Marc Darrow MD,JD

We will often see patients who have lingering elbow pain. They continue to receive and remedy themselves with traditional “conservative” treatments that include resting, icing, anti-inflammatory medications and various other health care provided treatments including physical therapy, massage, cortisone injections and even acupuncture. While some will respond to these treatments the patients who come into our office have not. They have been scheduled for one of the many surgical procedures often suggested for treatment of lateral epicondylitis. Most will be recommended to a debridement, the removal of tissue “too far gone,” to be saved. For many, removing tissue may not be their optimal way way to go. These people will reach out to us to discuss the realistic surgical alternatives we can offer. In this report we will discuss PRP and stem cell treatments as well as look at some new research on tennis elbow surgery.

TENNIS ELBOW IN OFFICE WORKERS AND LABORERS

There is a great probability that the people reading this article have been diagnosed with tennis elbow that have never played tennis in their life. We have seen patients with tennis elbow who were carpenters, rock climbers, office workers, landscapers, golfers, and more. Many never having picked up a racquet.

• Tennis Elbow (lateral epicondylitis) is a term for severe elbow tendonitis, or an inflammation, soreness, or pain on the outside (lateral) part of the upper arm near the elbow.
• The cause is usually common extensor tendinosis or a partial tear in the tendon fibers, which connect muscle to the bone. The traditional term tendinitis refers to the acute (recent) inflammatory stage of tendon injury, while the new term, tendinosis refers to the chronic injury when inflammatory cells are no longer seen, but the tendon is worn.
• Symptoms include elbow pain that gradually worsens and radiates outside of the elbow to the forearm and to the back of the hand.

While many of these people have never picked up a racquet, they usually have picked up a shopping cart filled with elbow tapes, braces, and sleeves that they hope will help them.

Patients with tennis elbow may not respond to the conventional treatments of “wait, rest, and medicate for pain relief.” For many patients, this slow track to healing is not on their schedule. Most
patients prefer getting on with their lives by fast-forwarding the healing process. So they try many things. Some work. Some don’t.

WHY TAPE, SLEEVES AND PHYSICAL THERAPY DID NOT HELP YOUR ELBOW.

Some people find great comfort in taping up their elbow or getting elbow sleeves. If it helps, then it is a good thing. For many however, sleeves, kinesiotaping, and ace bandages are not really helpful. Some people get great benefit from physical therapy.

A study from July 2019 (1) had three groups of people (10 in each group) with a new onset of elbow pain go to physical therapy. At the physical therapist’s they would receive treatment and taping.

• Ten patients received kinesiotaping plus exercises
• Ten patients received sham taping (Tape that would not help) plus exercises
• Ten patients received  exercises only.

Findings:

• “Kinesiotaping in addition to exercises is more effective than sham taping and exercises only in improving pain in daily activities and arm disability due to lateral epicondylitis.” In other words, this conservative care option of kinesiotaping did not fix the problem of the elbow degeneration.

But, despite this people still go online and buy expensive elbow braces. Why? As many patients say. “it gives me comfort.”

HEADLINE: ONE TYPE OF TENNIS ELBOW SURGERY, WITH A TRACK RECORD OF “EXCELLENT” RESULTS, IS FOUND TO BE NO MORE EFFECTIVE THAN PLACEBO OR SHAM SURGERY

When conservative treatments do not respond, often a patient is suggested to surgery. In 2018, Australian surgeons made headlines when they published their study in the  American Journal of Sports Medicine (2) comparing tennis elbow surgery to placebo surgery.

Here is what the research team wrote:

“A number of surgical techniques for managing tennis elbow have been described. One of the most frequently performed involves excising (shaving away) the affected portion of the extensor carpi radialis brevis (ECRB, a muscle of the forearm). The results of this technique, as well as most other described surgical techniques for this condition, have been reported as excellent, yet none have been compared with placebo surgery.”

When the surgery was compared to a sham surgery, the doctors concluded: “this study failed to show additional benefit of the surgical excision of the degenerative portion of the ECRB over placebo surgery for the management of chronic tennis elbow.” So the surgical removal of damaged tissue did not help the patient anymore than the conservative treatments. How about regenerative treatments?

PRP AND STEM CELLS FOR TENNIS ELBOW – ARE THEY REALISTIC TREATMENT OPTIONS OR NOT?

Platelet Rich Plasma therapy extracts the healing platelets from your blood and then re-injects the Platelet-Rich Plasma into the injured elbow. The research below from leading medical universities and research centers from around the world helps confirm our own observations of these treatments.

PRP injections vs. Cortisone

In December 2018 a multi-national team of doctors wrote in the journal Current reviews in musculoskeletal medicine (3) compared PRP treatments to cortisone for tennis elbow. They wrote that:

“The response to PRP seems to be favorable when compared to steroid injection for pain management and for patient-reported outcomes in lateral epicondylitis. PRP injection does not seem to have the potential complications associated with a steroid injection such as skin atrophy, discoloration, and secondary tendon tears.” They also noted that in comparison with extracorporeal shockwave, dry needling, or surgical treatments, (PRP injections in tennis elbow seems to be the best-studied intervention.”

