Diagnosis and treatment of knee and ankle pain - palpation and injection skills

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Diagnosis and treatment of knee and ankle pain -
palpation and injection skills

• Dr Margaret E Taylor MB.BS, BSc, FACNEM, cert.
  Sports Med in GP. Adelaide GP, Treasurer, Aust
  Assoc for Musculoskeletal Med

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Prolotherapy - basic premise
Injections to stimulate growth factors and
regenerate ligaments, tendons or cartilage.
Introduced by US surgeon George Hackett who
first experimented with sclerosant solutions in
low back pain in 1939 and published many times in
1950s. Injury initiates inflammation then
effective repair depends on the balance between
proliferation of collagen and apoptosis of the
early stage of inflammation. This is inhibited by
VEGF (Vascular endothelial growth factor) High
levels of VEGF in tendinosis, and it causes
neovessels around the tendon. Pufe Scand J Med
Sci Sports 200515211 Glucose inhibits VEGF, as
does 0.1 lignocaine
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Summary

• Glucose injections are useful in 3 types of
  lesions
• Enthesis strain, eg sprained ankle treat by
  touching bone gently with the needle and restart
  the inflammatory cascade
• Tendinosis treat by injecting next to tendon to
  inhibit VEGF and restart apoptosis, ending
  granulation tissue
• Chronic results of old injuries treat all
  tender points relieve pain and stabilise joints
• Aim to generate new collagen, increasing
  strength and decreasing laxity, and relaxing
  muscle spasm

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63yr old footballers knee made pain free
Football injury age 22 and cartilage
removal terribly painful driving car and in
morning Taking NSAID or Digesic daily Xray
advanced degenerative change with lipping 5 prolo
treatments to June 2003 virtually pain free.
2006 - on extended overseas trip with no
trouble 2008 still OK
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MRI showing repair of meniscus tear
Fullerton BD, Arch Phys Med Rehab Feb 2008 vol 8
377-385
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Knee tender points

• Sports injuries
• around patella
• Osgood Schlatters both sides of tendon
• Various other ligs

• Osteoarthritis
• Medial joint line
• Pes anserinus goes further down than youd
  think
• Various other ligs

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Prolotherapy in OA of knee DB trial
38 knees devoid of cartilage in at least one
compartment Either 10 dextrose or lignocaine
9cc into the joint, bimonthly for 3 or 6
injections

• Significant difference by 12 months in
• pain - 44 decrease
• swelling - 63 decrease
• knee buckling - 85 decrease
• flexion range - 14 increase
• Xrays stabilised or improved
• 8 of 13 with ACL laxity were no longer lax after
  12 months
• Reeves, Alt Ther Health Med 2000 6 68

www.integrativemedicineresearchonline.com/knee2000
.pdf
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Osgood Schlatters epiphysitis
12 - 16 year old with painful insertion of
patellar tendon on tibia at the growth plate ?
Zinc deficiency - Teenagers need more zinc than
adults for growth and sexual maturation, and eat
terribly (nb acne, striae) Normally can take up
to 2 years to go 2 injections and zinc supplement
will fix it Kidd RF reported 6 cases treated with
prolotherapy. 5 responded in 1 or 2 treatments.
The other was a 26 yr old with a 10 yr history
and ossicles in the tendon. J Orthop Med
19931562-3 1cc prolo solution to tender points
on each side of tendon
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Prolotherapy and Achilles tendinopathy Lyftogt
J, Aust Mus Med May 2005 p16-19
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Osteitis pubis and/or adductor tendinopathy
responded in an average of 2.8 treatments with an
improvement in VAS from 6.3 to 1.0. Twenty of 24
patients had no pain. Topol et al, Arch Phys Med
Rehabil. 2005 Apr86(4)697
Common tender points to be treated
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Leg, foot ankle

• Chronic ankle sprains
• Achilles tendinopathy
• persistent pain after fracture metatarsalgia
• Mortons neuroma
• Bunions
• Hammer toes
• Compartment syndrome
• Aching feet Tib posterior syndrome

Common sites for sprained ankle
Complete tear of Achilles J Orthop Med 2005
27(3) 128-132
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Solutions made with 25 glucose
1 Litre bags of 25 IV glucose from Baxter -
about 7Prolo solution 20 (10ml/12ml x 25
20.8) 10cc 25 glucose 2cc 1 lignocaine (in
12ml syringe) Joint solution (22.5) 4.5cc 25
glucose (4.5 x 25 /5ml) 0.5cc 1 or 2
lignocaine Basic textbook Hackett G et al
Ligament and Tendon Relaxation Treated by
Prolotherapy 1991 US50 http//www.benuts.com/beul
ah.asp Next workshop 28-30 November 2008
Adelaide See Prolotherapy for Doctors
www.drmtaylor.com.au for more details, links to
references and to register. the most
cost-effective medical education Ive ever done
Dr Peter Henderson, Gold Coast