Dr. Jay Kimmel’s Sports Medicine

        Many of our patients at Greater Hartford Orthopedics remain active for longer than ever before. More and more middle age and older men and women continue to exercise and play the sports they enjoy. Unfortunately some of them have knee pain.  In this age group, pain in the knee is often due to osteoarthritis (OA). While OA is frequently associated with aging, it can develop for a variety of reasons including obesity, mal-alignment syndromes or injury.

Usually, osteoarthritis develops over time and tends to worsen with age.  It results from the breakdown of cartilage and fluid in the joint.  Cartilage and fluid are essential components of a joint because they are responsible for cushion and lubrication. When these are lost, repetitive use of the knee can cause the surfaces of the bones to rub against one another leading to pain and stiffness.   In the knee, osteoarthritis can be very symptomatic because the knee is a weight-bearing joint that relies on cushion and lubrication for everyday activities such as walking, sitting, changing positions, and exercise.  Joint fluid therapy is a new form of treatment for patients with osteoarthritis of the knee.  Through a series of injections, joint fluid therapy can provide supplemental fluid and cushion in an osteoarthritic knee.

        It can sometimes be difficult to tell if you have osteoarthritis of the knee.  Common symptoms include pain and stiffness.  Patients tend to have these symptoms in the morning upon waking, when changing positions, such as getting in and out of a chair, and climbing stairs.  This may also be accompanied by swelling, even though there is generally no injury to the knee.  Patients may also experience a sensation of “grinding” coming from the knee, or “buckling” of the knee.  Muscle soreness or weakness of the leg muscles is also common.  The best way to diagnose knee OA is by seeing an orthopedist and having x-rays of the knee.

        There are several treatment options available for patients who have osteoarthritis of the knee.  Each patient with osteoarthritis of the knee presents differently because there are varying degrees of osteoarthritis, ranging from mild to severe.  Therefore, patients may respond to different treatments.  Conservative, or non-operative measures, include rest, ice, and physical therapy.  Anti-inflammatory medication such as Motrin, Ibuprofen and Advil can also help.  Sometimes, a cortisone injection can be performed.  If the osteoarthritis is severe or end-stage, joint replacement may be the only option. Many of our patients wish to remain active but wish to avoid joint replacement. Joint fluid therapy is useful for patients who have not benefited from conservative treatment, but who are not ready for knee replacement.        

The goal of joint fluid therapy is to restore the cushion and fluid in the knee.  Patients with osteoarthritis lack one particular element that is found in cartilage and joint fluid, hyaluronic acid.  Joint fluid therapy involves delivering hyaluronic acid to the joint through a series of injections.  At Greater Hartford Orthopedic Group (GHOG) in Connecticut, Dr. Jay Kimmel is performing joint fluid therapy in the office.   There are a variety of products on the market, however, the particular brands Dr. Kimmel uses are Supartz, Synvisc, and Synvisc-1.  Supartz and Synvisc are available in a series of 3 injections.  The injections are performed in a three-week series, each injection is done a week apart.  Synvisc-1 is a new product which delivers the same amount of hyaluronic acid to the knee, but requires only one injection.  In the office, Dr. Kimmel, or Elizabeth, his physician assistant, will perform the injection.  After the injection many patients return to their activities after 24 hours, however, Dr. Kimmel may advise you to rest for 48 hours.  Many insurance companies require pre-authorization for joint fluid therapy, so the injection or injections may not be done on your initial visit.  

         Many studies have demonstrated the success of Supartz, Synvisc, and Synvisc-1.  With Supartz, studies have shown that pain relief can start as early as after the first injection and can last for up to six months.   Patients treated with Supartz injections demonstrated a 50% decrease in their knee pain.  Clinical studies have also reported favorable results with Synvisc injections.  One study showed patients having pain relief as soon as one week after the injection.  The most pain relief and greatest amount of success were documented at two and three months after the injection.  Similarly, clinical studies of Synvisc-1 have shown that 71% of patients reported pain relief as soon as one month after the injection.