• University researchers in India suggest Platelet-rich plasma (PRP) offers a better option for the treatment of lateral epicondylitis. In a comparison of PRP and cortisone injections, the doctors say  PRP is a superior treatment option in the long-term. (4)

• A second study published in the Indian journal of orthopaedics compared single injection of platelet-rich plasma for tennis elbow as compared with single injections of triamcinolone (corticosteroid) and placebo (normal saline) over a short term period.
  • Both the PRP and triamcinolone groups had better pain relief at 3 and 6 months as compared to normal saline group, but at 6 months followup, the PRP group had statistically significant better pain relief than triamcinolone group.
  • In the triamcinolone group, 13 patients had injection site hypopigmentation (loss of skin color) and 3 patients had subdermal (skin and subdermal fat layer) atrophy. (5)

• In the journal The Physician and sports medicine, doctors found steroid could slightly relieve pain and significantly improve function of elbow in the short-term (2 to 4 weeks, 6 to 8 weeks). PRP appears to be more effective in relieving pain and improving function in the intermediate-term (12 weeks) and long-term (half year and one year). Considering the long-term effectiveness of PRP, the researchers recommend PRP as the preferred option for tennis elbow.(6)

• Doctors from teaching universities in Thailand examined injections of cortisone, autologous blood injection (simple blood injection) and PRP.  What they found was the blood injection and the PRP injection provided superior results to cortisone for pain reduction and functional improvement. The autologous blood injection had a higher rate of site complication that was significant enough to note.(7)

• A November 2019 study compared the effectiveness of Platelet Rich Plasma injections versus autologous blood injection (blood without making it Platelet Rich), and cortisone. The findings were “PRP was associated with more improvement in pain intensity and 29 function in the long-term than the comparators.”(8)

Long term-benefit of PRP vs Cortisone

• Dutch researchers writing in the American Journal of Sports Therapies documented the positive effects of PRP on tennis elbow. Treatment of patients with PRP reduced elbow pain and increased function significantly, exceeding the effect of corticosteroid injection even after a follow-up of 2 years.”(9)
• British doctors agree – research in the British Journal of Sports Medicine says cortisone should never be used and that injections therapies including PRP can be effective and excellent long-term treatments for elbow pain.(10)

Long term-benefit of PRP vs Physical Therapy

• In some of the more research reported in the surgical journal – Journal of Hand and Microsurgery doctors reviewed and presented their evidence on the effectiveness of PRP injections. They found PRP injections have an important and effective role in the treatment of elbow instability. Here is what they wrote:
  • The majority of sufferers recover within 1 year with conservative management which includes physical therapy. The most effective treatment for chronic lateral epicondylitis, however, is argued amongst experts.
  • In the opinion of this study, after review of the literature, PRP injections have an important and effective role in the treatment of debilitating tennis elbow pathology, in cases where physical therapy has been unsuccessful.
  • Previously, cases that persisted despite physical therapy have been treated with corticosteroid injections. Steroid injections are reported to give short-term pain relief, however the proven recurrence rates and complications (including dermal depigmentation, subcutaneous atrophy, and a theoretical risk of increased tendon rupture) should limit their use.
  • PRP has been shown to provide a continuing long-term benefit in cases of chronic lateral epicondylosis, in the recent literature. It is superior to autologous blood injection injections and placebo/dry needling procedures.(11)

PRP can eliminate the need for elbow surgery

A team of researchers in the United Kingdom wrote in the Journal of orthopaedics (12)

• “Our study adds to the evidence that PRP injection for intractable lateral epicondylitis of the elbow is an acceptable and useful treatment with improvement in symptoms in 56 out of 64 patients (87.5%). It adds to the literature in that we have tried to ascertain the effect of PRP on reducing the need for a complex, risk laden, surgical intervention. . .we consider PRP injection, for intractable lateral epicondylitis of the elbow, not only a safe but also very effective tool in reducing symptoms and have shown it has reduced the need for surgical intervention in this difficult cohort of patients.”

Chronic elbow instability causing tennis elbows in people with physically demanding jobs and frequency of cortisone injections.

A study published in January 2021 (13) can offer evidence that strengthening and tightening the ligaments and tendons of the elbow can help with elbow pain. This is what the study said:

“Instability can coexist and may be associated with refractory lateral epicondylitis. The risk factors of instability associated with refractory lateral epicondylitis are heavy labor and multiple steroid injections.”

This is what I see in my patients. A person comes in with a history of elbow pain. They go to a few doctors, get the traditional treatments and do not get pain alleviation. Mostly in part because they continue at a job that is considered “heavy labor.” So they go onto get a few cortisone injections to help them at their jobs. The cortisone injections over time has lead to a wearing down or thinning of the ligaments and tendons of the elbow causing instability. Your bones are floating around in a hypermobile, unstable state and are compressing and impinging on nerves and other soft tissue. This instability is what PRP and stem cell therapy can address. By stabilizing the elbow, the tennis elbow pain can now be managed.

BONE MARROW DERIVED STEM CELLS FOR THE TREATMENT OF TENNIS ELBOW

A study in the Journal of natural science, biology, and medicine (14) found that a bone marrow aspirate (containing plasma rich in growth factors and mesenchymal stem cells) injection was an effective treatment for tennis elbow.

