What are connective tissue injuries, and how are they related to my pain?

Tendons and ligaments are composed of remarkably strong, elastic collagen fibers. While most people recognize the importance of tendons in musculoskeletal injury, the importance of ligaments in musculoskeletal injury is often overlooked. Not only do ligaments stabilize our bone-to-bone connections, but they are also have densely embedded  nerve sensors that provide us with pain and proprioception input, allowing smooth and fluid movement. Injury to ligaments not only causes pain but also results in destabilization of the joints. When overstretched, ligaments lose their elasticity become lax. Lax ligaments attempt to correct this destabilization by recruiting muscle contraction, which leads to the muscle spasms and pain associated with back and other types of injuries. Ligament injury and the resultant muscle spasms cause referred pain patterns that are often mistaken for primary nerve injury, herniated discs, and/or nerve impingement, leading to unnecessary surgeries.

Do I need surgery if my MRI shows I have a herniated disc? Or a torn meniscus?  Or a torn rotator cuff?

While MRI technologies provide great insight into the anatomy of dysfunction, they can be misleading, often missing the cause of our patient’s pain. It is well known that over 30% of patients with no history of back pain or back injury will show disk herniation on an MRI. Dr. Bradley K Weiner, reported in the Journal of Orthopaedic Surgery and Research (2008) that 28% of patients with pain who showed disk herniation on an MRI did not show herniation at surgery35. What this means is that while disk herniation can be the cause of back pain, it is often no more than a normal sign of back degeneration and that back pain is caused by many different types of injuries.

What about MRI of the knee?

In a study of 20 normal, symptom-free athletes, Brunner showed that 50% had abnormal findings on MRI, including tears to the meniscus, ACL, PCL, and MCL36. Kornick looked at 74 symptom-free volunteers age ten to seventy-four, and 25% showed a torn meniscus on MRI37. Martin England MD published in the New England Journal of Medicine that meniscus tears on an MRI should be regarded as an incidental finding, and found in 991 symptom-free subjects aged 50-90 years, that 60% of these symptom-free people had MRI positive meniscus tears, concluding that “Incidental meniscal findings on MRI of the knee are common in the general population and increase with increasing age.”38

What is meant by “autologous adipose graft therapy”?

Formerly known as a type of “stem cell therapy”, “autologous adipose graft therapy” uses your own fat cells and tissue to alleviate pain and restore joint function. It has many advantages over standard joint replacement surgery including being less invasive and having less downtime after the procedure. Adipose tissue contains a plethora of reparative cells and biochemical factors that reduce inflammation and promote tissue healing over the long term. When used in combination with platelet-rich plasma, the effect on degenerated joints can be remarkable.

What tissue do we harvest for the autologous adipose graft therapy?

The procedure we use harvests fat tissue in a low-pressure “mini liposuction” that provides a rich tissue matrix and bio scaffolding to aid in repair of affected tissues. These specific therapeutic components are located within the highly vascular adipose bed and serve to nurture and protect your stem cell population. When harvested and mixed with your own platelet rich plasma, these tissue products provide the tissue rich matrix, the cytokine cell signals, and scaffolding necessary for improving the condition of the joint. Therefore your adipose tissue is the most ideal site for harvesting.

In summary, adipose-derived regenerative cells:

  • Can be collected in far greater concentrations than those from bone marrow
  • Are able to differentiate into multiple lineages including cartilage, bone, ligament, tendon, blood vessels and nerves.

Fractions isolated from adipose tissue contain a diverse mixture of regenerative cells, including:

  • Mesenchymal stem cells (MSCs)
  • Endothelial progenitor cells
  • Pericytes
  • Immune cells
  • Fibroblasts
  • Other growth factor-secreting bioactive cells

What are the advantages of these regenerative cells?

Regenerative cells “communicate” with the cells of their local environment through paracrine and autocrine modalities, creating the optimal environment for repair.

Regenerative cells produce a variety of both secreted and cell surface substances that regulate tissue growth, integrity, and function.

