Marc Darrow MD,JD

I have already written about stem cell therapy as an alternative to meniscus surgery and Platelet Rich Plasma therapy as a meniscus tear alternative. In this article I want to offer research surrounding whether or not you even have a meniscus tear despite what your MRI may or may not say.

Do you even have a meniscus tear? “Understanding that this MRI finding does not represent a true meniscus tear may save patients from unnecessary arthroscopic surgery.”

The accuracy of MRIs, specifically the accuracy of MRIs in sending people to a knee surgery has always been questioned. A February 2021 study says (1) “MRI could be a diagnostic tool for meniscus tears, but has limited accuracy in their classification of the type and location.” Simply, it is not without its errors. Of course in this case you may get a surgery you did not need.

Also in February 2021, this editorial from Peter R Kurzweil, MD, Orthopedic surgeon, published in the journal Arthroscopy (2)

“The false-positive finding of anterior horn meniscus (pseudo) tear on magnetic resonance imaging (MRI) is an important finding of which to be aware. We have recently seen awareness similarly raised regarding root tears of the meniscus, which, if overlooked, could have detrimental consequences. Manifestations of the MRI finding of meniscus pseudotear arise from the variability of the insertion of the transverse geniculate ligament into the anterior horn of the lateral meniscus. Bearing in mind that anterior knee pain is a common reason that patients present for an orthopaedic and sports medicine evaluation, the understanding that this MRI finding does not represent a true meniscus tear may save patients from unnecessary arthroscopic surgery.”

“The negative role of MRI in promoting surgical expectations needs further consideration” – “A lack of evidence for the use of arthroscopy”

Also from February 2021, this paper in the journal Musculoskeletal science & practice (3). This is what a group of physical therapists wrote:

“Current clinical practice guidelines for degenerative meniscal tears recommend conservative management yet patients are frequently referred to the consultant orthopaedic surgeon despite a lack of evidence for the use of arthroscopy.”

What this study was about was that people went to their doctor fully expecting a meniscus surgery recommendation. The doctor told them that they may be better off with physical therapy. This seemed top upset some of the patients who conveyed their thoughts to the physical therapists in this way:

“Participants described beliefs, strongly influenced by magnetic resonance imaging (MRI) results, that damaged structures were causing their knee problems (“The meniscus is busted”), and expected their knee problems to inevitably worsen over time (“It’s only going to get worse”). Participants were hopeful the orthopaedic consultation would clarify their problem and lead to a subsequent definitive intervention (“Hopefully they will give me answers”). Most participants viewed surgery as “the quick and straightforward solution” necessary to repair faulty cartilage. Exercise was not seen as compatible with the recovery process by most (“Would I make it worse?”).

This is how the physical therapists concluded their paper: “How participants understand their knee problem contributes to surgical expectations and perceptions that it is not amenable to conservative management. Findings suggest a need to educate both patients and primary care clinicians about the safety and efficacy of exercise as first-line therapy for degenerative meniscal tears. The negative role of MRI in promoting surgical expectations needs further consideration.”

“There is a noticeable increase in the unnecessary ordering of Magnetic Resonance Imaging (MRI) of the knee in older patients.”

This is a study from November 2020. (4) “There is a noticeable increase in the unnecessary ordering of Magnetic Resonance Imaging (MRI) of the knee in older patients. This quality improvement study assessed the frequency of unnecessary pre-consultation knee MRIs and investigated the effect on the outcome of the patients’ consultation with the orthopedic surgeon.”

650 medical charts of patients aged 55 years or older referred to an orthopedic clinic with knee complaints were reviewed. Of the 650 patient charts reviewed, 225 patients presented with a pre-consultation MRI, 76% of which were not useful for the orthopedic surgeon.

The ordered knee MRI scans were considered not useful because they were requested for confirmed meniscal tear for patients more than 55 years, suspected degenerative disorder and ligament/tendon injury, or for patients with severe osteoarthritis without locking or extension. These MRI scans were done despite the absence of signs of effusion, tenderness, soft tissue swelling, decreased range of motion, or difficulty of weight-bearing, a lack of persistent knee joint pain at the time of assessment, or with no x-ray before ordering MRI.”

It was later noted: “patients with pre-consult (before being sent to the surgeon) MRI were less likely to be considered for total knee arthroplasty (TKA).”

Do you need an MRI before I come in?

