Category: Ankle

Weekly Education meeting 20200706- Replay
Topics discussed during this broadcast:
Heel pain:
Plantar fasciitis and Achilles tendinitis
Case 1
Case 2
Avoid steroids!
Nerve related pain.
PRP vs Amniotic fluid.

Live Weekly educational meeting for the team at Chicago Arthritis and Regenerative Medicine where we discuss the basics of what we do for arthritis, tendinitis, injuries, and back pain.
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Welcome everyone, this is Siddharth Tambar from Chicago Arthritis and Regenerative Medicine. Welcome to our weekly education meeting. So we’re doing this live, this week. So as an update, we’ve started to do this educational meeting where I’m talking to team members, about what we do in the office in terms of evaluation, treatment, key principles when it comes to arthritis, tendinitis, injuries and back pain. And it’s been interesting and helpful because it gives me a chance to talk and it gives a chance for team members to kind of learn and ask questions, and I think it’s relevant for not only us, but also relevant for general public or existing patients as well. And my natural course of doing this is videotape. And then just put it out there, maybe get some captions on it, but really nothing else post editing. So, I just decided let’s do this live. And I think that makes sense. It’ll get out there faster and maybe connect with more people, which is interesting.

I am using a software platform called StreamYard to connect on Facebook and LinkedIn and shout out to Orlando Landrum for giving me that idea. He is dramatically more technically savvy than I am. I was just saying to Devi and Jackie, that I think I’ve maximized my technical abilities at this point. I have the streaming on Facebook, YouTube, and now IG. And I think that’s as high level as I can possibly get. I think after this, it’s just like, do we have a rocket ship to Mars? That’s as far as I’m going.
Alright, so something interesting I thought would be interesting to talk about is heel pain or plantar fasciitis. So, we have two cases where that’s relevant from this past week, one where we actually treated, one where existing patient was emailing some questions. And so it kind of brings up some interesting topics, which I think are worthwhile learning about and talking about. So the first case is a man in his late 40s, who was presenting with heel pain, and what he has an exam is tenderness along the bottom of his foot, as well as tenderness along the Achilles tendon. So, the bottom of the foot where he has tenderness over the heel. He has plantar fasciitis, that’s a length of tissue along the bottom of the foot that basically helps to provide support and structure over the bottom of the foot. It can get chronically aggravated, which is what plantar fasciitis is. He also has tenderness over the Achilles tendon, the Achilles tendon is basically, the tendon from all the calf muscles that basically insert at the heel, so it’s an area of very high pressure, high tension and if it gets irritated, it can be very painful as well. So, we came to his diagnosis based on not only examination, but also ultrasound and X-ray, really ultrasound more than anything else because it shows chronic changes in the plantar fascia as well as chronic changes in the Achilles tendon. In both cases, there’s chronic kind of wear and tear changes, degenerative changes. There’s not any active inflammation, there’s no severe tear either.

So this is something that is still amenable to non surgical treatment. And in his case, he’d failed physical therapy, and his existing podiatrist had recommended a steroid injection. And so that brings up a couple different topics. Number one is what’s the right treatment if you fail conservative options for something like plantar fasciitis and Achilles tendonitis. So, traditionally a steroid injection could be considered. The problem with steroid injection is as follows number one, it can weaken tissue, and while it’s rare, but it can actually cause a tear or even rupture of a tendon. Something that was taught to me when I was in training was you need to be careful about injecting steroids into a weight-bearing tendon. And the reason why is because if it ruptures, even if that’s rare, that can be disastrous to that human being, meaning they can no longer ambulate. So, the idea of utilizing a steroid injection in this man’s case, I think, is a really bad idea.

My suggestion to him is, why do something that’s going to increase your risk that may give you short term pain relief, let’s consider something that makes a little bit more sense, which in his case was Platelet-Rich Plasma. Which is utilizing your own blood, platelets, growth factors from the blood and platelets, to inject that into the chronically damaged tissue and do what’s called Percutaneous Needle Tenotomy. Which is where under ultrasound guidance, you stick a needle into the chronically damaged tissue, and sort of needle that to create more blood flow. And there’s good evidence to suggest that this is helpful for plantar fasciitis. And there’s also evidence that this is helpful for Achilles tendinopathy as well.