Bone marrow aspirate injections contain plasma rich in growth factors and mesenchymal stem cells

In this research a total of 30 adult patients with previously untreated tennis elbow were administered a single injection of bone marrow aspirate (stem cells and platelets).

• This concentrate was made by centrifugation of iliac crest bone marrow aspirat.
• The researchers concluded: Treatment of tennis elbow patients with single injection of bone marrow aspirate showed a significant improvement in short to medium term follow-up. They suggest that in the future, such growth factors and/or stem cells based injection therapy can be developed as an alternative conservative treatment for patients of tennis elbow, especially who have failed non-operative treatment before surgical intervention is taken.

Let’s point out again bone marrow aspirate contains plasma rich in growth factors and mesenchymal stem cells. No separate PRP treatment was given.

More recently a 2018 study in the Journal of orthopaedics (15) commented on the above study:

“Bone marrow aspirate concentrate (BMAC) is an emerging, novel treatment for various bone and cartilage pathology and injury. Similar to other orthobiologic intra-articular injections like hyaluronic acid and PRP, BMAC gives patients the opportunity to restore the natural microenvironment of their damaged or diseased tissue. Bone marrow concentrate is commonly taken from pelvic bone, and contains mesenchymal and hematopoetic stem cells, platelets, growth factors, cytokines, and anti-inflammatory and immunomodulatory cells. . . Further evaluating the efficacy of bone marrow injections, thirty patients who were untreated for Lateral Epicondylitis were evaluated with the Patient-rated Tennis Elbow Evaluation (PRTEE) prior to and following the treatment of a single administration of Iliac Bone Marrow Aspirate. – This concentrate, composed of iliac bone marrow aspirate. . . was effective in simplicity and safety, avoiding further complications as other modes of treatment. Evaluated at 2, 6, and 12 weeks after administration, these patients showed drastic improvement in the two week evaluations, thus showing the efficacy of this treatment’s recovery time. Although (the authors} explained the limitation of their study in long term treatment, they believe that this treatment, when paired with growth factor and other stem cell treatment, can be an effective alternative in lieu of surgery.”

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 Giray E, Bingul DK, Akyuz G. The effectiveness of kinesiotaping, sham taping or exercises only in treatment of lateral epicondylitis: A randomized controlled study. PM&R. 2019 Jan 4.
2 Kroslak M, Murrell GAC. Surgical Treatment of Lateral Epicondylitis: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Clinical Trial. Am J Sports Med. 2018 Mar 1:363546517753385. doi: 10.1177/0363546517753385.
3 Kwapisz A, Prabhakar S, Compagnoni R, Sibilska A, Randelli P. Platelet-Rich Plasma for Elbow Pathologies: a Descriptive Review of Current Literature. Current reviews in musculoskeletal medicine. 2018 Sep 25:1-9.
4 Yadav R, Kothari SY, Borah D.  Comparison of Local Injection of Platelet Rich Plasma and Corticosteroids in the Treatment of Lateral Epicondylitis of Humerus. J Clin Diagn Res. 2015 Jul;9(7):RC05-7. doi: 10.7860/JCDR/2015/14087.6213.
5 Seetharamaiah VB, Gantaguru A, Basavarajanna S. A comparative study to evaluate the efficacy of platelet-rich plasma and triamcinolone to treat tennis elbow. Indian journal of orthopaedics. 2017 May;51(3):304.
6 Mi B, Liu G, Zhou W, Lv H, Liu Y, Wu Q, Liu J. Platelet rich plasma versus steroid on lateral epicondylitis: meta-analysis of randomized clinical trials. The Physician and Sportsmedicine. 2017 Apr 3;45(2):97-104.
7 Arirachakaran A, Sukthuayat A, Sisayanarane T, Laoratanavoraphong S, Kanchanatawan W, Kongtharvonskul J. Platelet-rich plasma versus autologous blood versus steroid injection in lateral epicondylitis: systematic review and network meta-analysis. J Orthop Traumatol. 2015 Sep 11.
8 Tang S, Wang X, Wu P, Wu P, Yang J, Du Z, Liu S, Wei F. Platelet-rich plasma versus autologous blood versus corticosteroid injections in the treatment of lateral epicondylitis: a systematic review, pairwise and network meta-analysis of randomized controlled trials. PM R. 2019 Nov 17. doi: 10.1002/pmrj.12287. [Epub ahead of print]
9 Gosens T, Peerbooms JC, van Laar W, den Oudsten BL. Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: a double-blind randomized controlled trial with 2-year follow-up. Am J Sports Med. 2011 Jun;39(6):1200-8. Epub 2011 Mar 21.
10 Dong W, Goost H, Lin XB, Burger C, Paul C, Wang ZL, Kong FL, Welle K, Jiang ZC, Kabir K. Injection therapies for lateral epicondylalgia: a systematic review and Bayesian network meta-analysis. Br J Sports Med. 2015 Sep 21. pii: bjsports-2014-094387. doi: 10.1136/bjsports-2014-094387.
11 Murray DJ, Javed S, Jain N, Kemp S, Watts AC. Platelet-Rich-Plasma Injections in Treating Lateral Epicondylosis: a Review of the Recent Evidence.J Hand Microsurg. 2015 Dec;7(2):320-5. doi: 10.1007/s12593-015-0193-3. Epub 2015 Jul 8.
12 Hastie G, Soufi M, Wilson J, Roy B. Platelet rich plasma injections for lateral epicondylitis of the elbow reduce the need for surgical intervention. Journal of orthopaedics. 2018 Mar 1;15(1):239-41.
13 Kholinne E, Liu H, Kim H, Kwak JM, Koh KH, Jeon IH. Systematic Review of Elbow Instability in Association With Refractory Lateral Epicondylitis: Myth or Fact?. The American Journal of Sports Medicine.:0363546520980133.
14 Singh, A., Gangwar, D. S., & Singh, S. (2014). Bone marrow injection: A novel treatment for tennis elbow. Journal of Natural Science, Biology, and Medicine, 5(2), 389–391. http://doi.org/10.4103/0976-9668.136198
15 Tarpada SP, Morris MT, Lian J, Rashidi S. Current advances in the treatment of medial and lateral epicondylitis. J Orthop. 2018 Feb 2;15(1):107-110. doi: 10.1016/j.jor.2018.01.040. PMID: 29657450; PMCID: PMC5895908.

