Sunday, April 13, 2014

The Best Initial Treatment for Knee Arthritis (Part 1)

What is the best initial treatment for knee arthritis?

The answer is diet and exercise.

It isn't easy but diet and exercise are highly effective at reducing pain and improving function.  In a recent study of about 400 patients the combination of diet and exercise decreased pain scores by 45%.  This is impressive because most injection therapies improve pain by 30-40% and often only last 6 months.  This study showed benefits up to 18 months.   Patients who also completed both a diet and exercise program were able to walk 136 feet more than patients who only dieted during a 6 minute walking test. (Messier et al JAMA 2013)  This is a simple and inexpensive way to treat a problem that affects 10 million Americans and millions more worldwide.

Too often patients and clinicians fail to select this strategy.  Patients often do not recognize how overweight they are and may even get angry if their physician points it out to them.  Physicians lack the time and tools to appropriate help patients begin an diet and exercise program.  With 69% of Americans either overweight or obese, it is very likely that weight reduction should be part of most knee arthritis treatment plans.

So, here are some suggestions to get started.
(Always check with your own physician before beginning any program.)

Give your knee a pain rating from 0-10 overall as a baseline measurement.

1.  Weight yourself and calculate your Body Mass Index.  (BMI Calculator)
     Be honest about the weight.  Record your weight daily.

2.  Set a goal to lose 5 pounds in two months and KEEP IT OFF.

3.  Lose weight by trying the One Less Diet (TM)
     One less dessert, one less sugary soda, one less beer, one less bagel, etc
     Use any other safe and effective means to lose weight.

Weekly, update your pain rating for your knee.  After two months, compare your baseline weight and pain to your new weight and pain.  You may find that if you simply lose weight your knee will begin to feel better.  The side effects of losing weight will also be good for your heart and your waistline.

In the next post, we will discuss a simple exercise plan.


Tuesday, April 01, 2014

TIger Woods Back Surgery Video (Example)

Tiger Woods will miss the Masters for the first time in 20 years because of back surgery for a herniated disc.  He had the surgery on Monday in Park City, Utah and will soon begin rehabilitation.  There is no time table for his return.

Below is a video of my own back surgery for a discectomy that was done via small portal incisions about 5.5 years ago.  I was miserable prior to the surgery and am amazingly better.  Many thanks to my excellent surgeons and physical therapists.  View the video below to gain a better understanding of the mechanics of the surgery.

Video of Lumbar Disc Herniation Surgery

I wish Tiger the best of luck in his recovery.  I hope his surgery will allow him to return to the golf course soon but more importantly at a much higher functional level for a long time.

It is important to note that a variety of biologic treatments for this condition are presently in development.  Hundreds of professionals worldwide are working on these solutions.  For more information, visit:

More info via a detailed story about Tiger Woods and his back.


Wednesday, January 29, 2014

Losing Weight Helps Knee Arthritis Pain

Knee arthritis has no cure, but one treatment consistently decreases pain---Weight Loss.  It is not simple but it is effective.

What stops patients with knee arthritis from losing weight?
1.  No clear, simple program that produces weight loss and improves function.
2.  Lack of will power
3.  No consistency

Here are a few simple tips:
1.  Eat one less bite of everything. (The one-less diet)
2.  Drink less soda and alcohol
3.  Exercise

But you say, I can't exercise because my knees hurt.  I cannot count the number of times I have heard that one.  Instead of complaining.......
1.  Try stretching to start
2.  Try water aerobics
3.  Try an exercise bike (30 minutes 3x/week)

Hamstring Stretch

Set a goal of losing 3 pounds to start.  You knees may feel like you lost up to 15 pounds because of the joint forces that occur especially when you go up and down stairs.

Always check with your own doctor prior to initiating any program.

Send me any tips on weight loss and arthritis:  @bloodcure on twitter.


Published articles supporting weight loss for arthritis

Wednesday, January 01, 2014

Acupuncture with Gold for Knee Osteoarthritis

I have treated thousands of patients with knee arthritis and never heard of gold acupuncture as an option.  In the most recent issue of the New England Journal of Medicine, a case report discusses the topic.

Gold Acupuncture Knee X-ray
From the NEJM, 2013, See Link Below

Apparently, this form of treatment is common in some Asian countries.  As you can see from the x-ray above, it looks like a a bunch of pine needles or staples have invaded the knee.  I do not know of any data supporting this type of approach but it does make for a very interesting x-ray.

Here is a link to the New England Journal of Medicine Case Report:
Yoo and Yoo NEJM 2013

Please post any comments or links to data about this topic below.