In many emails that I get, people ask me if they should get an MRI. Usually an MRI is not necessary as outlined in the research above. I want to first do a physical examination. Other people email and some of them have had a recent MRI and a report of what the MRI recorded and what the radiologist interpreted. Some of these MRI reports are deep and comprehensive in their description of an unseemly insurmountable amount of damage to the person’s knees. The person who sends in the email will sometimes add something in the email to suggest that their MRI is one of the worst that their doctor has ever seen. The funny thing is when we ask, “well how does your knee feel today?” Sometimes we get the answer, “not bad.”

Meniscus tear treatment at the Darrow Stem Cell Institute

The meniscus has an ability to heal itself. When someone comes into our office with knee problems we start with a conversation so we can learn about the patient’s lifestyle and what are his/her goals of the treatment. Is it to get back to marathon training or is it to get up and down a staircase without his/her knee locking up? Then we will do a detailed physical examination looking for those signs that will tell us how helpful stem cell therapy may be.

Please see my articles

Stem Cell Therapy Alternative For Meniscus Surgery

Platelet Rich Plasma Therapy | Meniscus Tear Injections

Do you have questions? Ask Dr. Darrow

A leading provider of stem cell therapy, platelet rich plasma and prolotherapy
11645 WILSHIRE BOULEVARD SUITE 120, LOS ANGELES, CA 90025

PHONE: (800) 300-9300 or 310-231-7000

Stem cell and PRP injections for musculoskeletal conditions are not FDA approved. We do not treat disease. We do not offer IV treatments. There are no guarantees that this treatment will help you. Prior to our treatment, seek advice from your medical physician. Neither Dr. Darrow, nor any associate, offer medical advice from this transmission. This information is offered for educational purposes only. The transmission of this information does not create a physician-patient relationship between you and Dr. Darrow or any associate. We do not guarantee the accuracy, completeness, usefulness or adequacy of any resource, information, product, or process available from this transmission. We cannot be responsible for the receipt of your email since spam filters and servers often block their receipt. If you have a medical issue, please call our office. If you have a medical emergency, please call 911.

References

1 Kim SH, Lee HJ, Jang YH, Chun KJ, Park YB. Diagnostic Accuracy of Magnetic Resonance Imaging in the Detection of Type and Location of Meniscus Tears: Comparison with Arthroscopic Findings. Journal of Clinical Medicine. 2021 Jan;10(4):606.
2 Kurzweil PR. Editorial Commentary: False-Positive Meniscus Pseudotear on Magnetic Resonance Imaging: A False Sign That Rings True.
3 O’Leary H, Ryan LG, Robinson K, Conroy EJ, McCreesh K. “You’d be better off to do the keyhole and make a good job of it” a qualitative study of the beliefs and treatment expectations of patients attending secondary care with degenerative meniscal tears. Musculoskeletal Science and Practice. 2021 Feb 1;51:102281.
4 Mohammed HT, Yoon S, Hupel T, Payson LA. Unnecessary ordering of magnetic resonance imaging of the knee: A retrospective chart review of referrals to orthopedic surgeons. Plos one. 2020 Nov 2;15(11):e0241645. —1315

Marc Darrow MD,JD

Over the years we have seen many patients with Plantar Fasciitis that had been unresponsive to conventional treatments. These conventional treatments included physical therapy, cortisone, and anti-inflammatories. While not the best choice for doctor or patient, many of these people considered the surgical option as the ultimate choice because they “have to do something.” But will surgery be any more effective? We will cover this in research cited later in this article.

Is it the heel spur causing pain or is it plantar fasciitis?

When a patient comes into our office with plantar fasciitis and a bone or heel spur revealed on an x-ray or an MRI, the first thing they want to know is can we get rid of the bone spur? I usually have to do a little convincing that it is usually not the bone spur that is causing them their pain and that heel spur is not the issue we want to tackle at the start of the treatment. I explain to the patient that the issue is that you’re overdoing an activity which is irritating the place where the fascia (the soft tissue that connects the toes to the heel) meets the heel bone. When that irritation is constant and chronic, bone spurs form. We want to treat that problem.

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Marc Darrow MD,JD

Many emails that come in from this website, come from people asking about SLAP tear surgery. Some people want to know if they can avoid surgery. Some people are looking for options because they cannot get a SLAP tear surgery. Why can’t they get the surgery? Because their doctor/surgeon does not hold out good hope that surgery will be effective for them. Who are these people? From the emails we get, they are usually people with multi-directional shoulder instability, or, people who already had the surgery and despite it being a successful surgery, the person still had pain and range of motion issues.