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Marc Darrow MD,JD

There is a difference between a “true” sciatica and the phenomena of “pseudo sciatica,” or “fake sciatica.” If you have been diagnosed with sciatica you may have been one of the people where it took some time and a lot of tests and examinations to confirm that in fact you had sciatica or you did not have sciatica but you had sciatica like symptoms. Even then there may be still be some doubt about your diagnosis.

This article will discuss possible treatments for sciatica-like symptoms. If you do not have back pain, but you do have numbness, burning pain, weakness or other neurologic type symptoms that radiates into your legs and feet, treatments such as Platelet Rich Plasma Therapy and Stem Cell Therapy will likely not be effective for you. What this article will focus on is if you have a true sciatica or a pseudo sciatica. In the case of pseudo sciatica, Platelet Rich Plasma Therapy and Stem Cell Therapy may be able to help this condition.
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Marc Darrow MD,JD

Knee pain is one of the most common problems we see at our institute. When it comes to a more active individual, there can be many knee pain causes. One possible cause is Iliotibial band syndrome or more often referred to as IT band syndrome. It is also commonly referred to by patients as “pain on the outside of my knee.” The people I see with this problem are usually long distance runners and those who are starting up a very aggressive exercise routine and they overdo it.

The pain of IT band syndrome is very familiar to those who have it and those who treat it. It is usually located not only on the outside of the knee but on the length of the the outer thigh from hip to knee. What causes this pain? As just mentioned, overuse injury especially in distance running and over doing it when you start a new exercise program. As you bend your knee, the IT band at its attachment at the shin bone can impinge or trap soft tissue beneath it causing pain. The friction of rubbing against this soft tissue can also thin out and wear away at the Iliotibial band itself.

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Marc Darrow MD,JD

In this article I will present research on the use of stem cell therapy treatments for knee osteoarthritis. I will discuss published research by the Darrow Stem Cell Institute on the use of bone marrow derived stem cells. I also invite you to ask your questions using the form below about your knee pain.

Stem Cells Instead of Knee Replacement?

Over the years it became clear to many researchers that knee replacement had to be redefined and disputed as the gold standard of knee osteoarthritis, “bone-on-bone,” treatment. Other doctors, however, had already decided to abandon joint replacement and explore growing tissue as the new standard of care. The thinking was simple—why remove bone and tissue when these could be repaired and rejuvenated?
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Marc Darrow MD,JD

Over the years we have seen many patients with problems and challenges related to migraine headaches. Of course the biggest challenge these new patients are facing was finding good, effective, long-term relief. Headache is a very complex subject. Headaches can be caused by many things. In my article here we will concentrate on the musculoskeletal causes of headache: neck ligament damage and neck muscle weakness caused by tendon weakness and damage.

In the Journal of Headache Pain (December 2017), (1) researchers examined the relationship and cause of  migraine, co-existing tension-type headache, and neck pain in headache patients. One hundred forty-eight people participated in this study.

• Out of 148 persons with migraine, 100 (67%) suffered from co-existing tension-type headache and neck pain.
• Only 11% suffered from migraine only.
• Persons with migraine and co-existing tension-type headache and neck pain had lower level of physical activity and psychological well-being, higher level of perceived stress and poorer self-rated health compared to healthy controls.
• They reported reduced ability to perform physical activity owing to migraine (high degree), tension-type headache (moderate degree) and neck pain (low degree). The most burdensome condition was migraine, followed by tension-type headache and neck pain.

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Marc Darrow MD,JD

Patients will often come into our office with an MRI, low back pain and a diagnosis of sacroiliac joint dysfunction. They are in our office because they may have been told that they should consider a surgical recommendation to spinal fusion. For many of these people, the MRI was the confirmation that their surgeon needed to go ahead with the surgical recommendation. For many patients, this may have been the same doctor who had taken them through a course of conservative treatments. These treatments may have included long bouts with anti-inflammatory medications, back braces, physical therapy, and cortisone injections.

