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Diagnosis and treatment of knee and ankle pain - palpation and injection skills

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.

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Diagnosis and treatment of knee and ankle pain - palpation and injection skills

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  1. 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

  2. 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

  3. 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

  4. 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

  5. MRI showing repair of meniscus tear Fullerton BD, Arch Phys Med Rehab Feb 2008 vol 8 377-385

  6. Knee tender points • Sports injuries: • around patella • Osgood Schlatters – both sides of tendon • Various other ligs * * * * * * • Osteoarthritis • Medial joint line • Pes anserinus – goes further down than you’d think • Various other ligs * * * * * * *

  7. Prolotherapy in OA of knee – DB trial 38 knees devoid of cartilage in at least one compartment Either 10% dextrose or lignocaine 9cc into the joint, bimonthly for 3or 6 injections Significant difference by 12 months in: • pain - 44% decrease • swelling - 63% decrease • knee buckling - 85% decrease • flexion range - 14% increase • Xrays stabilised or improved 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

  8. 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

  9. Prolotherapy and Achilles tendinopathy Lyftogt J, Aust Mus Med May 2005 p16-19

  10. 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

  11. Leg, foot & ankle • Chronic ankle sprains • Achilles tendinopathy • persistent pain after fracture – metatarsalgia • Morton’s neuroma • Bunions • Hammer toes • Compartment syndrome • Aching feet – Tib posterior syndrome Common sites for sprained ankle Complete tear of Achilles – J Orthop Med 2005 27(3) 128-132

  12. Solutions made with 25% glucose 1 Litre bags of 25% IV glucose from Baxter - about $7Prolo 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

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