Before we get into the research, here is my story. I have a labral tear in my right shoulder. I have a supraspinatus and subscapularis tear as well. I also have NO pain. How do I know I have the tears? Because I looked at my shoulder under ultrasound when I was having shoulder pain, one day especially, when I had a frozen shoulder from hitting too many golf balls. I am a very repetitive motion type athlete.
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Marc Darrow MD,JD

There is countless research surrounding low back pain and the golfer. Many studies suggest many causes and theories as to what can be causing low back pain. In this article I want to draw attention to research that suggests more rare or lesser known causes of your golfer’s low back pain. Spinal ligaments.

Is it always the golf swing? Higher average club head speed and low back pain

The most researched and the most discussed cause of low back pain is usually the golf swing. A 2020 study came out of the University of Chicago (1) which hypothesized that professional golfers who achieved a higher average club head speed had more lower back injuries. The theory was tested on male professional golfers who suffered lower back injuries while playing golf. The injured group was composed of 14 Professional Golfers’ Association (PGA) golfers who withdrew from a PGA tour event due to a back injury during the years 2017-2019.

What the researchers found what that age, height, weight or Body Mass Index did not play significant factors in causing low back pain alone. The injured group had a higher mean club head speed than a control group of golfers who had no lower back pain. This study concluded then that: “average club head speed was significantly higher in PGA golfers who suffered back injuries while golfing.” It was the swing.

But what would cause it to be the swing? In some people, the energy needed to strike the ball at a high head speed would come not only from core muscles but core ligaments. Ligaments are often an overlooked factor for pain during a golf swing.

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Marc Darrow MD,JD

We get many emails from people asking us about our ability or the ability of stem cell therapy to repair their knee damage. Some of these people have had a recent MRI and a report of what the MRI recorded and what the radiologist interpreted. Some of these MRI reports are deep and comprehensive in their description of an unseeingly insurmountable amount of damage to the person’s knees. The person who sends in the email will sometimes add something in the email to suggest that their MRI is one of the worst that their doctor has ever seen. The funny thing is when we ask, “well how does your knee feel today?” Sometimes we get the answer, “not bad.” How can someone who has one of the worst knee MRIs their doctor has ever seen, have a knee that is “not bad”? That is what a lot of research is focusing on.

We also get emails from people who have terrible knee MRI reports and a have a frozen joint, fused by excessive bone spurring. These people cannot bend their knee. In these situations where knee range of motion is compromised, increasing functional ability may not be a realistic goal of stem cell treatments, a discussion with this person would turn towards an assessment of the treatment’s ability to help with their pain. Not every person with damaged knees is a good candidate for stem cell therapy.

However for the patient who is active, has a good range of motion in their knee, can bend their knee, even with a bad MRI, this person would be considered a realistically good candidate for stem cell therapy.
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Marc Darrow MD,JD

Biological knee replacement or knee reconstruction is a more recent term to describe the surgical procedure of combined meniscal allograft transplantation and surgical cartilage repair. It is recommended to patients with painful, meniscus-deficient knees and full-thickness cartilage damage. In the research we will examine below, some surgeons are questioning the value of these procedures. Also I will show studies on how this biological knee replacement may be achieved by using stem cell therapy for meniscus and cartilage repair.

Meniscal allograft transplantation

Since I first wrote about this subject there is new research to examine.

• Meniscal allograft transplantation is a surgery in which a meniscus from a cadaver is used to replace your meniscus.

Doctors in South Korea have published findings in which they suggest that clinical outcomes after meniscal allograft transplantation in arthritic knees are unclear.  Further, the procedure is not recommended to patients with osteoarthritic bone changes because the doctors found that the procedure is not effective if there is already bone damage.(1)

In November 2017 doctors published even more troubling research in the American Journal of Sports Medicine.

“When comparing a patient series with  full-thickness chondral defects  who underwent Meniscal allograft transplantation with a patient series with NO chondral defects, there were no differences in the change in individual patient outcomes from preoperative to the final follow-up.

Similarly, there were no differences in complications or failure between those with NO chondral defects or full-thickness chondral defects diagnosed intraoperatively.

The results of the current study suggest that chondral damage identified and treated by cartilage restoration (repaired full thickness cartilage) at the time of Meniscal allograft transplantation may not affect the clinical outcomes of Meniscal allograft transplantation.”