Tuesday, October 08, 2013

Kobe Bryant goes to Germany Again

Kobe Bryant recently went to Germany again to be treated with "Orthokine".  From his recent instagram post, it looks like he also received accupuncture.  (See below)  The  combination of treatments may make it difficult to determine which one could be responsible for any improvement he may feel.

No details about the condition of his knee prior to the treatment.  Many clinicians and researchers are working on a variation of this treatment----platelet-rich plasma.  


Sunday, July 21, 2013

Dramatic Rise in Platelet Rich Plasma References

Over the last decade, there has been a dramatic rise in the number of PubMed and Google references about platelet-rich plasma.  This represents worldwide interest in this point-of-care biologic treatment for a variety of research and clinical applications.

Patients are already seeing the benefits of this research and new breakthroughs will come from expected and unexpected sources.


Thursday, July 04, 2013

Platelet Rich Plasma Significantly Improves Outcomes for Tennis Elbow in a 230 Patient Study

The American Journal of Sports Medicine (AJSM) has just published the largest study evaluating platelet-rich plasma.  The 230 patient study was conducted over the course of more than five years and represents the work of dozens of clinicians and researchers.  Overall, it is clear from the data that the use of PRP to treat chronic tennis elbow results in significant reductions in pain and elbow tenderness compared to an active control of needling of the elbow without PRP.  It is also safe and cost effective compared to cortisone and surgery.  This type of study is time consuming and expensive but will help guide patient and physicians decisions about how to best treat chronic tennis elbow.

Here is a lay press article on the article from Healio.

Read the full AJSM Abstract below.

Total Tendon

Platelet-Rich Plasma Significantly Improves Clinical Outcomes in Patients With Chronic Tennis Elbow
A Double-Blind, Prospective, Multicenter, Controlled Trial of 230 Patients
  1. Arthur C. Rettig, MD‡‡

  1. Department of Orthopedic Surgery, Menlo Medical Clinic, Stanford University Medical Center, Menlo Park, California
  2. Tucson Orthopaedic Institute, Tucson, Arizona
  3. §Division of Hand and Elbow Surgery, Georgetown University Hospital, Washington, District of Columbia
  4. Department of Orthopaedic Surgery, The Ohio State University, Columbus, Ohio
  5. The Orthohealing Center and The Orthobiologic Institute, Los Angeles, California
  6. #Orthopaedic Research Clinic, Anchorage, Alaska
  7. **Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
  8. ††The Steadman Clinic, Vail, Colorado
  9. ‡‡Methodist Sports Medicine, Indianapolis, Indiana
  10. Investigation performed at Department of Orthopaedic Surgery, Menlo Medical Clinic, Stanford University Medical Center, Menlo Park, California
  1. *Allan K. Mishra, MD, Department of Orthopedic Surgery, Menlo Medical Clinic, Stanford University Medical Center, 1300 Crane Street, Menlo Park, CA 94025 (e-mail:


Background: Elbow tenderness and pain with resisted wrist extension are common manifestations of lateral epicondylar tendinopathy, also known as tennis elbow. Previous studies have suggested platelet-rich plasma (PRP) to be a safe and effective therapy for tennis elbow.
Purpose: To evaluate the clinical value of tendon needling with PRP in patients with chronic tennis elbow compared with an active control group.
Study Design: Randomized controlled trial; Level of evidence, 1.
Methods: A total of 230 patients with chronic lateral epicondylar tendinopathy were treated at 12 centers over 5 years. All patients had at least 3 months of symptoms and had failed conventional therapy. There were no differences in patients randomized to receive PRP (n = 116) or active controls (n = 114). The PRP was prepared from venous whole blood at the point of care and contained both concentrated platelets and leukocytes. After receiving a local anesthetic, all patients had their extensor tendons needled with or without PRP. Patients and investigators remained blinded to the treatment group throughout the study.
Results: Patient outcomes were followed for up to 24 weeks. At 12 weeks (n = 192), the PRP-treated patients reported an improvement of 55.1% in their pain scores compared with 47.4% in the active control group (P = .094). At 24 weeks (n = 119), the PRP-treated patients reported an improvement of 71.5% in their pain scores compared with 56.1% in the control group (P = .027). The percentage of patients reporting significant elbow tenderness at 12 weeks was 37.4% in the PRP group versus 48.4% in the control group (P = .036). At 24 weeks, 29.1% of the PRP-treated patients reported significant elbow tenderness versus 54.0% in the control group (P < .001). Success rates for patients with 24 weeks of follow-up were 83.9% in the PRP group compared with 68.3% in the control group (P= .012). No significant complications occurred in either group.
Conclusion: Treatment of chronic tennis elbow with leukocyte-enriched PRP is safe and results in clinically meaningful improvements compared with an active control group.