Recently in orthopedics there is increasing interest in using a patient’s own blood to promote healing of chronic soft tissue injuries. Platelets, which are found in the blood, play a very important role in tissue healing. Platelets are traditionally thought of as the component in the blood that helps with clotting. However, recent research has shown that platelets are also very rich in growth factors and proteins that stimulate healing and repair of soft tissue. Platelet rich plasma contains a highly concentrated dose of these platelets. A typical blood specimen contains only 6% platelets. By centrifuging or “spinning down” the blood, the amount of platelets in the plasma increases to 94%. Platelet Rich Plasma(PRP) therapy is taking this mixture of platelets with its inherent healing factors and injecting it at the site of injury.

When there is an injury to a tissue with a good blood supply like muscle or skin, platelets are delivered to the injury site and healing ensues. Unfortunately there are many tissues in the body like tendons which connect muscle to bone and ligaments that connect the bones, that do not have a very good blood supply and subsequently do not heal. Many visits to the orthopedist are due to these injuries to tendons and ligaments around our joints. If you have a minor injury to a tendon( tendonitis )or a mild injury to a ligament( sprain) we will often suggest some combination of rest, non steroidal anti-inflammatory agent such as motrin, home exercises, physical therapy or cortisone injections. If these conservative treatments fail surgery may be suggested. If the injury is more severe such as a complete rotator cuff tear or anterior cruciate ligament tear surgery may be required. Platelet Rich Plasma therapy is a promising new and experimental treatment that may be helpful in preventing surgery and as an aid when surgery is needed.

Platelet rich plasma (PRP) has been used in Europe for the past 20 years in an effort to facilitate healing. While new to orthopedics and sports medicine it has been used safely in other fields such as dentistry for years. This treatment has recently become popularized in the United States and is being used for chronic tendon injuries including tennis elbow, Achilles tendonitis, and patellar tendonitis. There have been multiple animal studies which have demonstrated the effectiveness of PRP treatments. A number of professional athletes have used this treatment. Hinds Ward of the Pittsburgh Steelers reportedly used PRP therapy when he injured his knee prior to the 2009 superbowl to help him recover faster. However, there have been few clinical trials that have been conducted. Most of the literature is based on case studies where the sample size of patients is very small. In two clinical trials, PRP treatment has been used to treat tennis elbow and Achilles tendonitis, with promising outcomes. Mishra et al. evaluated patients with chronic tennis elbow. In their study, 20 patients had failed conservative treatment and were considering surgery. Fifteen patients had PRP injections and 5 patients had a local anesthetic injected instead. Mishra et al. found that patients who received the PRP injection had a 60% improvement in 2 months, 81% improvement in 6 months, and 93% improvement within a year. Also, 94% of those patients returned to their sporting activities. Although these studies have shown favorable outcomes, more clinical trials need to be done to further demonstrate the efficacy of PRP treatment.

In our practice, we have begun to use PRP in the operating room to promote post-operative healing. PRP injected into the surgical site has been shown to decrease inflammation, post-operative blood loss, infection, and the need for narcotics, while simultaneously increasing soft tissue healing. We have used it in ACL reconstructions of the knee and rotator cuff repairs of the shoulder. The blood is drawn in the pre-operative area by the surgical nurse. The surgery is performed. The PRP is placed at the site of the repair at the end of the surgical procedure.

PRP treatment can also be done in the office setting. We are just beginning to do PRP injections in the office for various conditions including tendonitis of the shoulder and elbow. In the office, Elizabeth, my physician’s assistant, will draw your blood. The blood will then be placed in a centrifuge and “spun down” to isolate the platelet rich plasma. This process will take only 5 minutes. I will then inject the PRP into the area of tendonitis. You will be told to rest for a few days and apply ice to the injection site, in case there is some soreness afterwards.

If you feel you are a candidate for PRP therapy or are interested in learning more about PRP treatment please call our office to schedule a consultation.

– written by Jay Kimmel M.D. and Elizabeth McAvoy, PA-C