My Achilles tendon…

It’s been a little more than 3 weeks since my tenotomy/PRP  procedure for my Achilles tendon.  I have to confess, it hurt alot for the first 2 weeks.  But this past week I’ve seen the light at the end of the tunnel.

I’ve done my eccentric stretching exercises religiously- the ones Dr. Mulvaney gave me.  (And believe me, I’m the world’s worst patient when it comes to following orders). And I have no pain and I no longer limp.  The lump that was really painful where my tendonitis and tear was located isn’t tender anymore.

I haven’t started to run yet but I can do the bike and the elliptical without pain.

Would I recommend this procedure to others?  Absolutely!  In fact, now that I have first hand experience with tenotomy and PRP, I am a real zealot.

I’ll go way out on a limb and say that this is the procedure of choice for people with chronic Achilles tendonitis with or without a partial tear.

Great news for us Baby Boomers.

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New treatment for shoulder tendonitis

Healthday (6/30 Preidt) reported a study from the University of Milan, published in the July issue of Radiology, showing that a minimally invasive procedure is helpful for patients with calcific tendonitis of the shoulder. 

What the researchers did was to randomize 287 patients with calcific tendonitis of the shoulder to one of two grouops.  One group underwent ultrasound guided needling of the tendon with “washing out” of the shoulder and the other control group had no treatment.

Followup of the patients showed that the treatment group had significantly less pain and more mobility at one month, three months, and one year.

[This study actually describes a not so new procedure.  The “new” part is the use of ultrasound guidance, which actually is “old news”.  And the ability to break up the calcific depositis and wash out the shoulder is something that’s been done by many practitioners for several years.  This study confirms through a controlled study what has been known for quite some time. 

What really is new is something I’ve written about before… and that is the use of tenotomy… poking holes in a diseased tendon under ultrasound guidance  and injecting platelet rich plasma to heal the tendon and make new stronger tendon tissue. This is particularly useful for people with chronic rotator cuff problems.

My feeling is that  any press regarding the use of ultrasound guidance is a good thing since it informs prospective patients that they should demand a technology that will help them recover faster. NW]

Practice What You Preach…

This past Friday was a busy day.  I performed three stem cell procedures on patients with osteoarthritis of the hip and knee, a PRP procedure on another patient with posterior tibial tendonopathy…  and then (drumroll please….)

…had a PRP procedure done to me… on my Achilles tendon.

So let me explain…

As you know my area of expertise is regenerative medicine for patients with arthritis.  That’s why my practice focuses on conditions like OA, RA, and tendonitis.

And when my nurses and I talk to patients and prospective candidates for these procedures, we tell them what to expect.  But how  can you tell a patient what to REALLY expect unless you’ve undergone the experience yourself.

Actually, one of our nurses had a stem cell procedure on her knee for osteoarthritis (yes… I did it),  so she’s been there and can tell patients bout the experience.

Now… don’t think I had this procedure done to me because I just wanted to be able to tell patients what to expect.  I think I’m a pretty empathetic physician but there are limits!

Here’s the background…

Twenty-seven years ago, I tore my left Achilles tendon playing basketball… (so beware, Mr. President).  It was not fun.  The injury was painful, plus I had to undergo major surgery to repair it, then I was confined to a long leg cast for 7 weeks, then a short leg cast for another 6 weeks.

For the last 10-15 years I’ve had intermttent pain in my right Achilles with activities like running and so forth.  My fear was that I was going to tear it like I did the other (there is an increased risk for tearing the other Achilles if you’ve torn one side).

So, I made my mind up to have a percutaneous needle tenotomy with PRP done.  If you’re experiencing chronic tendonitis, this is by far and away the best treatment for it.

But what do you do when you feel like you’re THE GUY.

What I mean is this…  There are those who think I’m the person to see when it comes to these types of ultrasound-guided tissue regenerative procedures.

But what do you do if you can’t do this type of thing to yourself?  Well… I did the next best thing.  I arranged  it for when doctors I really trusted and respected would be around.

I had planned for Dr. Tom Clark, the world’s foremost ultrasound anatomy expert and Dr. Sean Mulvaney, one of the best sports medicine physicians  in the area, to visit me Friday to observe and assist me in my cases.

So at the end of the afternoon, I said… “OK, let’s do it…”

Before I go on, let me explain one thing.  I am a WUSS.  I hate needles and I hate pain. I am a wimp, a coward when it comes to pain.  I admit it. So this thing was scaring me.  I had this upside down feeling in the pit of my stomach and I was breaking out in a cold sweat.  But, I told myself, “Nathan… how can you honestly talk with patients about this procedure … be brave… suck it up!)