All of these treatments did not help them. Why? A recent study in the Clinical Spine Journal (1) offers the suggestion that sacroiliac joint dysfunction patients do not get treatment relief because they do not have sacroiliac joint dysfunction. This may be somewhat difficult for you to believe because all along you have been told you have SI joint pain.

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Published research in the medical literature from the Darrow Stem Cell Institute

Treatment of shoulder osteoarthritis and rotator cuff tears with bone marrow concentrate and whole bone marrow injections

The Darrow Stem Cell Institute has published new research on the treatment of shoulder osteoarthritis and rotator cuff tears with bone marrow derived stem cells.The research appears in the peer-reviewed journal Cogent Medicine. The study can be found here in its entirety: Treatment of shoulder osteoarthritis and rotator cuff tears with bone marrow concentrate and whole bone marrow injections with a June 20, 2019 publication date.

Treatment of shoulder osteoarthritis and rotator cuff tears with bone marrow concentrate and whole bone marrow injections
Marc Darrow, Brent Shaw, Nicholas Schmidt, Gabrielle Boeger & Saskia Budgett | Udo Schumacher (Reviewing editor)
Article: 1628883 | Received 02 Jan 2019, Accepted 30 May 2019, Accepted author version posted online: 18 Jun 2019, Published online: 20 Jun 2019

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Marc Darrow MD,JD

One of the most fascinating subjects in health is caloric restriction and fasting, since both have been shown to promote healing, health, and longevity.

• Short-term caloric restriction suppressed oxidative stress and improved cardiac function.(1)
• Caloric restriction increases the level of the hormone DHEA (short for dehydroepiandrosterone) in muscle and blood, suggesting that DHEA might partially mediate anti-aging, anti-obesity, and
  health-promoting effects.(2)
• Caloric restriction has been found to reverse the impairment caused by a high-fat diet with very high energy efficiency in a short period.(3) In the context of joint repair, caloric restriction becomes especiallyintriguing.
• Caloric restriction may be beneficial for wound healing efficiency in aging individuals.(4)

Fasting triggered stem cell-based regeneration

In 1985, doctors at the University of Southern California released research showing that fasting triggered stem cell-based regeneration. They found that cycles of prolonged fasting not only protect against immune system damage, but also induce immune system regeneration, shifting stem cells from a dormant state to a state of self-renewal.

Such findings have significant implications for healthier aging, as the decline in immune system function with aging contributes to increased susceptibility to disease. Calorie restriction with adequate nutrition is the only nongenetic intervention, and the most consistent nonpharmacological one, that both extends the lifespan and reduces inflammation.(5,6)

Inflammation and caloric restriction

Arthritis is related to inflammation in the joint tissue. Reducing inflammation through proper food choices and diet is something I recommend to all my patients. Then why do I use the  nflammation of regenerative medicine to heal the body? Consider the following precepts:

1. Musculoskeletal pain and arthritis is often caused by chronic inflammation that is uncontrolled.

2. Regenerative medicine causes a controlled, short burst of inflammation, which is needed to initiate the growth of new tissue.

3. The short burst of inflammation brings new healing cells to the injured or worn tissue, stimulating new tissue growth which stops the chronic inflammation.

Foods that may aggravate arthritis and should be minimized in the diet:

• Foods high in saturated fat (e.g., dairy, red meat, and baked goods)
• Coffee (because of the high acid content)
• Sugary foods
• Refined grains (e.g., refined pasta, white rice, and white breads)
• Refined or processed foods (if it’s in a box or a can, it’s processed)
• Alcohol

Foods that help lower inflammation in the body and should be mainstays of the diet:

Vegetables and certain fruits (create an alkaline environment)

• Whole grains, such as brown rice and bulgur wheat
• Sources of omega-3 fatty acids, such as fatty fish (e.g. salmon and mackerel), fish oil supplements, and walnuts
• Lean protein sources (e.g., chicken, turkey, or beans)
• Green tea

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 Kobara M, Furumori-Yukiya A, Kitamura M, Matsumura M, Ohigashi M, Toba H, Nakata T. Short-term caloric restriction suppresses cardiac oxidative stress and hypertrophy from chronic pressure overload. J Card Fail. 2015 May 13. pii: S1071-9164(15)00127-X. doi: 10.1016/j.cardfail.2015.04.016. [Epub ahead of print.]
2. Yokokawa T, Sato K, Iwanaka N, Honda H, Higashida K, Iemitsu M, Hayashi T, Hashimoto T. Dehydroepiandrosterone activates AMP kinase and regulates GLUT4 and PGC-1α expression in C2C12 myotubes. Biochem Biophys Res Commun. 2015 May 15. pii: S0006-291X(15)00908-0. doi: 10.1016/j. bbrc.2015.05.013. [Epub ahead of print.]
3. Gong H, Han YW, Sun L. The effects of energy intake of four different feeding patterns in rats. Exp Biol Med (Maywood). 2015 May 12. pii: 1535370215584890. [Epub ahead of print.]
4.  Yanai H, Toren D, Vierlinger K, Hofner M, Nöhammer C, Chilosi M, Budovsky A, Fraifeld VE. Wound healing and longevity: lessons from long lived αMUPA mice. Aging (Albany, NY). 2015 Mar;7(3):167-76. [Erratum: Aging 2016.]
5. Wu S. Fasting triggers stem cell regeneration of damaged, old immune system. USC News. 2014 June 5. http://news.usc.edu/63669/fasting-triggersstem-cell-regeneration-of-damaged-old-immune-system
6. Testa G, Biasi F, Poli G, Chiarpotto E. Calorie restriction and dietary restriction mimetics: a strategy for improving healthy aging and longevity. Curr Pharm Des. 2013 Sep 26. [Epub ahead of print.]

