Marc Darrow MD,JD

We do get many emails about ankle pain. Some people write that they are on a waiting list for an ankle fusion, sometimes one, sometimes both ankles, and while they are waiting, they want to know if stem cell therapy can be an option. Others write that the are bone on bone and have lost all the cartilage in their ankle, can we help?

I usually respond asking about the limitations the person has. If the ankle can still bend and rotate? Generally speaking, if your ankle is not locked in place by bone spurring and you can still move your foot around, we would think that stem cell therapy could help. I discuss this below.

Treatment options for advanced ankle osteoarthritis

A study published in March 2019 (1) discusses the problem orthopedists and surgeons have in presenting treatment options to their patients with advanced ankle osteoarthritis. As many doctors and patients are aware, ankle osteoarthritis treatment protocols have no real guideline recommendations of its own. Researchers say most doctors treat an ankle problem as they would treat a knee or hip and follow hip or knee treatment protocols when treating the ankle. Is this really such a bad thing?
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Marc Darrow MD,JD

Someone who has a medical history including numerous ankle arthroscopic procedures will usually contact out office looking for options to their next surgery which would be an ankle fusion or a total ankle replacement. Usually, someone being told they need one more surgery will lead these people to more exhaustively research alternatives. This includes the various types of ankle injections.

A July 2020 paper (1) compared various injection treatments for ankle pain caused by osteochondral lesions (loss of cartilage leading to a bone on bone situation) and osteoarthritis. The injection treatments included were hyaluronic acid, Platelet-rich plasma (PRP), saline, methylprednisolone (steroid), botulinum toxin type A, mesenchymal stem cells (MSCs), and prolotherapy.

This was a review study where researchers combined studies and the study data to form an opinion on which of these treatments would work best. The problem with the results of this study? There were not enough studies of good evidence in direct comparisons of ALL the treatments for the researchers to review to give any opinion. While we then cannot offer a direct comparison of the treatments, we can review the research in this article where there is a direct comparison and give a broad over view of these treatments for ankle pain.
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Marc Darrow MD,JD

In the more than 20 years we have been helping patients with their chronic pain, we have seen many people with hyper-extended neck injuries, or, in simpler terms whiplash injury. We have also seen patients who suffered from long-term effects of their whiplash injury until such time as they were diagnosed with Whiplash Associated Disorders (WAD). As noted in many studies including that published in the journal Frontiers in neurology:

• “The main concern with whiplash is that a large proportion of whiplash patients experience disabling symptoms or whiplash-associated disorders (WAD) for months if not years following the accident.”(1)

As noted, Whiplash associated disorders are a lingering and complex series of problems for patients who have suffered whiplash injury in the past and whose impact continues for years even decades after the initial injury. The complexity of pain issues these patients suffer from leaves many frustrated with their health care providers and leaves some fighting to prove that there is something really wrong with them. If one were to examine the research on whiplash related disorders, he/she would find that most of the new studies center around identifying those patients who cannot be helped or feel helpless.
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Marc Darrow MD,JD

Tendinitis occurs when a muscle is overused and pulls on the tendon that attaches it to the bone. In the hip, tendons perform an important role by keeping strong muscles attached to the femur (thighbone) as the legs move.

Hip abductor tendon tears

Hip abductor tendons are crucial for good gait and stability in the hip joint. When I see someone with hip pain and they have a good range of motion and no sign of degenerative arthritis, that is the clue that we are looking at something in the soft tissue, be it the labrum, the ligaments complex or the hip tendon complex. In many people, it is a combination of all three.

As mentioned, I see the person who may have degenerative or traumatic injury tears to their hip tendons. They do have outside hip pain and a degree of muscle weakness. This person is typically the athlete or person who does physically demanding work and a lot of them are trying to continue with activity or job with the pain.

Sometimes I see the patient who has continued pain after hip replacement. Sometimes the tendons and muscles are injured during the surgery.

Treatment options

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Marc Darrow MD,JD

Many times a patient will come into our office with a stack of MRIs, a post-surgical report, and a promise that they were told that they could resume their running after a hip resurfacing procedure. Unfortunately for them, the surgery did not meet their expectations. Recently published research in the American Journal of Sports Medicine, says “Running is possible after hip resurfacing, and runners can even return to some level of competition, but this short follow-up series of hip resurfacing in athletes should be interpreted with caution regarding implant survival.”(1)

A study from 2019 (2) presented a more optimistic outlook. Here the researchers suggested: “Patients undergoing hip resurfacing improved their preoperative gait pattern of a significant limp to a symmetrical gait at high speeds and on inclines, almost indistinguishable from normal controls. Hip resurfacing with an approved device offers substantial functional gains, almost indistinguishable from healthy controls.”