The paper notes that those with repaired full thickness cartilage and Meniscal allograft transplantation, had the same rate of need for secondary surgery and complete failure leading to knee replacement.(2)

In a recent study from Harvard, doctors found successful outcomes in 65% of the operated knees they examined post cartilage – meniscus transplant surgery. These surgical procedures, the study suggests, can allow patients to retain their biological knees, delay or prevent rapid degeneration to osteoarthritis, and could be recognized as a bridge procedure before artificial knee replacement. (A stop gap measure to delay knee replacement). The researchers noted a 35% failure rate.(3)

In April 2020, (4) army researchers examined soldier’s ability to return to active duty following meniscal allograft transplantation. These are their results:

“Meniscal allograft transplantation is considered a viable surgical treatment option in the symptomatic, post-meniscectomy knee and as a concomitant procedure with ACL revision and articular cartilage repair. “

While these surgeons noted that promising outcomes have recently been reported in active and athletic populations, Meniscal allograft transplantation has its limits, especially in a high-demand military population. In fact the results suggest that many army personnel cannot return to active duty. This is what they wrote:

“Surgeons should be aware of the low likelihood of return to military duty at more than 2 years after Meniscal allograft transplantation and counsel patients accordingly. Based on this study, Meniscal allograft transplantation does not appear to be compatible with continued unrestricted military duty for most patients.”

The Meniscal allograft transplantation surgery is considered successful even if you do not return to sports

A March 2020 study (5)  suggested:

“Meniscal allograft transplantation may improve symptoms and function, and may limit premature knee degeneration in patients with symptomatic meniscal loss. The aim of this retrospective study was to examine patient outcomes after Meniscal allograft transplantation and to explore the different potential definitions of ‘success’ and ‘failure’.

• Forty-three patients who underwent Meniscal allograft transplantation were asked if they considered the surgery a success or failure and were they able to return to sports.
  • Surgical failure was considered if: (removal of most/all the graft had to be done, revision Meniscal allograft transplantation or conversion to knee replacement had to be performed), pain relief was not achieved, complication rates (surgical failure plus repeat arthroscopy for secondary allograft tears). Patients were also asked if they would have the procedure again.
• Results
  • The complication rate was 9% surgical failures and 21% were clinical failures. Half of those patients considered a failure stated they would undergo Meniscal allograft transplantation again because it achieved some pain relief.
  • Inability to return to sport is not associated with failure since 73% of these patients would undergo Meniscal allograft transplantation again.

What is microfracture knee surgery?

Knee microfracture surgery is a common arthroscopic procedure where an awl (a sharp pointed tool) is pushed into the bone where the protective knee cartilage has worn away. The small holes made by the awl are called  microfractures. The goal of this surgery is to build new cartilage.

A multinational research team that includes the Harvard Medical School says evidence suggests that patient outcomes improve with microfracture for the most part, but in some studies these effects are not sustained. They highlight their study with these points:

• The quality of cartilage repair following microfracture is variable and inconsistent due to unknown reasons.
• Younger patients have better clinical outcomes and quality of cartilage repair than older patients.
• Patients with smaller lesions have better clinical improvement than patients with larger lesions.
• The necessity of long postoperative CPM (Continuous passive motion) and restricted weight bearing is widely accepted but not completely supported by solid data.
• All in all there is limited evidence that micro fracture should be accepted as gold standard for the treatment of cartilage lesions in the knee joint.(6)

This is not the only research to question the microfracture procedure’s effectiveness. Doctors at the Federal University of São Paulo in Brazil published their findings in which they compared microfracture to other surgical procedures. In their findings there was no evidence that allograft transplantation (cartilage transplantation from a donor) or microfracture drilling worked any better than each other. But they did note that “treatment failure, with recurrence of symptoms, occurred with both procedures.”(7)

Surgical Cartilage treatment strategies are characterized as:

• Chondroplasty, a procedure that shaves down or smooths out of cartilage.
• Debridement (power washing the the knee cartilage),
• Microfracture,
• Transplantation autologous chondrocyte implantation [ACI], osteochondral autograft [OAT], and osteochondral allograft [OCA]).

Authors from the University of New Mexico Health Sciences Center concluded:  These techniques may improve patient outcomes, though no single technique can reproduce normal hyaline cartilage. (8)

In agreement are Ohio State University researchers who say: The markedly limited healing potential of articular cartilage often leads these patients to continued deterioration and progressive functional limitations even after surgery. (9)

The problem with surgery is that it cannot do what patients want most – repair and regrow damaged tissue. 