Marc Darrow MD,JD

Systemic and local side-effects of corticosteroid injections including joint destruction

A patient will often come into our office with conflicting ideas about cortisone injections. The patient will tell us that his/her other doctors told them that cortisone injections are safe, effective, and will help their pain, if used sparingly. But, intuitively, the patient had doubts and concerns.

But as this patient continued to wait for a surgery, decisions had to be made as to how much pain management would be needed to “hold them over,” until the surgical date.

Corticosteroids are powerful anti-inflammatory substances. They are not used to relieve pain, but rather, to reduce inflammation, which in turn can lessen a patient’s level of discomfort. Numerous studies over the years have shown that prolonged use of cortisone will eventually cause degenerative joint disease in the joints they are injected into.

Understanding the possible complications of corticosteroid injections

Here are some of the most recent papers reminding doctors about the possible side effects of corticosteroids:

A January 2021 (1) study issued this statement:

“The current evidence would suggest that the use of corticosteroids provides moderate short-term benefit for reducing pain and improving functioning. These benefits generally last several weeks without long-term effectiveness. In addition to its limited short-term effectiveness, there are multiple potential adverse effects including toxicity to articular cartilage and numerous systemic side effects such as increases in blood glucose levels, a reduction in immune function, and an increased risk of infections.”

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Marc Darrow MD,JD

Most of the people that contact our office looking for treatment for their thumb pain have already had a long history of treatments with limited success. In fact, many will confess that their doctors are now recommending pain management (anti-inflammatories and painkillers) as their primary treatments now that splints, physical therapy, and a generous amount of ice are no longer helping. These people will receive pain management until the decision is made to go to surgery or “live with it.” For many, the benchmark of when to proceed to surgery is when cortisone injections fail to offer relief and is in fact giving the person more pain.

So what do we do for these bone on bone thumb people who have basically lost the use of the hands because they have no grip strength and are being pain managed? We offer a physical examination, and assessment of their pain and functional challenges, and when appropriate a recommendation for stem cell therapy into the thumb joint.

Can stem cell therapy help avoid surgery?

Surgery should always be considered the last option. For some people, damage in the joint is so severe and significant that surgery may be the only way. For many others, surgery can realistically be avoided and the thumb joint rebuilt with regenerative medicine injections.

Why should you avoid surgery? Let’s let the surgeons tell us.

Concerns surrounding trapeziometacarpal surgery.

Trapeziometacarpal joint osteoarthritis or rhizarthrosis is degeneration at the trapezium bone at the wrist and the first metacarpal bone of the thumb. The Trapeziometacarpal joint is a tricky joint to repair with surgery. This according to surgeons publishing research in the American Journal of hand surgery (June 2019). The surgeons expressed concerns that failure rates of trapeziometacarpal implants were considered high because of aseptic loosening, dislocation, and persisting pain.(1) This followed an April 2018 study (2) that also questioned whether thumb joint replacement surgery at the trapeziometacarpal joint provided significant benefits for the patient.

A brief look at this study reveals that doctors looked at four women diagnosed with stage III osteoarthritis at the Trapeziometacarpal who underwent total joint replacement surgery.

• What the surgeons found was the surgery was able to restore some thumb function but did not fully replicate the movements of a healthy trapeziometacarpal joint.

The irony is is that people have this surgery because they have limited range of motion and functionality of the thumb. Many came out of the surgery the same way. Now the goal of surgery differs for many patients. For some, it is pain relief, but for many it is a return to normal thumb motion so that they can return to work or increase the quality of life in retirement. Pain relief while a successful benefit of surgery, is not for many, the goal of restoring functionality to their thumb. Pain relief and restoration of movement is.

Trapeziectomy concerns

Trapeziectomy is the removal of the trapezium bone at the thumb’s base. Why remove a bone, even a small one? Because the bone is thought to be the primary cause of pain as it has become misshapen by osteoarthritis. In the trapeziectomy with LRTI surgery, a ligament reconstruction procedure is also performed to help the thumb function better anatomically. To someone who uses their hands a lot, as in physically demanding work, the recover time of this procedure is 4 to 6 months. If successful.

Why say, if successful? A study in the medical journal Hand.(3)

Here we have a study from doctors at the University of Massachusetts Medical School. In this study the patient charts of 179 patients who had a thumb surgery were examined. Noted is that 21 patients had both thumbs undergo surgery.

The patients in this study had:

• simple trapeziectomy with or without LRTI and with or without Kirschner wire stabilization, or a Weilby procedure. (Tendon reconstruction replaces the void left by the bone removal).
• The average follow-up was 11.6 months
• Seventy hands had a postoperative complication. (That is 70 out of 200 or 35%).
• Ten of these complications were considered major, defined as requiring antibiotics, reoperation, or other aggressive interventions. (That is 5% of all patients).