What’s the difference between the autologous adipose graft therapy that we use at Oregon Regenerative Medicine and banned fetal “stem cells”?

The procedure that we perform utilizes autologous tissue, meaning that it comes from each patient’s own body. Fetal stem cell lines are derived from fetuses and are not derived from the patient in whom they will be used and must be cultured to replicate and increase their cell numbers before being injected into the host. Culturing fetal cells for treatment is banned in the United States.

How do we harvest your adipose tissue?

Adipose tissue is an ideal site for harvesting mesenchymal stem cells, and compared with bone marrow aspirate, adipose tissue possesses between 500 to 1000 times the number of mesenchymal stem cells and stem-like stromal-vascular cells. This tissue is usually harvested from the buttocks or thighs and can be harvested from other fat deposition sites in the body. Once the optimal site is selected, an anesthetic is injected so that the Tulip harvester can be used to painlessly extract the adipose tissue. The tissue is minimally processed to remove impurities, concentrated, and combined with your own platelet rich plasma. This complex cell-tissue matrix is then injected into your damaged joints, ligaments, and tendons.

Is the harvesting procedure painful?

The harvesting procedure is minimally invasive and only requires 1-to-4 small ¼” incisions. A local anesthetic will be used to numb the area before the procedure. While many patients find the procedure only mildly uncomfortable, most of our patients choose to have nitrous oxide conscious sedation. Nitrous is a safe and effective method of sedation and will be administered through a breathing mask. Nitrous allows you to remain conscious throughout the entire procedure. Nitrous diminishes pain, reduces anxiety, and shortens your perception of time during the procedure. Nitrous will not leave you feeling drugged or drowsy.

Why do we use ultrasound (MSKUS) for diagnosis and injection guidance?

Unlike a static snapshot from an MRI, ultrasound offers the ability to scan the tissue during movement, thereby enabling a functional evaluation of the joint and exact needle placement of graft products. In addition to substantially lower costs, MSKUS has other advantages over MRI and fluoroscopy in orthopedics. With real-time ultrasound, we are able to correlate hands-on palpation simultaneously with direct ultrasound images. Fluoroscopy is ideally suited for guiding injections directly into intervertebral disks.

Frequency of treatment

The number of treatments required will depend on the condition being treated, the severity of your injury, the type of treatment provided, and how long the injuries and present. Most people will initially require 3-5 sessions of PRP injections spaced 2 to 6 weeks apart. Autologous adipose graft therapy treatments are spaced about 1-year apart if additional treatments are required. Our physicians can often predict the number of treatments needed in your first evaluation.

How soon can I go back to regular activity?

PRP, Prolotherapy, and autologous adipose graft therapies stimulate your own body to do the repair, and this requires time. Your body will need to go through all the necessary physiologic steps for repair, and your activities will need to keep pace with this rate of repair. Initially, gentle exercise and movement will be prescribed. Most people are able to resume activities of daily living within the 1st few days, followed by moderate exercise within the 1st 2 weeks. Avoiding the activity that caused the injury will be recommended until healing is complete.

How will I feel after my treatment?

Be prepared to take it easy for 2-to-4 days after treatment. The harvest sites will be mildly tender and there may be mild swelling. Joints and other regions treated will also be tender and quite stiff. If you are having your knees or hips injected, you may need to use crutches for a few days. You will benefit from strong pain medication for the 1st 24- hours and a prescription of Vicodin or other pain medication will be offered. For most pain, we recommend that you apply moist heat, 20 min. on, 20 min. off. Repeat as needed. For harvest site pain, wait 24 hours after the procedure before applying heat.

Adjunctive treatment

It is logical and self-evident that your overall health contributes to your rate of repair and recovery. Your physical conditioning, hormone status, and nutrition are all important factors contributing to the success of your procedures. Our team can assess you for your nutritional and hormonal status, and assist you in maximizing your road to recovery.

Will I need to exercise after my treatment?