BIOLOGICAL KNEE RECONSTRUCTION WITHOUT SURGERY – USING STEM CELLS

The definition of osteochondral is that it is related to the cartilage and bone. In the knee joint cartilage protects the shinbone, the thigh bone, and the back of the kneecap or the patella. A healthy knee has all its surfaces glide smoothly atop these cartilages for pain free, efficient, and in the case of athletics – explosive movement. In recent research investigators suggested that knee stem cell therapy could provide the answer where drug interventions and surgical procedures were lacking:

• “Drug interventions and surgical treatments have been widely attempted for cartilage regeneration in osteoarthritis. However, the results were largely unsatisfactory. Autologous chondrocyte implantation (ACI) or matrix-induced autologous chondrocyte implantation (MACI) offers potential for the regeneration of cartilage over the long-term. However, due to the limitations and disadvantages of ACI, alternative therapies for cartilage regeneration are in need. The availability of large quantities of mesenchymal stem cells (MSCs) and the multilineage differentiation (the morphing ability), especially their chondrogenic (for cartilage) differentiation property, have made MSCs the most promising cell source for cartilage regeneration.”(10)

From the medical journal Stem cell research & therapy “Since the cartilage is composed primarily of chondrocytes (a specialized cartilage cell) bone marrow-derived mesenchymal stem cells with its ability to morph into these cartilage cells appear to be ideally suited for therapeutic use in cartilage regeneration.” (11)

I have much more information on this site concerning stem cell therapy for knee osteoarthritis and degenerative knee disease. Please start here with this article on knee osteoarthritis and stem cell treatments. To learn more about stem cell therapy visit my stem cell therapy research page.

Do you have questions? Ask Dr. Darrow

A leading provider of stem cell therapy, platelet rich plasma and prolotherapy
11645 WILSHIRE BOULEVARD SUITE 120, LOS ANGELES, CA 90025

PHONE: (800) 300-9300 or 310-231-7000

Stem cell and PRP injections for musculoskeletal conditions are not FDA approved. We do not treat disease. We do not offer IV treatments. There are no guarantees that this treatment will help you. Prior to our treatment, seek advice from your medical physician.Neither Dr. Darrow, nor any associate, offer medical advice from this transmission. This information is offered for educational purposes only. The transmission of this information does not create a physician-patient relationship between you and Dr. Darrow or any associate. We do not guarantee the accuracy, completeness, usefulness or adequacy of any resource, information, product, or process available from this transmission. We cannot be responsible for the receipt of your email since spam filters and servers often block their receipt. If you have a medical issue, please call our office. If you have a medical emergency, please call 911.

1 Lee BS, Bin SI, Kim JM, Kim WK, Choi JW. Survivorship After Meniscal Allograft Transplantation According to Articular Cartilage Status. Am J Sports Med. 2017 Apr;45(5):1095-1101. doi: 10.1177/0363546516682235. Epub 2017 Jan 10.
2 Ogura T, Bryant T, Minas T. Biological Knee Reconstruction With Concomitant Autologous Chondrocyte Implantation and Meniscal Allograft Transplantation: Mid- to Long-term Outcomes. Orthopaedic Journal of Sports Medicine. 2016;4(10):2325967116668490. doi:10.1177/2325967116668490.
3 Wang D, Kalia V, Eliasberg CD, Wang T, Coxe FR, Pais MD, Rodeo SA, Williams III RJ. Osteochondral Allograft Transplantation of the Knee in Patients Aged 40 Years and Older. The American Journal of Sports Medicine. 2017 Nov 1:0363546517741465.
4 Antosh IJ, Cameron KL, Marsh NA, Posner MA, DeBerardino TM, Svoboda SJ, Owens BD. Likelihood of return to duty is low after meniscal allograft transplantation in an active-duty military population. A Publication of The Association of Bone and Joint Surgeons®| CORR®. 2020 Apr 1;478(4):722-30.
5 Searle H, Asopa V, Coleman S, McDermott I. The results of meniscal allograft transplantation surgery: what is success?. BMC musculoskeletal disorders. 2020 Dec;21(1):1-9.
6 Erggelet C, Vavken P. Microfracture for the treatment of cartilage defects in the knee joint – A golden standard? J Clin Orthop Trauma. 2016 Jul-Sep;7(3):145-52. doi: 10.1016/j.jcot.2016.06.015.
7 Gracitelli GC, Moraes VY, Franciozi CE, Luzo MV, Belloti JC. Surgical interventions (microfracture, drilling, mosaicplasty, and allograft transplantation) for treating isolated cartilage defects of the knee in adults. Cochrane Database Syst Rev. 2016 Sep 3;9:CD010675.
8 Richter DL, Schenck RC Jr, Wascher DC, Treme G. Knee Articular Cartilage Repair and Restoration Techniques: A Review of the Literature. Sports Health. 2015 Oct 12. pii: 1941738115611350. [Epub ahead of print]
9 Campbell AB, Pineda M, Harris JD, Flanigan DC. Return to Sport After Articular Cartilage Repair in Athletes’ Knees: A Systematic Review. Arthroscopy. 2015 Oct 30. pii: S0749-8063(15)00706-9. doi: 10.1016/j.arthro.2015.08.028.
10 Qi Y, Yan W. Mesenchymal stem cell sheet encapsulated cartilage debris provides great potential for cartilage defects repair in osteoarthritis. Med Hypotheses. 2012 Sep;79(3):420-1. Epub 2012 Jun 1.
11 Zhang L, Hu J, Athanasiou KA. The Role of Tissue Engineering in Articular Cartilage Repair and Regeneration. Critical reviews in biomedical engineering. 2009;37(1-2):1-57.

