For patients with severe chronic plantar fasciitis not manageable with traditional non-operative treatments, injections with platelet-rich plasma (PRP) is significantly more effective than using cortisone.  This is according to a study presented by Raymond R. Monto, M.D., from the Nantucket Cottage Hospital in Massachusetts at the annual meeting of the American Academy of Orthopaedic Surgeons, held recently in San Francisco.

Dr. Monto compared PRP with cortisone injections for the treatment of 36 patients with plantar fasciitis that was resistant to traditional non-operative management.  Patients underwent pretreatment magnetic resonance imaging and ultrasound studies.  Group 1, with an average age of 59 years, an average of 5.4 months of failed standard non-operative treatment, and an average pretreatment American Orthopaedic Foot & Ankle Society (AOFAS) score of 52, was treated with a single injection of methylprednisolone at the injury site.  Group 2, with an average age of 51 years, an average of 5.7 months of failed standard non-operative treatment, and an average pretreatment AOFAS score of 37, was treated with a single injection of un-buffered autologous PRP.

Monto found that, in Group 1, the average post-treatment AOFAS score improved to 81 at three months, decreased to 74 at six months, and then decreased to 58 at 12 months. In Group 2, the average post-treatment AOFAS score improved to 95 at three months, and remained at 94 at six and 12 months (P = 0.001).

Based on the improved AOFAS score, platelet-rich plasma injection was more effective and durable than cortisone injection for the treatment of severe chronic plantar fasciitis.

While there are still no large-scale studies of PRP’s effectiveness, this study does support the growing body of antidotal evidence that indicates that PRP is effective in treating musculoskeletal injuries and conditions.  It is used widely and openly in professional sports, the veterinary world, and we have seen patients have positive results following PRP treatment in this office.

If you weren’t aware, plantar fasciitis is a common source of foot pain.  The pain may sometimes be diffuse and confused with ankle pain.  The plantar fascia is a fibrous aponeurosis (a thick cord-like tissue).  It originates off the calcaneus or heel bone and fans out to attach to the plantar surfaces of the phalanges bones (foot bones). 

Plantar fasciitis is a common source of foot pain in athletes, especially ones who compete in running athletics.  However, plantar fasciitis may also been seen in over-weight non-athletes

The plantar fascia may either be caused by an inflammatory process or there may be an underlying degenerative process, such as seen in tendinopathies where there is thickening, scarring and abnormal collagen formations.  Rupture of the plantar fascia may occur with an extremely forceful injury, usually in the mid portion of the fascia. 

Information contained in this blog is intended for educational purposes only and not for medical diagnosis or treatment.  If you have a medical concern or issue, please consult with your physician.

Novak Djokovic’s rise from world tennis’ number three player to number one has generated a lot of interest – not just in the feat itself, but in speculation that Djokovic’s change in diet is a key to his success.

At the end of 2010, Djokovic began working with Igor Cetojevic, a Serbian doctor and nutritionist.  At this point in his career, he had won only one Grand Slam title (2008 Australian Open).  During the 2011 season, Djokovic has won the Australian Open, Wimbledon and the US Open, and compiled an amazing 64-3 record.

What therapy did Dr. Cetojevic prescribe for Djokovic that accounts for his stellar performance this year? 

Diet.  Djokovic changed his diet to a gluten-free diet. 

Gluten, a protein found in foods such as bread, pasta and other starchy foods, can trigger reactions in people.  Apparently, Djokovic had enough of an allergy to gluten that, eliminating it has made a big difference in his performance.

But could something as simple as a diet change account for Djokovic’s higher performance?

According to Dr. Dennis Lox, diet can have a huge influence on performance.  If you look at how diet impacts a person who is diabetic, then yes – diet plays a big factor in how that person performs.

Does it account for Djokovic’s success?  It is hard to say exactly, but at that level of performance, even a small adjustment, physical or mental, can have a big influence.

Leaving nothing to chance, world tennis’ number four player, Andy Murray adopted the “Djokovic diet.”  Murray’s performance?  He is one of only three players to have beaten Djokovic this year (although Djokovic had a shoulder injury and was forced to withdraw after a set).

Information contained in this blog is intended for educational purposes only and not for medical diagnosis or treatment.  If you have a medical concern or issue, please consult with your physician.

It came to light the weekend of September 17-18, 2011, that Indianapolis Colt’s quarterback, Peyton Manning had traveled to Europe for stem cell therapy.  The stem cell therapy was to help treat the bulging disc in Manning’s neck, which three previous surgeries have failed to repair.  Apparently the therapy did not help.

An ABC News blog report on Manning’s stem cell treatment in Europe raises several issues: Manning’s actions, as a role model, in seeking an unproven treatment overseas, and the validity of the treatment itself.

Manning is quoted as saying “that I am doing everything I can to get my health back.”  As a role model, Manning (or any other role model) does need to be cognizant of his actions.  But does he not have the same rights as anyone else to live his life to the fullest?  It just so happens he has the means and motivation to pursue all options.  “Winners never quit” is not a bad message for him to send.