I had my nurses draw my blood for the PRP collection, then I went to our procedure room and Dr. Mulvaney did the procedure.  Probably half the staff came in to observe and giggle.

(By the way I had the whole thing videotaped and you’ll be able to see it sometime soon).

I can tell you it hurt.  Not unbearable, but not like laying out on a beach, listening to the waves (but that’s what I focused on to take my mind off what was happening).

Afterwards, Dr. Mulvaney gave me post-procedural instructions:

He told me, “Tonight, it’s going to hurt.”

I asked, “How much?”

He said, “You’re going to feel ‘this hurts so bad there’s gotta be something wrong’ kind of pain.”


Well later that evening, Judy and I watched  the DVD, ‘Risky Business’ (by the way if you haven’t seen this movie with the young Tom Cruise, you should).

I had some discomfort… OK… I had pain. and I actually had to take some pain medicine (which I ordinarily dislike doing). But not excruciating… even for a wimp like me.

But today, even though it’s sore, I think I’m going to make it.  I start my stretching exercises tomorrow.

I know this procedure will make my Achilles tendon strong and normal so I won’t have to worry about tearing it.  No substitute for peace of mind. And I know it won’t hurt when I run – a major plus.

And I’m going to see my son, Jeffrey, in a play tonight, so when I hobble in with my crutches, maybe I won’t have to wait in line.

#@$%*&%^ Insurance companies!!!

[This news segment highlights a little known but clearly typical insurance company tactic.  There is so much written about how pharmaceutical companies are to blame for the health care system breakdown.  And everybody is taking shots at them… including different medical organizations. 


Even the American College of Rheumatology, of which I’m a member, publicly distances itself from pharmaceutical companies, but privately demands funding from these companies for various functions.


Insurance companies get a pass for reasons which are a complete mystery to me.  Any patient or doctor in practice knows that insurance companies call the shots when it comes to tests that patients can have or medicines that are ordered. 


I may order drug A, but the likelihood is about 80% the patient will receive drug B, because that’s what the insurance company wants them to have.  I have a patient who’s been taking a medicine that works great for her for three years.  But now the company says “they made a mistake” authorizing that medicine in the first place. They want her to take something she’s already failed.  GRRR!


I recently ordered a diagnostic test for a patient.  The insurance company denied it.  When I called the medical director and accused the insurance company of making medical decisions that were not in the patient’s best interest, he said, “We’re not making medical decisions.  She can have the test.  We’re just not going to pay for it…” 


I’ve got to admit, it takes alot of balls to say something like that…]



Segment highlights how health insurers hit consumers with unexpected fees.


On its website, KTVT-TV Fort Worth, Texas (6/12) highlights “how some health insurers get you to pay more — so they can pay less.” Several incidents are presented, such as the plight of Camille Privitt, who “slipped down a flight of stairs” and fractured “three thoracic vertebrae.” Privitt received a letter from her “insurance company, United Healthcare,” which among other things, said the “ambulance was an ‘out-of-network’ service” and said the fees “for the medical supplies that held Privitts’ neck in place” were not covered. The segment also provides “Tips to Fight Back” against insurance fees, such as calling the insurer and send letter via certified mail; and, as a “last resort,” consulting a lawyer.

Knife-happy surgeons?

[I thought this was a real good indicator of a couple of things.  The first is that the health care system is too focused on treatment rather than prevention.  And that orthopedic surgeons do far too many joint replacements. 


Most joint replacements are done for arthritis.  The emphasis should be on slowing the disease process and maybe even reversing it, rather than subjecting a patient to a potentially dangerous – even life-threatening- procedure.  The point CBS was trying to make was that informed consent- the process where risks of a procedure are explained to the patient- is confusing and most patients don’t understand what’s going to happen.  And that’s true.


I have many patients who have gone through joint replacement and are happy… however, I also have a significant number of patients who have had bad outcomes and rue their decision.  Too late!


That’s why more emphasis should be placed on regrowth of connective tissue- ie. prolotherapy, the use of natural growth factors such as platelet-rich plasma (PRP) and the use of stem cells to regrow cartilage.  Natural healing.


There are efforts now at some centers evaluating the use of stem cells for spine-related disorders.


Our experience with the implementation of an autologous stem cell program (using the patient’s own stem cells harvested from their bone marrow) for osteoarthritis of the hip and knee  is proving that tissue regeneration is an option- a far better one that joint replacement.  That’s why the orthopods are so angry with us!!!]



Study indicates informed consent forms may be of “limited value.”

