KNEE AND SHOULDER JOINT PAIN

What are the non-surgical treatment options for joint pain?

There are many different tools in our toolbox. For our patients, we usually start off slow and conservative and build in intensity depending on the level of pain.

Physical Therapy: The best way to treat joint pain is to fix the underlying improper forces. Physical therapy (PT) helps bolster up the musculoskeletal structure, so you’re better aligned.

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Holistic Therapies: Vitamin D is fantastic. It acts almost like a hormone, with implications on not just bone health, but on tendon/ligament/connective tissue strength, muscle health, digestion, mood regulation, immunity, and so many other positive effects on the body. we always recommend everybody takes Vitamin D, it’s safe for all ages of all ages.

Supplements can help a lot of patients but always consult a doctor before you start taking them.

Creams: If it’s a joint that’s more superficial and closer to the surface — like your wrist or ankle joint — a topical cream can provide some relief. There are many different kinds, including over-the-counter creams, anti-inflammatory gels, and herbal remedies, such as arnica gel and capsaicin creams which contain ingredients like chili pepper powder or tree bark or plants.

Medication: Medications to treat joint pain can include nonsteroidal anti-inflammatory drugs (NSAID) like  acetaminophen .Patients respond better to some medications more than others, and we usually follow the patient’s lead in a thoughtful approach as to which one gives them the most relief.

Injections: With advances in science and better understanding of the biomechanical principles of what causes pain and inflammation inside joints, we have a range of injections we can use and many more coming down the pipe:

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• Cortisone: Cortisone shots are commonly used, whether it’s athletes or people with arthritis. If a patient is in in tremendous pain, cortisone can be a great fire extinguisher. The general rule of thumb is that cortisone shots should be spaced roughly 3-4 months apart when injecting the same joint. 

• Gel shots: These are also known as viscosupplementation or hyaluronic acid injections, and the substance is the same material that’s put into face moisturizers or fillers. It’s a very viscous substance material that can smooth over the lining of the cartilage. It carries a “cooling,” effect and can act as a lubricant on the joint to address stiffness and pain. The injections come as a single shot, or in a series, and people could potentially have relief for about six months on average . The main problem with gel shots is that you can’t predict who they will work for.

• Platelet-rich plasma injection (PRP): With PRP, we draw blood from the patient, spin it down in a centrifuge, and extract the plasma layer from the blood. The plasma layer (also called the buffy coat layer) contains white blood cells, platelets, and proteins that signal the body to start the healing process. When you inject it into a joint, it superglues itself into areas of damage and inflammation. It acts like scaffolding, where proteins and growth factors can deploy and work to heal damage, similar to a construction crew working on the scaffolding on the side of a building.

• Microfragmented fat (mFat) / Bone Marrow Aspirate Concentrate (BMAC): I call this the last stop on the train to surgery.  If PRP is analogous to laying a fertilizer bed down in a joint space, using these materials would be considered the seeds. Microfragmented fat injections (or “adipose-derived mesenchymal signaling cells”) and BMAC are the pinnacle of FDA-cleared regenerative medicine treatments. You are injecting stem cells directly into the joint space to not just attempt to heal it, but more robustly reinforce it so it doesn’t break down in the future. These are excellent medium-to-long-term injection options.
  
  mFat and BMAC can be composed of a variety of different growth factors, proteins (like exosomes), and cells (like adipocytes or progenitor cells), all aimed to promote healing.  These products do contain Hematopoietic Stem Cells (HSCs) or Mesenchymal Stem Cells), but evidence shows stem cells are often not the only player in the healing process, and that there is a deep interplay between all the different components being injected to create what’s called an ‘immunomodulatory cascade’ for cellular migration to the injured area to start a healing response.  Basically, when injected, it’s like opening up a Lego set of healing materials into a joint space for the body to put together.
   

When should someone with joint pain consider surgery?

Surgery, I tell everybody, is a last resort. I always tell patients that surgery is reserved for when we can’t control their pain and restore their function. All these different injection options fill the orthopedic treatment gap between conservative measures and surgical ones. The list of available interventional options continues to grow, and it’s important to discuss these with a responsible medical professional who is well-versed in this new and exciting field of interventional orthopedics.

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