Sunday, July 20, 2014

QuadCrunch (TM) The Best Exercise for Your Knee

Quadriceps (Quad) muscle activation is crucial for both athletes and patients.  It is the foundation of any knee muscle development plan or rehabilitation protocol.  Too often neuromuscular activation is ignored or incompletely addressed.  

The QuadCrunch exercise is a simple and effective way to enhance muscle activation and to increase muscle tone.  If executed consistently, the entire quadriceps muscle and especially the VMO (Vastus Medialis Qbliqus) will be more functional.  

The QuadCrunch can be done alone or in combination with a variety of other leg stretches and exercises.  It can be done to simply improve knee strength or it can be used for patients with a variety of knee related problems such as arthritis, kneecap instability, tendonitis or after surgery.  

The video below outlines how and why the QuadCrunch can help both athletes and patients.

QuadCrunch Video
Try a set of 3, Hold for 5 Seconds Each, 5 Times per day



Please share this post with anyone who would like to enhance their knee function and post any comments below.

AM

TotalTendon.com

Please do not start any exercise program without consulting your physician first.

Wednesday, July 02, 2014

Fat Stem Cells help Knee Arthritis

Knee Arthritis is a very difficult problem to solve.  Millions of patients suffer daily from this progressive disease state.  A variety of novel biologic therapies are in development.

Stem cells can come from a variety of sources including your own fat.  These cells are known as adipose derived stem cells.  A recent study from Korea suggests there is value using this type of cell for knee arthritis.  Researchers gave patients escalating dose of the cells and found the high dose resulted in improved pain and function scores.  They also found the cartilage defect defect size decreased while the volume of cartilage in the knee increased.


Fat Derived Stem Cells

This data is encouraging and will need to be repeated prior to broad clinical use.  (See abstract below)

For patients with this problem, the horizon is bright with many potential options like stem cells from your own fat.

AM
TotalTendon


 2014 May;32(5):1254-66. doi: 10.1002/stem.1634.

Intra-articular injection of mesenchymal stem cells for the treatment of osteoarthritis of the knee: a proof-of-concept clinical trial.

Abstract

Mesenchymal stem cells (MSCs) are known to have a potential for articular cartilage regeneration. However, most studies focused on focal cartilage defect through surgical implantation. For the treatment of generalized cartilage loss in osteoarthritis, an alternative delivery strategy would be more appropriate. The purpose of this study was to assess the safety and efficacy of intra-articular injection of autologous adipose tissue derived MSCs (AD-MSCs) for knee osteoarthritis. We enrolled 18 patients with osteoarthritis of the knee and injected AD MSCs into the knee. The phase I study consists of three dose-escalation cohorts; the low-dose (1.0 × 10(7)cells), mid-dose (5.0 × 10(7)), and high-dose (1.0 × 10(8)) group with three patients each. The phase II included nine patients receiving the high-dose. The primary outcomes were the safety and the Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) at 6 months. Secondary outcomes included clinical, radiological, arthroscopic, and histological evaluations. There was no treatment-related adverse event. The WOMAC score improved at 6 months after injection in the high-dose group. The size of cartilage defect decreased while the volume of cartilage increased in the medial femoral and tibial condyles of the high-dose group. Arthroscopy showed that the size of cartilage defect decreased in the medial femoral and medial tibial condyles of the high-dose group. Histology demonstrated thick, hyaline-like cartilage regeneration. These results showed that intra-articular injection of 1.0 × 10(8) AD MSCs into the osteoarthritic knee improved function and pain of the knee joint without causing adverse events, and reduced cartilage defects by regeneration of hyaline-like articular cartilage.

Tuesday, June 24, 2014

Platelet Rich Plasma Helps for "High" Ankle Sprains

"High" ankle sprains are significant injuries that typically result in prolonged recovery and time away from sports.  This type of injury involves the strong ligaments that connect two of the major bones of the ankle.  They are also known as syndesmotic injuries.

A recent randomized, controlled trial found that athletes that were treated with ultrasonic guided injections returned to play faster and has less pain than a control group.  Return to play was almost 20 days faster for the PRP group.  (40.8 days vs 59.6 days, p = 0.006)  (See abstract below)

This data supports the use of PRP for athletes with this type of injury.  Further studies will help confirm this value.

AM
TotalTendon

 2014 Jun 18. [Epub ahead of print]

Plasma rich in growth factors (PRGF) as a treatment for high ankle sprain in elite athletes: a randomized control trial.

Abstract

PURPOSE:

Syndesmotic sprains are uncommon injuries that require prolonged recovery. The influence of ultrasound-guided injections of platelet-rich plasma (PRP) into the injured antero-inferior tibio-fibular ligaments (AITFL) in athletes on return to play (RTP) and dynamic stability was studied.