The other aspect of his case is that he also has burning sensation in the bottom of his foot. My original suggestion was let’s do also work up for the lower back to see if you also have evidence of a pinched nerve in the L5 or S1 level, they could also be causing pain and burning sensation in the foot. He had actually declined treatment for the lower back, but when we ended up treating him we ended up taking the consideration of possible nerve condition as well. And I’ll describe that. So, the way that we end up proceeding with treatment in his case, was to utilize a high concentration of Platelet-Rich Plasma under ultrasound guidance, to inject that into the plantar fascia on the bottom of the heel. And then to also inject that into the Achilles tendon on the other side of the heel. And because he also had some of the burning sensation to also inject a concentration of growth factors in the platelets called platelet lysate, which is healthy for nerve tissue and inject that around the posterior tibial nerve, which is a nerve that supplies the bottom of the heel in terms of sensation, and, can also cause pain as well if it’s irritated. So the goal in his case, is to utilize a product that’s going to be healthy, his own cells that doesn’t have the risk of causing disruption or tearing of the tendon or plantar fascia. And that has evidence of giving longer term pain relief and functional improvement. And I think he’ll actually do pretty well.

The second case is a woman in her late 50s, who sent me an email over the weekend, someone who I’ve treated for various other things in the past knees, lower back, I think maybe an ankle issue in the past as well. And she was basically emailing saying that she’s been seeing a podiatrist and for again, heel pain and was diagnosed with plantar fasciitis. She had failed conservative treatment, again, physical therapy, some orthotics, and her podiatrist had recommended amniotic stem cell treatment, and she was asking, is that the way to go, or should she do something else? And so, my recommendation to her is, okay, you failed conservative options, what injection options are right. So, okay, good she hasn’t been recommended a steroid injection. She had been recommended amniotic stem cell injection. Does it make sense to use that versus platelets versus some other kind of cell based treatment from herself.

So, number one, you need to understand what are amniotic stem cell treatments, there are no live cells in that product. So the way amniotic stem cell treatments get packaged to be sold as an over the counter product to physicians, is that they take it from birth cord tissue after a baby’s been born, then it has to be processed. And by process, I mean that it first gets freeze dried, gamma irradiated and then pulverized into a powder tissue. So it’s no longer tissue actually, it’s just a powder. That powder is then re-hydrated with saline in the physician’s office and then re-injected back into the area that needs to be treated. So number one important to understand that there are no live cells in that like, no human or live tissue can actually survive that kind of process. And there’s a reason for that. Meaning from the FDA standpoint, they want to reduce the risk of transmissible diseases. And they do that by requiring that kind of process. The other part to that is in order to be sold as an oft over the counter shelf product that needs to have a certain shelf life, months. And so you can’t just have live cells sitting around for months, it’s really created into this kind of powder package product. So there are no live cells in that, that’s been looked at multiple organizations to see are there any live cells or no live cells. So it’s not really a stem cell treatment, what it is a growth factor treatment.

So there’s a couple aspects to that. Number one is, if you have the option of utilizing your own cells versus foreign cells, you should always use your own cells if you can get the same kind of effect. Number two is if you have the option of utilizing a product with your own live cells versus a product that has maybe growth factors, which is what amniotic products do. You might as well use your own live cells, there’s benefit to that. Lastly, there is a good deal of evidence in using your own live cells for this kind of condition, plantar fasciitis. And there’s less on the amniotic fluid product standpoint. You can still get a good response from utilizing amniotic product. But, why not use your own cells, less risk, non foreign material with live cells that has good evidence. And so my recommendation to her is, if you have a moderate level condition, let’s utilize just your own platelets to begin with. Now, I personally do have experience combining amniotic cell products with someone’s own platelets, or even with someone’s own bone marrow derived stem cells. That’s a pretty, rare indication where I would do that. In her case, I would say stick with your own platelets as first line treatment before doing anything else a bit more creative, because of all those reasons that I’ve mentioned.