The CBS Evening News (6/9, story 10, 3:45, Couric) reported that “the high cost of medical care is a huge issue today, and…patients often make the problem worse by giving doctors permission to do procedures they don’t need. Experts point to four procedures — coronary angioplasty, spinal fusion, knee replacement, and hip replacement — that are responsible for billions of dollars in hospital costs every year.” In fact, data indicate that 30 “to 40 percent of those procedures are considered unnecessary.” But, Dr. Elliott Fisher, the Dartmouth Institute for Health Policy, noted that “proper informed consent would eliminate 30 to 40 percent of other unnecessary expensive procedures.” He explained, “The problem starts with consent forms. A review of hundreds of consent forms at more than 150 hospitals found them to be of, quote, ‘limited value.’ They are not standardized, loaded with confusing language. They are often missing specific risks, and generally not well explained by doctors.”

Doctors…Modern Day Natural Healers

If you are a Baby Boomer who wants to stay active and stay in the game…. (and no, I’m not talking about male enhancement)…and recover from nasty problems like tendonitis and arthritis, you ought to pay attention to this post …

Because this past week I interviewed Dr. Sean Mulvaney, a sports medicine doctor who specializes in PRP (platelet-rich plasma) techniques and Dr. Dean Reeves, a specialist (in fact one of the foremost experts in the world) in prolotherapy.

Both of these physicians discussed the  revolution in natural healing of conditions such as tendonitis and arthritis using the body’s own growth factors.

While our ability to regenerate new tissue declines as we age, it is not completely lost.  It’s possible to turbocharge it using newer methods.

With old technologies like prolotherapy and new technologies like PRP and stem cells, we are able to accomplish amazing things.  Some of these medical approaches sound like stuff out of Star Wars. Truly amazing stuff and important if you’re a Boomer who wants to continue to do the things you want to do without having to take toxic medicines or worry about joint replacement surgery lurking in the background.

Dr. Mulvaney discussed the biology and indications for PRP. 

Since he is an Army guy with hush-hush connections, he told me that if he revealed any more, he’d have to kill me….

… and Dr. Reeves talked about the amazing regenerative and rejuvenating properties that our bodies have if given the right opportunity.  While he uses the standard prolotherapy solutions (generally dextrose), he is also an advocate of PRP.

In future discussions, I’ll be yapping about PRP and stem cells. 

The reason? …I’m working a on a big project  on regenerative medicine.  In the upcoming weeks, I’ll be telling you more about it. Stay tuned.

Cellphone hazard… another one!

I ran across this article recently.  We’ve all heard about brain tumors and cell phone use and highway driving and cell phone use.  Well… how about this hazard…

Cubital tunnel syndrome may be caused by excessive cell phone use, researchers say.

HealthDay (6/2, Thomas) reported that, according to research published in the May issue of the Cleveland Clinic Journal of Medicine, “the latest affliction of the wired age” appears to be “cell phone elbow.” The condition, which is “medically known as cubital tunnel syndrome,” consists of “numbness, tingling, and pain in the forearm and hand caused by compression of the ulnar nerve, which passes along the bony bump on the inside of the elbow,” and may be caused by “too much gabbing, often brought on by those cell phone plans with unlimited minutes, experts say.” In some people, “holding the bent-elbow position for extended periods can lead to decreased blood flow, inflammation and compression of the nerve,” explained Peter J. Evans, MD, PhD, director of the Cleveland Clinic’s Hand and Upper Extremity Center. And, “as symptoms progress, they can include a loss of muscle strength, coordination, and mobility.” Dr. Evans explained that “in chronic, untreated cases, the ring finger and pinky can become clawed.”

Do Bee Stings Work For Arthritis?

[I ran across this interesting article about a 91 year old dentist who uses bee sting therapy for his friends who have various types of arthritis.  I smiled as I read it…

When I first started practice almost 30 years ago, the specialty of rheumatology was filled with stuffed shirt academic types who scoffed at anything that wasn’t subjected to a double-blind randomized controlled study at least 50 times.

Since then, it has been shown on numerous occasions that several alternative types of treatment do have value and that they do pass the test of scientific scrutiny- if time is taken to examine them.  Most academic rheumatologists are very cynical creatures.  That doesn’t mean they’re not nice people.