Marc Darrow MD,JD

Many golfers play as long as they can with a painful hip. Then one day the hip pain becomes severe enough that it is just not worth playing any more. As avid and recreational golfers, many people do not embark on surgery to get themselves back on the course. They get the surgeries because of other quality of life factors or they need to return to work. But as golf is an important aspect of their lives, if they can get back to playing, that would be an added bonus to the surgery.

The question many people wrestle with is, surgery or no surgery?

Many golfers know other golfers who had very good success with surgery so it is easy to think surgery would be the answer. For many people surgery may indeed by the answer. But what if you cannot get a surgery in a timely manner or you do have a job that you cannot take the time off of work? Maybe you are simply not interested in the months of extensive physical therapy or the rehab required to recover or maybe you are simply not interested in getting a surgery? Are there options?

The realities of hip replacement and the return to sport

A December 2019 paper published in the journal International orthopaedics (1) examined the return to golf after hip replacement.

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Marc Darrow MD,JD

I frequently see patients with an MRI of a tendon tear or an MRI of a problem of chronic tendinopathy. Tendinopathy is a more recent term to describe a chronic pathology of a tendon that causes pain. The problem of Tendinopathy can be It is divided into two broad categories:

• Tendinitis means inflammation of the tendon. This is the characteristic swelling that comes with a worsening wear and tear or acute injury.
• Tendinosis is the “old, nagging injury.” The tendon is injured but the body has given up trying to heal it. It is an injury without inflammation. Why did the body give up? In some of the people we see, it comes as the result of a long and extensive anti-inflammatory or cortisone treatment history.

Anti-inflammatory drugs and cortisone injections are effective at reducing pain and inflammation, but do not have a healing effect. Worse, their detrimental effects may lead to complete tendon rupture which usually requires surgical repair. For more on this and supportive research, I invite you to review my articles:

• Systemic effects of corticosteroid injections
• How anti-inflammatories accelerate degenerative knee disease.

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Marc Darrow MD,JD

Over the years we have seen many patients with hip pain. Many of them having a “hip bursitis.” If you have a diagnosis of bursitis, you know what it is, as most you have been diagnosed with a trochanteric bursitis or an iliopsoas bursitis. Sometimes both. The iliopsoas bursitis is felt in the groin area on the inside of the hip. The trochanteric bursitis is felt on the outer part of the hip.

However, most of the patients we see may or may not have a bursitis even though they have a diagnosis of one and they are on anti-inflammatory medications. Bursitis is an inflammation of the protective, fluid filled sacs that prevent excessive friction between the functional soft tissue of the hip, i.e., the ligaments and tendons, and the bones they attach to and rub against. These bursae can become irritated from injury, excessive pressure, and overuse. More often this diagnosis is actually a problem of tendonitis or tendinosis. However, for the purpose of this article, I will focus on the problem of bursitis.

