Jan 24, 2017

Dr. Miller: Rest, ice, and stretching are not the only ways to repair tendon injuries. We're going to talk about some of the new treatments next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi, I'm Dr. Tom Miller and I'm here with Nick Monson. He's a physician here at the University of Utah in the Department of Orthopedics. He's a non-operative physician and he specializes in sports medicine. Nick, what's the story? I understand there are some new treatments out there to help with folks who have tendon injuries that have become chronic.

Dr. Monson: Well, one of the things that we've been really looking at over the last decade or two is the usage of ultrasound and the ability to find issues within tendons or joints or different areas of the body by an in-office imaging modality which is ultrasound, kind of like looking at babies. But now, rather than just looking at babies, you can actually look in and see a tendon. Then, what you can do is you find that area of pathology or the area of irritation within a tendon. You can actually see it with the ultrasound, which makes it much easier for us to actually find approaches to attack that area of issue in patients.

The areas develop typically from overuse. It also happens because tendons just notoriously don't have a great blood supply to them, and blood is what brings the healing factors to our body. So when you don't have that healing component coming to the tendon, it has a hard time healing. That's the way that we've addressed it.

Dr. Miller: So how do you use the ultrasound to guide treatment? And what are these treatments that you're using now?

Dr. Monson: Yeah. So one option is something called PRP, platelet-rich plasma. There's also another treatment option which is in the same family, which is called stem-cell therapy. These are both areas of a lot of excitement. The research on them is still forthcoming. In the orthopedic usage of it, or in the tendon issues, we've seen that it does seem to provide benefit for patients. It's a discussion I have with them. It's not always the perfect option. But for a lot of patients, it's something that we can offer where, ultimately, it involves a blood draw.

We take the blood off of a patient. We spin that blood down. We take the healing components of that blood and actually reinject that into the tendon under visualization of ultrasound so we can find that area that looks like it's irritated or has the issue. We directly inject into that area using that PRP injecdate that we've harvested from the patient by a blood draw. Then we can stimulate regrowth of the tendon as the theoretical purpose of it. But often, what it seems to do is cause the inflammatory reaction in the area, or it just kind of stimulates the healing in the area, and has provided a lot of relief for our patients.

Dr. Miller: Which tendons do you usually look at when you consider this therapy, or which tendons do you most frequently treat?

Dr. Monson: It can be done on any tendon that there is noted pathology in. So if you see an area of issue, it can be done in just about any tendon. Tendons that we typically think of, of having frequent issues are the shoulder, so the rotator cuff. We think about tennis elbow, so that's on the outside of the elbow. Golfer's elbows, on the inside of the elbow. We'll do it there. We see it in knees, particularly for people that have something called jumper's knee which is at the tendon of the knee. Achilles' tendon. Even in like the plantar fascia, this can be done.

Dr. Miller: These tendon injuries, they're not short-term injuries. Would these be folks that have chronic problems with the tendons that would be over weeks or months, perhaps?

Dr. Monson: Certainly. Yeah. Yeah. So that's usually, somebody will come to see me. They have a new injury, we'll work them through the things that we have the best evidence for, what we know works. Things like rest, avoiding aggravating activities, pain modification, medications. Then also, eccentric exercises are very important. We have good research showing that those are helpful.

Dr. Miller: What are eccentric exercises?

Dr. Monson: Yeah, so those are the exercises where the muscle is fired but it's actually lengthening at the same time. So we're lengthening a tendon and muscle unit while there is force.

Dr. Miller: Well, for stretching.

Dr. Monson: Yes, correct.

Dr. Miller: Okay. So how do you use the ultrasound to guide your therapy?

Dr. Monson: So the ultrasound, first of all, identifies the lesion. So then I know exactly where I need to go. The second thing you can do is the ultrasound will actually, if I place a needle into a patient, I can follow the course of the needle the entire time. I can see the surrounding nerves. I can see the surrounding blood vessels and I know exactly where I'm at. First of all, it's very effective for safety or avoiding those structures that we don't want to hit. But second of all, it helps us target very directly where we want to be within a tendon and make sure that we're in the correct spot.

Dr. Miller: Now, I'm assuming before you enter, you have a patient undergo this type of treatment, you have gone through the standard therapy. So they've gone through a physical therapy. They've done the stretching. They've done the icing, and they're just not getting results.

Dr. Monson: Correct. There's one other procedure that we've added to this as well. It's a needle procedure as well. So that means that it's not done in an operating room, but it is done in a procedure room where we, again, identify that area of concern. We're able to use a specialized needle tip that it pulsates at the very tip of it very quickly, about 17,000 times per second.

Dr. Miller: That's fast.

Dr. Monson: We're talking about a millimeter of movement. Yeah, it's fast. It's not a lot of movement. It's enough that it actually, you think of it as kind of pulverizing the tissue in there. It's emulsifying the tissue is the term that we use. It's the same technology that cataract doctors, or eye doctors, use to remove cataracts out of patients. It breaks up the tissue, removes it from the body, and then leaves the healthy tissue around it. This is a newer treatment, probably in about the last five years that this one's been out. For the same tendon issues that we just talked about, this is another treatment option for patients that's been very promising so far.

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