The Biomet Biologics GPS device was used to prepare the PRP for this study.

Tuesday, May 14, 2013

Platelet-rich Plasma Update from Toronto, ISAKOS 2013

The International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) is a gathering of several thousand professionals that is presently taking place in Toronto, Canada.  Today, a platelet-rich plasma (PRP), Instructional Course Lecture was offered to over 100 participants.  Lectures about how to use or not use PRP were given by Dr. Rogerio Silva, Dr. Allan Mishra, Dr. Nicola Maffuli and Dr. Steven Arnoczky.  At least ten other PRP lectures were given at the conference including Dr. Mandeep Dhillion from India presenting his excellent study showing the value of PRP for knee osteoarthritis.  Basic science papers by Dr. Joon Lee et al from Korea also showed a chondro-protective effect of PRP after acute ACL tears.  It is becoming increasingly difficult to keep up with the dramatic rise in PRP related presentations and papers.  Overall, it is clear that there is increasing worldwide interest in this point-of-care, blood-derived bioactive treatment.  As the data matures we will better understand how to use PRP to help care for patients.  Presently, there is excellent level one support for its use in chronic tennis elbow.


Monday, May 06, 2013

Platelet Rich Plasma Update, JBJS Webinar

Worldwide interest in Platelet-Rich Plasma is increasing significantly.  471 new publications have appeared on PubMed about platelet-rich plasma in just the last year, making it quite challenging to keep up with the published literature.  There has also been a dramatic rise in Google "hits" for PRP to over 1.3 million.  (See the graphs below)   New data recently accepted for publication to the American Journal of Sports Medicine confirms the value of PRP in the treatment of chronic tennis elbow.  See American College of Surgeons Report on the paper.

Tonight the Journal of Bone and Joint Surgery will be holding a webinar on the topic.  Over 1000 professionals have already signed up for the event.  This is totally unprecedented for a major, elite journal to sponsor a discussion on a single specific biologic orthopedic topic.  Follow Dr. Mishra:  @BloodCure for real time updates about tonight's webinar.

Or, consider joining the Biologic Orthopedic Society Group on LinkedIN to participate in a discussion about the webinar and other biologic orthopedic topics.

Thursday, April 25, 2013

DNA Structure Discovered 60 Years Ago

One of the world's most important scientific papers was published in the journal Nature on April 25, 1953, 60 years ago today.  The entire paper was just one page!  In the short communication, James Watson and Francis Crick not only detailed the definitive structure of DNA (deoxyribonucleic acid)  but also proposed the unzipping mechanism by which the molecule could replicate itself.  They initially announced they had found "the secret of life" at the Eagle Pub in Cambridge, England.    (See the DNA diagram from the actual paper to the right)

These two brilliant men figured out the chemical structure of DNA without doing any experiments.  They started by carefully digested and then synthesizing the world's literature.  They attended conferences and sought data anywhere they could find it.  They were ridiculed for building stick models instead of conducting costly and time consuming lab investigations.  The solution to the beautiful double helix structure of DNA arose via the collaboration of biologist Watson and physicist Crick.  Neither one of them had an elite understanding of chemistry.  They even challenged and eventually proved wrong the triple helix structure proposed by famous chemist Linus Pauling.  

Sixty years later, their discovery and the subsequent research on recombinant DNA and genomic sequencing has transformed our lives.  Today, we take for granted our ability to "grow" human insulin in bioreactors and target specific cancers with molecular designer drugs.  It is appropriate to pause for just a moment today and thank the two dreamers who via their hard work and intuition discovered the structure of DNA.  Let's hope we can find and encourage many more dreamers like Watson and Crick.

References:  Watson and Crick,  Nature April 1953

Saturday, April 13, 2013

Kobe Bryant Tears Achilles Tendon

Kobe Bryant last night in made a cut on the basketball court he has made a million times and felt like "somebody kicked" him.  He unfortunately sustained an achilles tendon tear.   See the video below of the injury:

He will likely have surgery in the near future.  The surgical takes about an hour.  Rehabilitation typically takes anywhere from 9-12 months.  Some surgeons are augmenting achilles repairs with platelet-rich plasma pointing to anecdotal evidence suggesting PRP could accelerate recovery.

Here is a video of how to clinically diagnosis an achilles tendon tear:

Below are some pictures that outline the steps in an Achilles tendon repair  
Torn tendon, suture repair, closure
If anyone can come back from this injury, Kobe can.  The NBA and all of basketball are wishing him the the best for his surgery if needed and for his full recovery.


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