3: stretching improves athletic performance

The purpose of muscles is to stabilize and move our joints. If you stretch the muscles around a joint, you essentially make that joint less stable and less sensitive to stresses placed on it. This, in turn, dramatically increases the risk of injury to the joint and the surrounding connective tissues and muscles.

Suppose a runner stretches right before a run, and therefore reduces the nerve sensitivity in that area. The runner’s nervous system could be slower to catch an injury – like a rolled ankle – before significant harm occurs.

The bottom line? Stretching muscles desensitizes them, leaving athletes at increased risk of injury. Studies continue to show that stretching before an event actually decreases overall performance.

How can I improve my flexibility?

If stretching doesn’t improve flexibility, what will? Macdonald states that the #1 way to become more flexible is simply to become stronger.

Stronger tissue is healthier, and healthier tissue is naturally more pliable. This pliability, in turn, gives a person better range of motion while creating a stronger and more stable environment for the joints.

Is it still OK for me to stretch?

If you really enjoy the sensation of stretching, Macdonald’s advice is to wait until after your activity to do so. Even so, he believes stretching is only truly beneficial if you’re hurting, since the desensitizing quality may help reduce pain.

Alternately, Macdonald recommends a dynamic stretch to kick off your workout. This takes your muscles through the full range of motion and warms up the nervous system in the specific firing pattern that’s required for that activity. Google-search ‘dynamic warm up drills for runners’ or any other exercise for better pre-activity results.