METHODS:

Sixteen elite athletes with AITFL tears were randomized to a treatment group receiving injections of PRP or to a control group. All patients followed an identical rehabilitation protocol and RTP criteria. Patients were prospectively evaluated for clinical ability to return to full activity and residual pain. Dynamic ultrasound examinations were performed at initial examination and at 6 weeks post-injury to demonstrate re-stabilization of the syndesmosis joint and correlation with subjective outcome.

RESULTS:

All patients presented with a tear to the AITFL with dynamic syndesmosis instability in dorsiflexion-external rotation, and larger neutral tibia-fibula distance on ultrasound. Early diagnosis and treatment lead to shorter RTP, with 40.8 (±8.9) and 59.6 (±12.0) days for the PRP and control groups, respectively (p = 0.006). Significantly less residual pain upon return to activity was found in the PRP group; five patients (62.5 %) in the control group returned to play with minor discomfort versus one patient in the treatment group (12.5 %). One patient in the control group had continuous pain and disability and subsequently underwent syndesmosis reconstruction.

CONCLUSIONS:

Athletes suffering from high ankle sprains benefit from ultrasound-guided PRP injections with a shorter RTP, re-stabilization of the syndesmosis joint and less long-term residual pain. LEVEL OF EVIDENCE: II.

Sunday, June 08, 2014

Biologic Orthopedic Update from Las Vegas

The TOBI biologic orthopedic meeting this past weekend in Las Vegas was simply outstanding.  Dr. Steve Sampson put together an excellent collection of lectures and then followed by an impressive ultrasound anatomy session by Dr. Jay Smith from the Mayo Clinic.   Hands on injections and bone marrow aspiration in a cadaver lab completed the stellar conference held at the Red Rock Resort.


Las Vegas Red Rock Area


Some highlights of the sessions.  We heard about the use of PRP in soccer players from Dr. Imtiaz Ahmad from London, England, the use of PRP for osteoarthritis from Dr. Brian Cole from Chicago, the use of adipose-derived stem cells for the treatment of knee osteoarthritis from Dr. Yun Choi from South Korea, minimally invasive techniques for articular cartilage damage from Dr. Neil Ghodadra from Los Angeles and the Andrews Institute Experience using Biologics to Accelerate Healing from Dr. Adam Anz.   Lectures about hydrodissection using ultrasound (Dr. Lam, Hong Kong), the current landscape of disc regeneration challenges and promises (Dr. Bae, Los Angeles) and the value of mesenchymal stem cells (Dr. Caplan, Cleveland) were also given.  That was just part of day one of the conference.  Day two included several more interesting and important lectures.  I think there were over 300 attendees and many more following the streaming video (including myself on day one).  In between the lectures, discussions were carried out in the hallways and exhibit area.  Overall, it was a fantastic international event.

The field of biologic orthopedics is exploding.  Worldwide interest in minimally invasive techniques to treat challenging musculoskeletal problems is rising rapidly.  It will still take time, effort and some luck to discover and develop clinically meaningful treatments.  The good news is, progress is definitely being made toward these lofty goals.

AM
TotalTendon

Friday, June 06, 2014

Biologic Orthopedic Conference in Las Vegas (TOBI)

Today in Las Vegas a group of elite clinicians and researchers from around the world have gathered in Las Vegas for the 5th annual TOBI biologic orthopedic conference.  Discussions about platelet rich plasma, stem cells and a variety of other approaches for difficult problems such as arthritis, tendonitis and degenerative disc disease of the back.

Specific data has been presented suggesting various formulations of PRP and stem cells have value in the treatment of knee arthritis.  Clinical trials ongoing.

I'll be speaking at the conference on Saturday morning and will continue to report breaking news from the conference over the next two days.  Follow me on Twitter for real time updates (@BloodCure)

Dr. Steve Sampson has done a great job organizing the event.  Congrats!


AM
TotalTendon

Monday, May 26, 2014

Can Curry Cure Knee Arthritis?

It sounds like a plot for a silly Bollywood movie, but published data actually supports the idea that one of the key components of curry powder can help alleviate pain for patients with knee arthritis.

Curcumin, a bright yellow spice found in curry powder, recently was found to have the same efficacy as ibuprofen (the active ingredient in Motrin and Advil) for patients with knee arthritis.  In a recently published study of 367 knee arthritis patients, researchers found 1500 mg of Curcuma domestica extract had the same effectiveness in terms of pain reduction as 1200 mg of ibuprofen at four weeks (Kuptnirataikul et al). Importantly, the curcumin treated patients had less episodes of abdominal pain or discomfort compared to the ibuprofen patients.  Importantly, another published study of of the same dosage of curcumin (1500 mg) was found to have significant improvements in terms of pain and physical function when compared to placebo at six weeks (Panahi et al).   Curcumin has been noted to block several substances involved in the inflammatory pathway and also inhibits activation of free radicals.  This could help explain why the spice works to reduce pain in arthritis patients.  