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Marc Darrow MD,JD

The shoulder comprises a complex matrix of bone and soft tissue that enables an extreme range of motion. But the price the shoulder pays for that range of motion is a greater risk of chronic injury.

Sometimes the bones in the joint slip out of normal alignment or are forced out by injury-subluxation and dislocation. For those individuals who suffer from chronic shoulder instability, dislocations may occur frequently. This occurs because first dislocations usually require a significant amount of force as in anterior dislocations, in which the anterior static shoulder stabilizers are stretched or torn away from the bone. Approximately 95% of shoulder dislocations are this type and typically occur when a person falls on their outstretched hand, or sustains a downward motion blow to the shoulder.

Until recently it was common in cases of dislocation to immobilize the shoulder for long periods of time. But studies showed that while immobilization helped alleviate the pain of such injuries, it also contributed to a general weakening of the ligaments and predominance of adhesive capsulitis.

The shoulder is held together by soft tissue stabilizers, the ligaments that connect bone to bone. Over the course of time, especially in sports that involve heavy shoulder-to-shoulder contact (such as hockey, lacrosse, football, wrestling, and basketball), the ligaments may stretch out and become “lax.” When the ligaments become lax, the risk of dislocation and separation becomes greater.

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Marc Darrow MD,JD

Stem cell therapy works in a multi-factorial way. Stem cells repair, stem cells regenerate, and stem cells communicate. Communication is one of the key but less understood functions of stem cell therapy. In this communication aspect, newly introduced stem cells (those introduced in stem cell therapy injections) can mobilize stem cells already in your knee to jump start a new repair cycle for degenerative and acute injury damage.

In 2011, doctors at the University of Aberdeen published research in the journal Arthritis and rheumatism that provided the first evidence that resident stem cells in the knee joint synovium underwent proliferation (multiplied) and chondrogenic differentiation (made themselves into cartilage cells) following injury. (1) This paper, presenting the idea that stem cells in an injured knee increased in numbers in preparation of healing has been cited by more than 68 medical studies.

One of the more recent of these 68 papers is a June 2019 study (2) in which researchers suggest that in both rheumatoid arthritis and degenerative arthritis, communication between the native cells in the damage knee causes an increase of stem cells found in the synovial fluid.

A new study in The journal of knee surgery,(3) May 2020 noted that synovial fluid-derived stem cell population increase exponentially in patients with joint injury or disease, pointing to a potential use as a biomarker or as a treatment of some orthopaedic disorders.

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Marc Darrow MD,JD

A Baker’s cyst can be a very confusing knee ailment for some patients. First, it has nothing to do with being a baker, but rather it was named for the surgeon who first described it, Dr. William Baker. Secondly, often it is not explained by the attending physician that the Baker’s cyst itself is not the cause of the patient’s knee problems, but rather a symptom of knee instability and developing osteoarthritis.

Typically a patient will call or email our office asking for help for the problems of Baker’s Cyst. Some of these patients have had the cyst drained before and it has returned. Most tell us that the orthopedist who drained the cyst the first or even second time warned them that the cyst will return and that they will need some type of knee surgery to prevent it from coming back.

One of the reasons it keeps coming back is because the person’s knee has a lot of damage. Here is an example of an email I will get:

Hello Dr Darrow. I have been having pain in my knee. I have been to several doctors and have had an MRI. The MRI says I have a torn meniscus. This is causing me a lot of pain when I walk. A few months ago, I had a cortisone injection in my knee. For a while, my knee felt great. But now that pain is back. I have been told to consider a meniscus surgery by one doctor and a  full knee replacement by another. I also has a Baker’s cyst that has now grown much larger and it causing me great discomfort. I have been told I can drain it, but it will just keep coming back.

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Marc Darrow MD,JD

The majority of total knee replacement patients are overweight or obese and physical activity levels and weight do not appear to change in a high proportion of patients after knee replacement

I was reading a study in the journal Disability and rehabilitation.(1) It was led by Northwestern University. It talked about the weight problems people have after they had total knee replacement and the continued problems the patients had in the inability to losing weight despite the new knee.

This study may come as a surprise to many who think that a knee replacement will help them shed pounds put on by the immobilization caused by their long battle with degenerative knee disease and knee pain.

I want to give some of the learning points here directly from the research so you can get the story directly from the people in the study.

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Marc Darrow MD,JD

In Germany there is a medical procedure called Orthokine in which anti-inflammatory factors are removed from the patient’s blood, manipulated, and then re-injected into the painful areas. It is an anti-inflammatory treatment used to suppress back and joint pain. By admission of its proponents it is only an anti-inflammatory and not a healing remedy.