Once a diagnosis of bursitis is made, the patient will typically be given a “healing,” regiment that will include:

• Activity modification and rest
• Nonsteroidal anti-inflammatory drugs (NSAIDs).
• Physical therapy.
• Injection of a corticosteroid

These treatments may be effective for some, non-effective for others. Once the cortisone injection or injections fail to provide any relief, the patient will usually start seeking other options. One option is Platelet Rich Plasma therapy or PRP. PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected back into the injured area to stimulate healing and regeneration. Why PRP?
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Marc Darrow MD,JD

One of the most frequent emails we receive is one from people in pain who are waiting for a knee replacement and have a lot of pain issues. Because of the delay or wait in getting a knee replacement they have found themselves taking more medications. Research is showing us that the use of painkillers to help people manage knee pain before knee replacement is putting these same people at a greater risk of knee replacement failure.

In this article I will discuss the medical research surrounding concerns of painkiller (opioid) use pre and post joint replacement surgery.

From Stanford University research: “Patients taking opioids (narcotic painkillers) prior to surgery experience prolonged postoperative opioid use, worse clinical outcomes, increased pain, and more postoperative complications.”(1)

From the same research comes something even worse: Patients presenting with preoperative opioid use have potentially an increased risk for opioid misuse after surgery. 

More than 10% of people over 65 getting total knee replacement become persistent opioid users after knee replacement

A study from January 2021 (2) found that 10.6% of patients, over the age of 65, became persistent high dose opioid users after total knee replacement.

Researchers in Canada had earlier come to the same conclusion: Here is what they wrote in the American Journal of Bone and Joint Surgery : (3)

• “Chronic use of opioid medications may lead to dependence or hyperalgesia, (Opioid-induced hyperalgesia is an increased sensitivity to pain) both of which might adversely affect perioperative and postoperative pain management, rehabilitation, and clinical outcomes after total knee replacement.”

The purpose of this study was to evaluate patients who underwent total knee replacement following six or more weeks of chronic opioid use for pain control and to compare them with a matched group who did not use opioids pre-operatively.

A significantly higher prevalence of complications was seen in the opioid group,

• of the 49 knees replaced in this group –
  • 5 needed arthroscopic evaluations and
  • 8 needed revision surgery for persistent stiffness and/or pain, compared with none in the matched group.
  • Ten patients in the opioid group were referred for outpatient pain management, compared with one patient in the non-opioid group.

CONCLUSIONS: Patients who chronically use opioid medications prior to total knee replacement may be at a substantially greater risk for complications and painful prolonged recoveries. Alternative non-opioid pain medications and/or earlier referral to an orthopaedic surgeon prior to habitual opioid use should be considered for patients with painful degenerative disease of the knee.”

This research from 2011 was brought up to date by the 2020 pandemic. An October 2020 paper (4) noted:

“Although a moderate delay in surgical intervention may not produce a significant progression of osteoarthritis within the knee, it could lead to muscle wasting due to immobility and exacerbate comorbidities, making rehabilitation more challenging.

Importantly, it will have an impact on comorbidities driven by osteoarthritis severity, notably decreased quality of life and depression. These patients with unremitting pain become increasingly susceptible to substance use disorders including opioids, alcohol, as well as prescription and illegal drugs. Appreciation of this downstream crisis created by delayed surgical correction requires aggressive consideration of nonsurgical, nonopiate supported interventions to reduce the morbidity associated with these delays brought upon by the currently restricted access to joint repair.”

Painkillers after joint replacement causing more concerns

The problems of painkillers after joint replacement are a cause of heightened concern in the medical community:

In a paper from leading French researchers published in the European pain journal, the doctors wrote:

• Despite the development of multimodal analgesia (many different pain medications) for postoperative pain management, opioids are still required for effective pain relief after knee replacement.(5)

Doctors at Mount Sinai in New York wrote in The Journal of the American Academy of Orthopaedic Surgeons

• “Total knee replacement is associated with substantial postoperative pain that may impair mobility, reduce the ability to participate in rehabilitation, lead to chronic pain, and reduce patient satisfaction. Traditional general anesthesia with postoperative epidural and patient-controlled opioid analgesia is associated with an undesirable adverse-effect profile, including postoperative nausea and vomiting, hypotension, urinary retention, respiratory depression, delirium, and an increased infection rate.”(6)

In another study doctors found that many patients undergoing hip or knee replacement are still taking prescription opioid pain medications up to six months after surgery. The study that appeared in the medical journal PAIN was led by  Jenna Goesling, PhD, of the University of Michigan, the study identifies several “red flags” for persistent opioid use–particularly previous use of high-dose opioids. The results also suggest that some patients continue to use these potentially addictive pain medications despite improvement in their hip or knee pain.(7)

Concerns about Persistent Opioid Use after Joint Replacement

Dr. Goesling and her team analyzed patterns of opioid use in 574 patients undergoing knee or hip replacement surgery. Patients were followed up at one, three, and six months after surgery to assess rates of and risk factors for long-term opioid use.