CONCLUSIONS: Patients undergoing trapeziectomy with LRTI or Weilby had a greater incidence of reported complications when compared with trapeziectomy alone. These results suggest an advantage of simple trapeziectomy.

Why is there a risk that total joint replacement of the Trapeziometacarpal will not reduce pain?

A study from March 2020 (4) suggests that total joint replacement of the trapeziometacarpal joint provides good restoration of the thumb motion and pain relief in most patients. But there is also a risk of no improvement following the operation. The purpose of this study was to identify patients at risk of no clinically important improvement following operative treatment of osteoarthritis of the TMC joint.

• The researchers included 287 consecutive patients (225 women, 62 men) treated with total joint replacement of the trapeziometacarpal joint due to osteoarthritis with an average age of 58.9 years (range 41-80) in a prospective cohort study.
• Looking for who would have the greatest risk for no improvement following the surgery, the researchers found there was an increased risk of no clinically important improvement in hand function for patients with high preoperative grip strength. Also, we found an increased risk of no clinically important improvement in female patients.

But I am young, I need the surgery to get back to work or sport activities

Above we spoke about the realistic 3 – 6 month recovery time that will include splints, medications, therapies. Some doctors believe that the surgical repair of Trapeziometacarpal osteoarthritis is too aggressively recommended and this can lead to unwanted complication.

A study in the journal Hand Surgery and Rehabilitation, (5) they suggests:

“The demand for surgical treatment is growing and the patients are becoming younger, adding to the challenge. Surgery can only be proposed after failure of well-conducted conservative treatment and requires a complete X-ray assessment. . . The ideal arthroplasty (joint replacement) technique has yet to be defined but nevertheless, the chosen technique must be well-suited to the patient’s condition. Although many studies have been published on this topic, they do not help us define the treatment indications.

Prospective studies focusing on the patient rather than evaluating a certain surgical technique are needed. Trapeziectomy with or without ligament reconstruction is still considered the gold standard, but the challenges associated with treating its complications limit its indications. Arthrodesis, interposition or arthroplasty are also viable therapeutic options. The patient must be sufficiently informed to be able to contribute to choosing the indication.”

PRP injection can help rebuild the thumb joint. A comparison of PRP to cortisone

Above I presented the studies from the surgeons above the challenges they face providing thumb surgery. In this section I will present the options that include Platelet Rich Plasma injections and stem cell therapy injections.

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 into the thumb/wrist area to stimulate healing and regeneration. PRP puts specific components in the blood to work. Blood is made up of four main components; plasma, red blood cells, white blood cells, and platelets. Each part plays a role in keeping your body functioning properly. Platelets act as wound and injury healers. They are first on the scene at an injury, clotting to stop any bleeding and immediately helping to regenerate new tissue in the wounded area.

A 2018 study in the journal Cartilage (6) offered this comparison between PRP injections and cortisone injections. Before I start with this study I would like to point out that many people reach out to me and tell me how painful the actual cortisone injection was for them. The problem is the size of the needle and the size of the joint space. When we inject into this area we typically use a freeze spray and very fine needles. This provides the patient with a lot of comfort during the procedure. Also we do not offer a single injection of PRP. We inject into various areas of the wrist and thumb area to maximize the healing effect of the PRP injection.

To the research – the summary learning points:

• Various systematic reviews have recently shown that intra-articular platelet-rich plasma can lead to symptomatic relief of knee osteoarthritis for up to 12 months. There exist limited data on its use in small joints, such as the trapeziometacarpal joint (TMJ) or carpometacarpal joint (CMCJ) of the thumb.
• A prospective, randomized, blind, controlled, clinical trial of 33 patients with clinical and radiographic osteoarthritis of the trapeziometacarpal joint (grades: I-III) was conducted.
• Group A patients (16 patients) received 2 ultrasound-guided IA-PRP injections, while group B patients (17 patients) received 2 ultrasound-guided intra-articular methylprednisolone and lidocaine injections at a 2-week interval.
  • Patients were evaluated prior to and at 3 and 12 months after the second injection.
  • After 12 months’ follow-up, the IA-PRP treatment has yielded significantly better results in comparison with the corticosteroids, in terms of pain relief, better function, and patients’ satisfaction.

A study published in January 2021 compared PRP to cortisone in patients with trapeziometacarpal joint arthritis

A prospective, randomized, blind, controlled, clinical trial of 33 patients with clinical and radiographic osteoarthritis of the TMJ (grades: I-III) was conducted.(7)

• Group A patients (16 patients) received 2 ultrasound-guided intra-articular PRP injections, while group B patients (17 patients) received 2 ultrasound-guided intra-articular methylprednisolone and lidocaine injections at a 2-week interval.
• Patients were evaluated prior to and at 3 and 12 months after the second injection using the visual analogue scale (VAS) 100/100, shortened Disabilities of the Arm, Shoulder, and Hand Questionnaire (Q-DASH), and patient’s subjective satisfaction.
• After 12 months’ follow-up, the intra-articular PRP treatment has yielded significantly better results in comparison with the corticosteroids, in terms of VAS score, Q-DASH score , and patients’ satisfaction. Corticosteroids offer short-term relief of symptoms, but intra-articular PRP might achieve a lasting effect of up to 12 months in the treatment of early to moderate symptomatic trapeziometacarpal joint arthritis.