Regarding stem cell therapy for vertebral disc conditions.  While the therapy did not work for Manning, and is not FDA approved, that does not mean there are not antidotal success stories of stem cell use with other orthopedic problems.  The recent stories of NY Yankee’s pitcher Bartolo Colon and New England Patriot’s Jarvis Green, each returning to the game after stem cell therapy, or the myriad of success stories of professional athletes receiving platelet-rich plasma (another therapy not FDA approved), while antidotal, should not be ignored.  While we do not condone all off-shore stem cell therapies, there is growing antidotal evidence that stem cell therapy seems to help in many musculoskeletal injuries.

What if Manning had sustained a much more serious spinal cord injury instead of a bulging disc injury?  Would the same physicians criticize him for going to Europe for stem cell therapy?  Put yourself in Manning’s cleats – What would you do if you were paralyzed?  Would you go to Europe for stem cell therapy if there were a possibility it would help?

In the news blog, Manning was criticized for not enrolling in a clinical trial researching the therapy.  In fact, the first human embryonic stem cell trial is now underway in the United States, evaluating the safety of embryonic stem cell therapy in humans suffering from acute spinal cord injury.  Unfortunately, Manning would not meet the criteria for inclusion in this study.  One of my patients is a collegiate football player who sustained a career and life-altering cervical spinal cord injury; he as well does not meet the criteria for the trial and as a result of his lack of resources is not able to go to Europe.

Perhaps, judgment should be put in the context of the individual.  The unfortunate reality that has evaded some professors is the evolving emergence of regenerative medicine, which may not be readily embraced by the insurance industry, is changing the health care environment.  

This will result in a paradigm for the future, a future not so far away.  The concept of a dedicated, outstanding athlete trying to recover would be viewed in a different vein had the injury been perceived as more catastrophic, and worse when the harsh reality emerges that the future of medicine may bring inequality as well.

When this is considered, casting a stone at Peyton Manning becomes a more weighty measure.

Information contained in this blog is intended for educational purposes only and not for medical diagnosis or treatment.  If you have a medical concern or issue, please consult with your physician.

Blood injections, especially of platelet-rich plasma, into the affected area help relieve the pain associated with "tennis elbow" where other treatment methods have failed, according to a Greek study.  Reuters article here.

Information contained in this blog is intended for educational purposes only and not for medical diagnosis or treatment.  If you have a medical concern or issue, please consult with your physician.

Here is a well-written article on stem cell therapy in athletes.

The article, by David Epstein in Inside Baseball on sportsillustrated.com, tells the story of New York Yankee pitcher Bartolo Colon’s elbow and shoulder stem cell treatment. 

In his article, Epstein also points out that stem cell therapy is nothing new and that it has been utilized for an extended period in many athletes who have undergone microfracture techniques.  Epstein’s article is interesting and worth the read.

Nothing contained in this blog is intended to be instructional for medical diagnosis or treatment. If you have a medical concern or issue, please consult with your physician.

As our inaugural blog post, I thought it appropriate to highlight a discussion I came across on Becker's Orthopedic and Spine Review.  “Four orthopedic sports medicine physicians discuss current use of platelet-rich plasma injections for athletes and whether they think the treatment will stand up to evidence-based research.”

Highlights of their comments:

T. Jeffrey Emel, MD, at Eastern Oklahoma Orthopedic Center in Tulsa, Oklahoma said that he has been impressed with how platelet-rich plasma works on chronic tendon problems and that it could negate the need for some surgical procedures – but he does not have strong supporting studies.  Until there are more studies, Dr. Emel said they want to do the right thing for the patient, provided there is enough science behind it in a non-academic setting.

Tom Hackett, MD, from the Steadman Clinic in Vail, Colorado noted they were initially seeing more promise in soft tissue than joint applications.  He also stated that they use biologic augmentation, a combination of platelet-rich plasma and a bone growth stimulator in fractures that will not heal and they had seen success in using patches with growth factors for Achilles tendon repair and rotator cuff repairs.  According to Dr. Hackett, one drawback to using platelet-rich plasma (PRP) injections is that insurance does not cover it.  Unfortunately, some patients do not opt for the procedure, since they have to pay out of pocket for the non-covered service. 

Bert Mandelbaum, MD, at St. John’s Health Center in Santa Monica, California stated that there are several studies looking at the efficacy of PRP, with contradictory results.  He thinks that in the appropriate situation, PRP might be of some use surgically to enhance the repair and regeneration, especially in an athlete.  As a sports medicine physician, Dr. Mandelbaum said he is always trying to get the best outcome and performance from his interventions.  As an example, he pointed out that there are studies that show using PRP during ACL repair decreases healing time and potentially enhances the graft strength

Eric Millstein, MD, at DISC Sports and Spine Center in Marina del Ray, California noted that he found PRP most helpful in chronic tendinopathy, such as tennis elbow and patellar tendonitis, as well as some revision surgery, although he does not think it helps with every surgery.  Dr. Millstein sees that enthusiasm for PRP is high among patients, but there is a misperception that it can do more than it actually does.

As a sports and regenerative medicine specialist, I see that PRP has become a hot topic among patients, especially those following professional athletes.  The fact that numerous athletes have had platelet-rich plasma treatment, and are now embracing biologic and even stem cell therapy, makes this a sought-after treatment modality, especially when other treatments have failed to provide relief.  As more studies become available, the future of regenerative medicine will include other modalities besides the growth factors in platelet-rich plasma.

Nothing contained in this blog is intended to be instructional for medical diagnosis or treatment. If you have a medical concern or issue, please consult with your physician.