So next time your knee starts to hurt, put down the ibuprofen and hobble over to your favorite Indian or Thai restaurant for a tasty curry meal.  It may just help your knees feel better.

On a more serious note, the published data supports trying a curcumin supplement 1500 mg per day divided in three doses for 4-6 weeks for patients with knee arthritis.  (See chart below)

AM
TotalTendon



Pain Reduction in Patients with Knee ArthritisKuptnirataikul et al









Sunday, May 18, 2014

Can Stem Cells Cure Knee Arthritis?


Can Stem Cells Cure Knee Arthritis?

Unfortunately, the answer to that question is not known today.  It is clear, however, that many novel regenerative therapies are emerging to help the tens of millions of patients worldwide that are suffering from knee arthritis.

First, we must explore what type of stem cells could be helpful in the treatment of arthritis.  Stem cells of various types can be obtained from your blood (peripheral derived stem cells), bone marrow (mesenchymal stem cells), fat (adipose derived stem cells), and even from umbilical cord blood.  Studies today are exploring various ways to extract, purify and concentrate many types of stem cells.  The cells can then be injected as a suspension into your knee, used as part of surgical procedure or even injected after an operation.

Microfracture of Damaged Knee Cartilage

One recent study (Vangsness et al 2014) showed how an injection of mesenchymal stem cells could lead to more meniscus tissue after a knee arthroscopy.  24% of the treated group were found to have at least 15% increased meniscal volume.  This is a small amount in only a a quarter of the patients but it does represent a start.  Another study published last year (Saw et al 2013), injected peripheral derived stem cells after a microfracture procedure and noted improvement in the cartilage quality.  Other approaches (Pak et al 2014) use adipose derived stem cells from liposuction in combination with platelet-rich plasma to treat meniscus tears.  Finally, a review (Anderson et al 2013) of potential stem cell therapies for knee cartilage outlines many potential and emerging options.

Also, a variety of procedures also use non-stem cells to treat arthritis of the knee.  One of the oldest is called autologous chondrocyte implantation.  This is where a biopsy of your own cartilage is taken and then grown in a lab.  The expanded cells and then reimplanted into an arthritic lesion of the knee.  Another procedure simply penetrates the bone under the defective cartilage.  This leads to leakage of some of the bone marrow along with your own the stem cells within the marrow into the defect.  This is called microfracture.  Yet another procedure uses juvenile cartilage that is minced and then glued into a arthritic zone of the knee.

It is clear that there are many competing approaches to the use of cells and stem cells to treat knee arthritis.  None have "cured" the problem.   There is, however, an earnest worldwide research effort that will produce clinically meaningful options for clinicians and patients.

Millions worldwide are waiting for that day.

AM
TotalTendon

References
Anderson et al 2013
Saw et al 2013
Vangsness et al 2014
Pak et al 2014


Sunday, May 11, 2014

Platelet Rich Plasma, Stem Cells and Biologic Orthopedics on Dr. Radio




On Monday May 12th, I will be on Sirius-XM Doctor Radio (Channel 81, 7 pm EST, 4 pm PST) discussing platelet-rich plasma, stem cells and other biologic orthopedic treatments.  It is an exciting time for this topic because research in these areas has progressed significantly just in the last few months.  Also, patients and payers are demanding less invasive and more effective treatments for difficult problems such as knee osteoarthritis and degenerative disc disease.  So, tune in at 7 pm EST, 4 pm PST on Monday May 12th to learn more about the frontiers of musculoskeletal medicine and surgery.  

Wednesday, May 07, 2014

Platelet Rich Plasma Helpful for Patellar Tendonitis in Athletes

A new study published in the American Journal of Sports Medicine that ultrasonic guided platelet rich plasma  (PRP) injections improved pain and function in athletes with chronic patellar tendinopathy.  (See abstract below)

Patellar tendinopathy typically affects running and jumping athletes such as tennis, volleyball and basketball players.  It manifests itself with pain in the front of the knee and typically is worse with repeated jumping activities.  Most often, it will resolve with appropriate non-invasive treatment such as rest, icing and physical therapy.  It can be difficult to treat.  When the symptoms persists, published data supports the use of PRP injections.