In the United States it is called Regenokine and is considered a variant of Orthokine because of significant legal and medical issues surrounding the simple fact  that the Orthokine process is not approved for use in the United States.* The US ban has to do with blood manipulation and blood storage.

Orthokine/Regenokine is often confused with Platelet Rich Plasma Therapy, some even confuse it with stem cell therapy. The confusion comes from the belief that all the therapies have something to do with blood being injected into a painful joint. Below I describe the differences in detail.

Almost every email or phone call to our office eventually will ask “where is the research on PRP or stem cell injections?”  We are happy and eager to answer these questions as there is a great collection of research available on both PRP and Stem Cells.Including those published by our institute:

Please see our research here:

• Stem cell therapy for knee osteoarthritis –
• Stem cell therapy as an alternative to hip replacement –
• Treatment of shoulder osteoarthritis and rotator cuff tears with bone marrow concentrate and whole bone marrow injections
• Treatment of Lower Back Pain with Bone Marrow Concentrate

Sometimes we are asked where is the research on Orthokine or Regenokine. That is not as easy to provide. 

Pubmed the government repository of medical papers lists over 8,600 medical papers on PRP. Nearly 10,000 on stem cell therapy.

Only 8 appear for Orthokine, 154 appear under “autologous conditioned serum,” a descriptive term for “heated” or condition blood plasma injections. Under Regenokine there are NONE.

• Obviously the research on Orthokine/Regenokine is not as robust.

Dr. Peter Wehling, the pioneer of Orthokine, invented the technique in the 1980s after noticing that some patients with terrible spinal MRIs had no pain from mechanical problems but patients with less damage on MRI had terrible pain. Dr. Wehling concluded the “wildcard” factor was inflammation.

• The body heals by inflammation, so if inflammation is present the body is trying to heal something, if you stop the inflammation process you stop healing. Inflammation is not the enemy of pain patients, not enough inflammation or not enough healing is.

Let’s go back to Dr. Wehlin: On July 10, 2012 the New York Times reported the following “(Wehling’s treatment Orthokine) might sound similar to another blood-spinning treatment, known as platelet-rich plasma, or PRP., that has gained popularity in the United States in recent years. In that procedure, the goal is to produce a high concentration of platelet cells, which are believed to speed the healing process.

Wehling said his treatment differed from PRP  because he heats the blood before it is spun to increase the concentration of anti-inflammatory proteins, rather than the platelets. The idea is not just to focus on mechanical problems in the joints or lower back but to treat inflammation as a cause of tissue damage as well as a symptom. So there are two things to note – the joint is not being treated – the inflammation is being suppressed. The blood is heated and that is why it cannot be practiced in the United States.”

PLATELET RICH PLASMA, OR REGENOKINE?

PRP injection is a treatment method in which high concentrations of endogenous (your own) platelets are delivered to a specific area of injury in order to stimulate your body’s natural healing response. During the procedure your blood is drawn and placed in a centrifuge to separate the platelet rich plasma from the rest of your blood. This plasma is then injected using ultrasound guidance.

Here lies a crucial difference in the treatment methods.

Both draw blood, but one draws the anti-inflammatory portion, one draws the pro-inflammatory portion. Clearly the two treatments can never be combined.

Regenokine attacks the interleukin-1 (IL-1) inflammation producing system. As a joint continues deeper into a degenerative state, the immune system produces more interleukin-1 to break down dead, dying, diseased tissue to clear the way for new tissue. However, in degenerative joint or disc disease, the immune system can be destroying more tissue that the body can create to replace it. The immune system is destroying cartilage your body needs.

By contrast PRP contains healing agents, or “growth factors.” Let’s look at some of the growth factors and what they do:

• Platelet-derived growth factor (PDGF) is a protein that helps control cell growth and division, especially blood vessels. When more blood (and the oxygen it carries) is delivered to the site of a wound, there is more healing.
• Transforming growth factor beta (or TGF-β) is a polypeptide and is important in tissue regeneration.
• Insulin-like growth factors are signaling agents. They help change the environment of the damaged joint from diseased to healing by “signaling” the immune system to start rebuilding tissue.
• Vascular endothelial growth factor (VEGF) is an important protein that brings healing oxygen to damaged tissue where blood circulation might be damaged or inadequate.
• Epidermal growth factor plays a key role in tissue repair mechanisms.

The PRP is also working to remove dead dying tissue and reduce an overactive immune system from breaking down too much cartilage. BUT, the PRP is also creating new tissue simultaneously.

Stem cell therapy also works in the capacity of removing dead tissue, shutting down an overactive immune breakdown system. It also works by bringing stem cells into a damaged area to facilitate a quicker and somewhat more powerful healing response.

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.