Dr. Jay Kimmel's Sports Medicine Blog

Ultrasound is a powerful diagnostic tool for evaluating and treating disorders of joints, muscles, tendons and ligaments throughout the body.  Diagnostic ultrasound has been used to evaluate musculoskeletal disorders for many years in Europe. Recently this imaging technique has become more prevalent in the United States. With the advent of smaller, less expensive, better resolution machines, diagnostic ultrasound can now be done in the orthopedists’ office. At Greater Hartford Orthopedic Group (GHOG) we are now using ultrasound in our office to help with the diagnosis and treatment of many orthopedic problems.

Magnetic Resonance imaging, MRI, is still the gold standard for imaging many disorders of the musculoskeletal system. MRI scanning and ultrasound are complementary. However ultrasound has some advantages over MRI in certain situations. First, ultrasound can be used in all patients, unlike MRI which can’t be used in patients with pacemakers and certain metal implants. Second, ultrasound can be used to evaluate muscles and joints in motion unlike MRI, which can only see images at rest. Third, MRI scanning requires a separate appointment for the scan while diagnostic ultrasound can be done in the office setting. Lastly ultrasound can be used to more accurately guide many of the injections done in our office.

Musculoskeletal ultrasound has been used extensively in the shoulder. MRI scanning of the shoulder is still the gold standard in this country for diagnosing musculoskeletal disorders. MRI is reportedly 90% accurate for diagnosing full thickness rotator cuff tears. In skilled hands, ultrasound of the shoulder has been shown to be over 90% accurate as well. In addition studies have shown that patients prefer ultrasound to MRI scanning. In addition, there are certain structures in the shoulder such as the biceps tendon that cannot be imaged well with MRI. Injuries such as a subluxating biceps tendon, where the biceps moves in and out of its groove with motion, can only be seen using a dynamic imaging technique such as ultrasound.

Musculoskeletal ultrasound is useful in other joints as well.  Ultrasound is very helpful in evaluating elbow problems.  For patients with elbow pathology such as tennis or golfers elbow, ultrasound can be used to more accurately locate the damaged tissue.

Ultrasound is not only useful in diagnosing orthopedic problems; it plays a very important role in treating various orthopedic ailments.  At GHOG we are using ultrasound to better guide some of our injections. While standard injections into the shoulder such as a subacromial injection for bursitis do not always require ultrasound guidance, some injections such as an injection into the biceps sheath can only be done accurately with ultrasound.  Other injections such as an injection into the glenohumeral or acromioclavicular joint for patients with arthritis can be more accurately done with ultrasound guidance.

Ultrasound is used to guide injections in other joints as well.  Patients with tennis or golfers elbow can have a steroid injection or platelet rich plasma (PRP) injection placed directly into the damaged tissue under ultrasound guidance.  Ultrasound has been quite helpful to us at GHOG for injections and aspirations around the knee joint as well. Hyaluronic acid injections(synvisc,supartz) into the knee are best done with ultrasound to insure accurate placement of the material.  Ultrasound guidance is not necessary for routine aspiration or injection around the knee but is useful in a number of clinical situations. Patients found to have tendonitis around the knee may benefit from ultrasound-guided injections of cortisone or platelet rich plasma (PRP) into the damaged area. Having ultrasound in our office is very useful for aspirating cysts around the knee joint such as a bakers cyst.  While previously this would have required an additional visit to a radiologist, it can now be done in our office the same day.

There are many other applications and uses for musculoskeletal ultrasound. At GHOG we are making this available to our patients to enable us to provide the best possible orthopedic care. For more information about the use of ultrasound at GHOG please call our office at 860-253-0276.

– Dr. Jay Kimmel and Elizabeth McAvoy, PA

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) inConnecticut, 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 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.

If you think you are a candidate for joint fluid therapy or would like to speak with Dr. Kimmel about your options, please contact our office to schedule a consultation.

– Dr. Jay Kimmel and Elizabeth McAvoy, PA

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 inEuropefor 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 theUnited Statesand 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 super bowl 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 beginning to do PRP injections in the office for various conditions including tendonitis of the shoulder and elbow. We do this using ultrasound guidance to find the damaged area and inject it with PRP.  In the office, Elizabeth, my physician’s assistant, will draw your blood.  Sharon, my medical assistant, will then place your blood in a centrifuge and then “spin it  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 under ultrasound guidance.  You will be told to rest for a few days and apply ice to the injection site, in case there is some soreness afterwards. Our short term results have been excellent.

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.

– Dr. Jay Kimmel and Elizabeth McAvoy, PA