AM
TotalTendon

  1. Benjamin Bouyer, MD
+Author Affiliations
  1. Institut Osteo Articulaire Paris Courcelles, Paris, France
  2. Laboratory of Bioengineering and Biomechanics for Bone Articulation, University of Paris, Paris, France
  3. §Centre D’image Médicale Bachaumont, Paris, France
  4. Biostatistics and Epidemiology Department, Hotel Dieu Hospital 1, Paris, France
  5. Investigation performed at the Institut Ostéo Articulaire Paris Courcelles, Paris, France
  1. * Christophe Charousset, MD, Institut Osteo Articulaire Paris Courcelles–60 Rue de Courcelles, 75008 Paris, France (e-mail: dr.charousset@ioapc.fr).

Abstract

Background: Chronic patellar tendinopathy (PT) is one of the most common overuse knee disorders. Platelet-rich plasma (PRP) appears to be a reliable nonoperative therapy for chronic PT.
Purpose: To evaluate clinical and radiological outcomes of 3 consecutive ultrasound (US)–guided PRP injections for the treatment of chronic PT in athletes.
Study Design: Case series; Level of evidence, 4.
Methods: A total of 28 athletes (17 professional, 11 semiprofessional) with chronic PT refractory to nonoperative management were prospectively included for US-guided pure PRP injections into the site of the tendinopathy. The same treating physician at a single institution performed 3 consecutive injections 1 week apart, with the same PRP preparation used. All patients underwent clinical evaluation, including the Victorian Institute of Sport Assessment–Patella (VISA-P) score, visual analog scales (VAS) for pain, and Lysholm knee scale before surgery and after return to practice sports. Tendon healing was assessed with MRI at 1 and 3 months after the procedure.Results: The VISA-P, VAS, and Lysholm scores all significantly improved at the 2-year follow-up. The average preprocedure VISA-P, VAS, and Lysholm scores improved from 39 to 94 (P < .001), 7 to 0.8 (P < .0001), and 60 to 96 (P < .001), respectively, at the 2-year follow-up. Twenty-one of the 28 athletes returned to their presymptom sporting level at 3 months (range, 2-6 months) after the procedure. Follow-up MRI assessment showed improved structural integrity of the tendon at 3 months after the procedure and complete return to normal structural integrity of the tendon in 16 patients (57%). Seven patients did not recover their presymptom sporting level (among them, 6 were considered treatment failures): 3 patients returned to sport at a lesser level, 1 patient changed his sport activity (for other reasons), and 3 needed surgical intervention.
Conclusion: In this study, application of 3 consecutive US-guided PRP injections significantly improved symptoms and function in athletes with chronic PT and allowed fast recovery to their presymptom sporting level. The PRP treatment permitted a return to a normal architecture of the tendon as assessed by MRI.
http://ajs.sagepub.com/content/42/4/906.abstract

Saturday, May 03, 2014

Best Overall Exercise: PowerKnee Bike Program (Knee OA Part 4)

The PowerKnee Bike Program uses an upright exercise bike to work out all of your leg muscles.  It is the best overall exercise for knee pain and arthritis because it can do so much for you without significant impact on the joint.   By simply riding the exercise bike for 30 minutes 3 times per week you can also improve your cardiovascular fitness and burn a bunch of calories.  See the video below for details.



Record the calories you can burn in 30 minutes and compare your results week by week for a month.  If you are consistent in applying the PowerKnee Bike Program you have an excellent chance of decreasing your pain and improving your knee function.

As always, check with your doc before beginning any exercise program.

AM
TotalTendon

Sunday, April 27, 2014

Best Initial Knee Stretch "The Hammy" (Knee OA, Part 3)

Your hamstring tendons start on your pelvis and insert behind and below your knee. In almost every person, these tendons tighten with time.  Stretching your hamstring tendons is one of the best exercises you can do for your knee and back.  One study found "individuals with and without osteoarthritis of the knee are able to demonstrate immediate beneficial adaptations to a stretching intervention."
Reference

I recommend do a set of 3 hamstrings stretches, 3 times PER DAY.  Stretching multiple times per day is better than stretching only once a day or not at all.  You may be surprised with your improved flexibility if you are consistent about stretching.  See the video below for a simple stretch that can done anywhere.  I call it the "Hammy Stretch".



Start by placing your leg on a step, or low table.  Keep your back straight and your toes pointed toward the ceiling.  Then, simply hinge forward at your waist.  You will likely feel the stretch in the back of your thigh, knee and calf.

Consistency is the key to improvement.  Try this simple exercise and it will help your overall knee health and improve your ability to straightening your knee.  Hamstring stretching is like sunscreen, it is best to start early and continue to stretch throughout your life.

As always, check with your own doctor before beginning any exercise program.

Next time, we reveal the simple yet highly effective way to strengthen all of the muscle of your legs.

AM
TotalTendon

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