Doctors at the University of Malaga in Spain presented this case study of a concert pianist helped by PRP

This case review (8) was published in October 2019:

“Thumb carpometacarpal osteoarthritis is a progressively disabling, debilitating condition presenting with thumb base pain and hand functional impairment. Platelet-rich plasma has been used widely for the management of musculoskeletal pathologies, osteoarthritis being among them.

• A 59-year-old male professional pianist presented with chronic, mild onset of right thumb base pain involving a progressive lack of pinch strength in his right hand, and severe difficulties with playing.
• Three PRP injections were administered to the Thumb carpometacarpal joint on a 1-week interval regime.
• Clinical outcomes were assessed by using standard scoring scales including those for pain, grip and pinch strength
• Functional outcome was excellent according to patient’s capability with daily living activities and specific playing demands.
• At 12 months follow-up, no recurrences or complications were identified, with the musician returning to his previous level of performance 2 weeks before the end of this period.

“Patient self-reported satisfaction was high and he reported to return to his routine piano activity with no limitations. This case-based review study documents the clinical efficacy of PRP treatment from both functional and perceived-pain perspectives in a professional pianist. Presenting this case, our aim is to draw attention of healthcare providers dealing with Thumb carpometacarpal osteoarthritis to PRP as a safe, beneficial therapy for this condition which needs further assessment in randomized controlled trials.”

Stem Cell Therapy for thumb osteoarthritis

In our experience of over 23 years seeing patients with thumb osteoarthritis we have seen positive results with PRP and with bone marrow derived stem cell. There is research coming suggesting that the positive effects of stem cell therapy studied and documented in the large joints, the hips and knees for example, can be demonstrated in the small joints, those of the thumb for example. This was suggested and shown by research in the journal Plastic and reconstructive surgery. Global open. (9)

Stem cells offered in the thumb region act in the same manner as those injected into the knee. In our observations we have noted:

• We found that in the short-term, receiving multiple injections into a painful joint is more effective than receiving a single stem cell injection.
• Functionality score increased after first treatment, illustrating that patients experienced an immediate benefit in performing everyday activities with less difficulty.
• By the second injection, patients began to report improvement with pain at rest. Patients then experienced additional decreases in resting pain with each treatment thereafter.
• The increase in mean functionality score with successive stem cell treatments shows that increasing the number of BMC treatments improves patient performance in daily activities.

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 Ganhewa AD, Wu R, Chae MP, Tobin V, Miller GS, Smith JA, Rozen WM, Hunter-Smith DJ. Failure Rates of Base of Thumb Arthritis Surgery: A Systematic Review. The Journal of hand surgery. 2019 Jun 28.
2 D’Agostino P, Dourthe B, Kerkhof F, Vereecke EE, Stockmans F. Impact of Osteoarthritis and Total Joint Arthroplasty on the Kinematics of the Trapeziometacarpal Joint: A Pilot Study. The Journal of hand surgery. 2018 Apr 1;43(4):382-e1.
3 Brandt KD, Radin P, Dieppe P, Putte L. Yet more evidence that osteoarthritis is not a cartilage disease. Ann Rheum Dis. 2006;65(10):1261-1264.
4 Mosegaard SB, Stilling M, Hansen TB. Risk factors for limited improvement after total trapeziometacarpal joint arthroplasty. Health and Quality of Life Outcomes. 2020 Dec;18:1-8.
5 Gay AM, Cerlier A, Iniesta A, Legré R. Surgery for trapeziometacarpal osteoarthritis. Hand Surgery and Rehabilitation. 2016 Sep 30;35(4):238-49.
6 Malahias MA, Roumeliotis L, Nikolaou VS, Chronopoulos E, Sourlas I, Babis GC. Platelet-Rich Plasma versus Corticosteroid Intra-Articular Injections for the Treatment of Trapeziometacarpal Arthritis: A Prospective Randomized Controlled Clinical Trial. Cartilage. 2018 Oct 20:1947603518805230.
7 Malahias MA, Roumeliotis L, Nikolaou VS, Chronopoulos E, Sourlas I, Babis GC. Platelet-rich plasma versus corticosteroid intra-articular injections for the treatment of trapeziometacarpal arthritis: a prospective randomized controlled clinical trial. Cartilage. 2018 Oct 20:1947603518805230.
8 Medina-Porqueres I, Martin-Garcia P, Sanz-De Diego S, Reyes-Eldblom M, Cantero-Tellez R. Platelet-rich plasma for thumb carpometacarpal joint osteoarthritis in a professional pianist: case-based review. Rheumatology international. 2019 Oct 14:1-9.
9 Murphy MP, Buckley C, Sugrue C, Carr E, O’Reilly A, O’Neill S, Carroll SM. ASCOT: Autologous Bone Marrow Stem Cell Use for Osteoarthritis of the Thumb-First Carpometacarpal Joint. Plast Reconstr Surg Glob Open. 2017 Sep 19;5(9):e1486. doi: 10.1097/GOX.0000000000001486. PubMed PMID: 29062653; PubMed Central PMCID: PMC5640358.

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