Diagnosis and treatment of knee and ankle pain - palpation

and injection skillsDr Margaret E Taylor MB.BS, BSc, FACNEM, cert.

Sports Med in GP. Adelaide GP,

Treasurer, Aust Assoc for Musculoskeletal Med

Prolotherapy - basic premiseInjections 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

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Osteoarthritis

•Medial joint line

•Pes anserinus – goes further down than you’d think

•Various other ligs

Knee tender points

Sports injuries:

•around patella

•Osgood Schlatters – both sides of tendon

•Various other ligs

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 3 or 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

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 go2 injections and zinc supplement will fix itKidd 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

posterior syndromeCommon sites for sprained ankle

Complete tear of Achilles – J Orthop Med 2005 27(3) 128-132

Solutions made with 25% glucose1 Litre bags of 25% IV glucose from Baxter - about $7

Prolo solution 20% (10ml/12ml x 25% = 20.8%)10cc 25% glucose2cc 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 AdelaideSee 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