• About 30 percent of the patients were taking opioids prior to their joint replacement surgery. Of this group, 53 percent of knee-replacement patients and 35 percent of hip replacement patients were still taking opioids at six months after surgery.

Patients who were not taking opioids prior to surgery were less likely to report persistent opioid use: About 8 percent in the knee-replacement group and 4 percent in the hip-replacement group continued to take opioids at the six-month follow up. Although these are relatively small percentages, this suggests that a portion of patients who were “opioid naïve” prior to surgery will become new chronic opioid users following arthroplasty.

• The strongest predictor of long-term opioid use was taking high-dose opioids before joint replacement surgery. For patients in the highest preoperative dose group (equivalent to more than 60 milligrams of oral morphine per day), the predicted probability of persistent opioid use at six months was 80 percent.
• Among patients not previously taking opioids, those with higher pain scores the day of surgery–both in the affected joint and overall body pain–were more likely to report persistent opioid use at six months.
• Opioid use was also more likely for patients who scored higher on a measure of pain catastrophizing–exaggerated responses and worries about pain–than those with depressive symptoms.

For all patients, reductions in overall body pain were associated with decreased odds of being on opioids at six months. However, improvement in knee or hip pain after joint replacement did not reduce the likelihood of long-term opioid use.

Persistent opioid use after knee or hip replacement surgery may be more common than previously reported, the new results suggest. Importantly, continued opioid use is not necessarily related to pain in the affected joint. “We hypothesize that the reasons patients continue to use opioids may be due to pain in other areas, self-medicating affective distress, and therapeutic opioid dependence,” the researchers write.(8)

problem is they are confused and not getting the correct instructions. Stem cell therapy has the potential to fix the communication problem and begin the repair process anew.

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1 Hah JM, Sharifzadeh Y, Wang BM, Gillespie MJ, Goodman SB, Mackey SC, Carroll IR. Factors associated with opioid use in a cohort of patients presenting for surgery. Pain research and treatment. 2015;2015.
2 Gopalakrishnan C, Desai RJ, Franklin JM, Jin Y, Lii J, Solomon DH, Katz JN, Lee YC, Franklin PD, Kim SC. Development of a Medicare Claims‐Based Model to Predict Persistent High‐Dose Opioid Use After Total Knee Replacement. Arthritis Care & Research.
3 Zywiel MG, Stroh DA, Lee SY, Bonutti PM, Mont MA. Chronic opioid use prior to total knee arthroplasty. J Bone JointSurg Am. 2011 Nov 2;93(21):1988-93. doi: 10.2106/JBJS.J.01473.
4 Cisternas AF, Ramachandran R, Yaksh TL, Nahama A. Unintended consequences of COVID-19 safety measures on patients with chronic knee pain forced to defer joint replacement surgery. Pain Reports. 2020 Nov;5(6).
5 Thomazeau J, Rouquette A, Martinez V, Rabuel C, Prince N, Laplanche JL, Nizard R, Bergmann JF, Perrot S, Lloret-Linares C. Acute pain Factors predictive of post-operative pain and opioid requirement in multimodal analgesia following knee replacement. Eur J Pain. 2015 Oct 30. doi: 10.1002/ejp.808.
6  Moucha CS, Weiser MC, Levin EJ. Current Strategies in Anesthesia and Analgesia for Total Knee Arthroplasty.  J Am Acad Orthop Surg. 2016 Feb;24(2):60-73. doi: 10.5435/JAAOS-D-14-00259.
7 Goesling J, Moser SE, Zaidi B, Hassett AL, Hilliard P, Hallstrom B, Clauw DJ, Brummett CM. Trends and predictors of opioid use following total knee and total hip arthroplasty. Pain. 2016 Jun;157(6):1259.
8. http://www.eurekalert.org/pub_releases/2016-05/wkh-mpc053116.php