So, in both both of these cases, there’s important understanding in terms of why we’re selecting certain products, there’s an important understanding of what products not to use and what products to use preferentially. And then even how to proceed with treatment, which is to be more expansive in treatment for treating not only let’s say plantar fasciitis, but the other side of the heel, such as the Achilles tendon if there’s pathology and a nerve issue, if that’s involved as well.

Questions?
– [Devi] What’s an example where amniotic cells would be better than your own cells?
– [Devi] Or is it amniotic cells versus-
– They’re described as amniotic stem cells, right? but there’s no live cells. So it’s not really a accurate way to describe it right?
-Yeah I think the the indication to utilize amniotic cells is that you can get a very aggressive pro-inflammatory response. That’s, considered one of its benefits. The thing is that you can just concentrate platelets to a much higher degree and get that similar kind of response. So one of the advantages that we have for doing this in an open lab format in being in the Regenexx Network is that we can, sort of determine what concentration of platelets that we want to use, whether we want to use just platelets or growth factor some platelets like platelet lysate, we have more flexibility in that regard. So if you’re taking a very low concentration of platelets, comparing that to let’s say, amniotic cells is not a fair comparison. On the other hand, if you can increase the concentration of platelets, you can initiate a higher inflammatory response, which means you can get a similar or better effect. So, I wouldn’t say that there’s a indication to use amniotic cells in preference to some of our other cell products, I would say, are there indications where you can combine that. And I think there are depending on the degree of pathology.

– [Jackie] What would be the pain scale for patients after the procedure-
– Okay, so great question. So, Jackie is always asking about what’s the discomfort associated after treatment. But that’s cause what patients ask. And so the nature of injecting into a plantar fascia or Achilles tendon is that, like you’re walking on that so it’s sore, it’s already inflamed. If you’re gonna be putting pressure on it, it’s gonna be more inflamed. So what I generally recommend is utilize a CAM Walker boot, basically, it takes all the pressure off the foot, and you’re able to put pressure on it as you’re walking. So you’re basically offloading it. You could use crutches or a cane as well. But I personally find that using the boot, is easier for that first week. And normally it’s that first week where people are most uncomfortable. I’ve done this without that. And I think it’s just harder for people to kind of get around. But if they can use the boot for that first week, they’re generally okay with that. And then after that they can transition off and then as they start to work with physical therapy, they can then start to progressively put more and more load and strain on that heel and foot and then keep on pushing it. Does that makes sense?

– [Jackie] Mhm! And when will they see a difference four to six weeks?
– I always recommend that four to six weeks mark I can tell you that if like in that initial case that I mentioned where we’re treating the nerve part of it as well, if he does have a component of like nerve irritation that’s driving his heel pain as well, which he probably does, cause he does have that burning sensation symptom, that even just treating that he’ll get some relief up front. That’ll slowly wear off and then it’ll start to get effect from treating the actual tissue as well over the next few weeks.

– [Jackie] Thank you. I got nothing else
– Yeah, nothing else. Jackie?
– Okay, good plantar fascia. There’s more nuances to it in terms of how we treat it, how we evaluate it. I hope this has been helpful.

And until next week, I hope everyone is well. Again, as a reminder, we do two live broadcasts per week now, I’m trying to do that. There’s the weekly educational meeting that I’m doing live now. We have a set weekly live meeting every Wednesday we’re gonna have to kind of rethink about how we define that just as weekly live live. Is there some other name to it? I’m not sure. But we’re trying to do two of these per week. And until next time, I hope everyone is well. Have a good day and live well. Bye bye.

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***About this video***
In this video Siddharth Tambar MD from Chicago Arthritis and Regenerative Medicine discusses heel pain, plantar fasciitis, achilles tendinis, and prp treatment.