Transcript Diagnosis and treatment of knee and ankle pain

Diagnosis and treatment of
knee and ankle pain - palpation
and injection skills
Dr Margaret E Taylor MB.BS, BSc, FACNEM, cert.
Sports Med in GP.
Adelaide GP,
Treasurer, Aust Assoc for Musculoskeletal Med
Prolotherapy - basic premise
Injections to stimulate growth factors and regenerate
ligaments, tendons or cartilage.
Introduced by US surgeon George Hackett who first
experimented with sclerosant solutions in low back pain in
1939 and published many times in 1950s.
Injury initiates inflammation then effective repair depends on
the balance between proliferation of collagen and apoptosis
of the early stage of inflammation.
This is inhibited by VEGF (Vascular endothelial growth factor)
High levels of VEGF in tendinosis, and it causes neovessels
around the tendon. Pufe Scand J Med Sci Sports 2005:15;211
Glucose inhibits VEGF, as does 0.1% lignocaine
Summary
• Glucose injections are useful in 3 types of
lesions
– Enthesis strain, eg sprained ankle – treat by touching
bone gently with the needle and restart the
inflammatory cascade
– Tendinosis – treat by injecting next to tendon to inhibit
VEGF and restart apoptosis, ending granulation
tissue
– Chronic results of old injuries – treat all tender points
– relieve pain and stabilise joints
• Aim: to generate new collagen, increasing
strength and decreasing laxity, and relaxing
muscle spasm
63yr old footballers knee
made pain free
Football injury age 22 and
cartilage removal
“terribly painful driving car”
and in morning
Taking NSAID or Digesic
daily
Xray: advanced
degenerative change with
lipping
5 prolo treatments to June
2003 – virtually pain free.
2006 - on extended
overseas trip with no
trouble
2008 – still OK
MRI showing repair of meniscus tear
Fullerton BD,
Arch Phys
Med Rehab
Feb 2008 vol 8
377-385
Knee tender points
Sports injuries:
•around patella
•Osgood Schlatters –
both sides of tendon
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•Various other ligs
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Osteoarthritis
•Medial joint line
•Pes anserinus –
goes further down
than you’d think
•Various other ligs
Prolotherapy in OA of knee – DB trial
38 knees devoid of
Significant difference
cartilage in at least
by 12 months in:
one compartment
– pain - 44% decrease
– swelling - 63% decrease
Either 10 % dextrose
– knee buckling - 85% decrease
or lignocaine
– flexion range - 14% increase
9cc into the joint,
– Xrays stabilised or improved
bimonthly for 3 or 6
injections
8 of 13 with ACL laxity were no longer
lax after 12 months
Reeves, Alt Ther Health Med 2000; 6: 68
www.integrativemedicineresearchonline.com/knee2000.pdf
Osgood Schlatter’s epiphysitis
12 - 16 year old with painful insertion of patellar tendon on
tibia at the growth plate
? Zinc deficiency - Teenagers need more zinc than adults for
growth and sexual maturation, and eat terribly (nb acne,
striae)
Normally can take up to 2 years to go
2 injections and zinc supplement will fix it
Kidd RF reported 6 cases treated with prolotherapy. 5
responded in 1 or 2 treatments. The other was a 26 yr old
with a 10 yr history and ossicles in the tendon.
J Orthop Med 1993;15:62-3
1cc prolo solution to tender points on each side of tendon
Prolotherapy and Achilles tendinopathy
Lyftogt J, Aust Mus Med May 2005 p16-19
Osteitis pubis and/or adductor tendinopathy
responded in an average of 2.8 treatments with an
improvement in VAS from 6.3 to 1.0. Twenty of 24
patients had no pain. Topol et al, Arch Phys Med
Rehabil. 2005 Apr;86(4):697
Common tender points to be treated
Leg, foot & ankle
• Chronic ankle sprains
• Achilles tendinopathy
• persistent pain after
fracture – metatarsalgia
• Morton’s neuroma
• Bunions
• Hammer toes
• Compartment syndrome
• Aching feet – Tib
Common sites for sprained ankle posterior syndrome
Complete tear of Achilles – J Orthop Med 2005 27(3) 128-132
Solutions made with 25% glucose
1 Litre bags of 25% IV glucose from Baxter - about $7
Prolo solution 20% (10ml/12ml x 25% = 20.8%)
10cc 25% glucose
2cc 1% lignocaine (in 12ml syringe)
Joint solution (22.5%)
4.5cc 25% glucose (4.5 x 25% /5ml)
0.5cc 1 or 2% lignocaine
Basic textbook: Hackett G et al: Ligament and Tendon
Relaxation Treated by Prolotherapy 1991 $US50
http://www.benuts.com/beulah.asp
Next workshop – 28-30 November 2008 Adelaide
See Prolotherapy for Doctors www.drmtaylor.com.au for more
details, links to references and to register.
“the most cost-effective medical education I’ve ever done”
Dr Peter Henderson, Gold Coast