Your ability to respond to therapy is enhanced by exercise. People with low activity levels tend to have impaired healing capacity. For this reason, you will need to engage in gradually increasing duration and intensity of exercise after your treatment. We consider exercise bikes and recumbent bikes to be ideal in strengthening both hips and knees. For strength training, we recommend you read The Slow Burn Fitness Revolution by Michael Eades, MD.

Does my diet affect the quality of my treatment?

Think of it this way: would you prefer to inject a sample of inflammation causing McDonald’s French fries grease into your joints, or healthy, omega-3 rich inflammation-reducing fats?

Your diet determines the quality of your tissue and the ease of extraction. We recommend an anti-inflammatory diet rich in fresh and cooked vegetables, high-quality Omega 3 rich proteins including salmon, sardines, cold water fish, walnuts and other tree nuts, hemp seeds, flax seeds, chia seeds, pumpkin seed and fresh berry fruits. These will all improve the quality of both your plasma and adipose that we use for your treatment.

Eat a healthy, low-fat meat light meal the night before your appointment. If your appointment is in the morning, then have a small sugar-free smoothie or green drink after rising.

Does hormone deficiency contribute to my arthritis?

Hormone deficiency can impair your body’s ability to repair and to generate healthy cartilage and endogenous stem cell populations. If you are over 40 years of age or have symptoms of hormone deficiency, hormone testing and treatment with bio-identical hormones may improve your response. Talk to your doctor about your hormone status and they will recommend a course of action that fits your profile.

How long have the physicians at Oregon Regenerative Medicine been treating male patients with testosterone pellet implants?

Dr. Peterson began treating his hormone-deficient male patients with testosterone pellets in 2004. Since then, he has trained many other physicians in the use of testosterone pellets. Subcutaneous testosterone implants have a proven record of safety and have been in use in Europe and Australia since 1938, and in America since 1949.

What are the advantages of pellet implant over gels and creams applied to the skin, or over testosterone injections?

The typical male body requires about 3-5 mg of testosterone a day to function at his peak. Over 5-months, 800 mg (four pellets) will dissolve at a rate of about 5 mg a day.

Contrast this to creams and gels, which require applications of 50-75 mg a day to provide a similar testosterone effect. Injections require 100-200 mg every 1-2 weeks to get an equivalent effect. And with creams, gels, and injections, all that excess testosterone can be converted by the body to estrogen through the process of aromatization, directly interfering with the metabolic benefits of testosterone. Even worse creams, gels, and injections deliver the hormone in peaks that can suppress the body’s own production of testosterone.

What are Bio-Identical Testosterone Pellets?

Used in the treatment of low testosterone, pellets provide consistent, sustained delivery of testosterone when implanted under the skin. Subcutaneous testosterone implants have a proven record of safety and have been in use in Europe and Australia since 1938, and in America since 1949.

What are the pellets made from?

They are 100% pure testosterone fused into a sustained-release form. The pellets are derived from extracts of wild yams, and are bio-identical, meaning they are the exact replication of what the body makes.

How are they administered?

A small incision is made over the posterior hip. Your doctor implants the pellets in the subcutaneous fat of hip. No stitch is required. The procedure takes about 5 minutes.

Is this therapy FDA approved?

The ingredients in the pellets are all FDA approved. The distribution of the pellets is FDA regulated. The procedure is a standard minor surgical procedure.

How long will hormone pellets last?

The average duration is 5 months, with a range of 4–to-6 months depending on the person. Everyone is different so duration depends on how you feel and what the doctor determines is right for you. If you are really active or you’re under a lot of stress your pellets may dissolve at a faster rate. The dissolution rate is based on cardiac output.

Are there any side effects to hormone pellets?

There are no serious side effects. Infection and/or expulsion of the pellets is rare. The vast majority of men are pleased with the results. While the majority of studies have concluded that testosterone therapy lowers prostate cancer risk, lowers diabetes risk, prevents bone loss, improves mood, lowers cardiovascular mortality, and lowers all-cause mortality in men with low testosterone, one recent study did show an overall increased mortality in men with advanced cardiovascular disease who were put on testosterone replacement.  Men with pre-existing advanced cardiovascular disease should receive testosterone cautiously.

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