Bee venom is very interesting because its mode of action involves chemical messengers that have an anti-inflammatory and possibly immunomodulatory effect.  Obviously, it should be used with caution because of the danger from anaphylaxis.  And it doesn’t work for everyone. NW]

Retired dentist uses bee venom as therapy

01:00 AM EDT on Saturday, May 30, 2009

By Tatiana Pina

Journal Staff Writer

Dr. Edward Ziegler Jr., above, gives a bee sting treatment in a wrist area, at left, for arthritis. Ziegler, 91, a retired dentist, stings himself 21 times every other day and says it relieves his rheumatoid arthritis. He keeps adrenaline in the refrigerator in case someone has an allergic reaction.

The Providence Journal / Kathy Borchers

PROVIDENCE — On the second floor of his Tabor Avenue home, Dr. Edward Ziegler Jr. sits at his kitchen table concentrating on a glass jar that seems to be humming.

Lawrence Knowles, 70, a Providence man with a shock of thick white hair, sits next to him with his left arm outstretched, awaiting relief from osteoarthritis, which pains his hands and makes them stiff.

The 91-year-old retired dentist opens the jar slightly and grabs a woman’s metal hair clip off the table. With all deftness of a man half his age he dips the hair clip into jar and plucks out a honey bee.

He presses the bee’s rump to Knowles’ wrist until it digs its stinger into him.

It hurts but Knowles says the venom from the bee helps alleviate his arthritis. Knowles, an adjunct faculty member at Bryant University, says it takes about three treatments before he starts to feel better. He’s been coming to Ziegler for six years. “He wants to beat me at squash,” Ziegler teases.

“The bee sting doesn’t cure a thing,” he declares. “It enhances the activity of the immune system.”

Ziegler has been practicing bee venom therapy for 30 years. He keeps adrenaline in the refrigerator in case someone has an allergic reaction. He invites people suffering from arthritis, multiple sclerosis and other ailments to his kitchen for treatment Monday, Wednesday and Friday from 12 to 1 p.m. It’s free, although he doesn’t mind the kisses from grateful women who have been helped by the treatment.

The Arthritis Foundation puts out a guide on alternative treatments for arthritis that lists bee venom therapy, saying it’s used as an anti-inflammatory for conditions such tendonitis, bursitis, rheumatoid arthritis and osteoarthritis. The guide says a study of mice with induced arthritis showed that after eight weeks of bee venom injections the incidence of arthritis was significantly lower than in the control group. The guide also says bee stings can hurt and may not work. It suggests that if the patient sees no improvement after eight sessions and a total of 20 to 70 bee stings or injections, it’s probably not going to work.

Ziegler says he scoffed when a colleague suggested bee venom therapy over 30 years ago. But he decided to try it when his feet hurt so much from rheumatoid arthritis that he could barely walk. He wasn’t about to miss out on the things he loved to do like riding a motorcycle, deer hunting or flying a plane. He stings himself 21 times every other day. He keeps five hives in his back yard.

Ziegler estimates that in his lifetime his bees have stung 7,000 people. “I would be a cripple if it weren’t for the bees. I had no choice but to help other people.”

FDA Posts Alert On "Killer" Over The Counter Pain Reliever

Common Over the Counter Pain Reliever Can Trash Your Liver!

  [This “news” is actually not news.  For years, rheumatologists have known that patients who take too much acetaminophen – and there are alot of patients who do this- develop liver toxicity and sometimes liver failure.  Acetaminophen may be the second leading cause of need for liver trans-plants (after hepatitis C).  Patients should be aware that just because it’s over the counter, it’s not necessarily safe.  And the risk is also made worse when patients combine over the counter acetaminophen along with prescription painkillers that also contain acetaminophen].

The NBC Nightly News (5/27, story 9, 0:20, Williams) reported, “An FDA report recommends stronger warnings and dose limits on drugs containing the painkiller acetaminophen,” which is “the active ingredient in Tylenol and a host of other pain relievers.” The report “cites an increased risk of liver damage.”

        The AP (5/28) adds that the recommendations cover “both prescription doses and over-the-counter medication” and “include enhanced public information efforts, stronger labels warning of liver side effects, and dose limitations.”

        The FDA working group that issued the report, “made up of 12 top officials in the FDA’s Center for Drug Evaluation and Research, recommended lowering immediate-release tablet strength to no more than 325 milligrams from the current 500 milligrams and reducing the single adult dose to 650 milligrams, from 1,000 milligrams,” according to Bloomberg News (5/28, Larkin). The FDA also said acetaminophen “overdose was linked to 458 deaths and 26,000 hospitalizations annually from 1990 to 2001,” and the drug “is a leading cause of acute liver failure in the US.” Meanwhile, the FDA “has asked members of its advisory panels on drug safety, anesthetic and life-support drugs, and nonprescription drugs to meet June 29-30… to discuss the group’s recommendations…and how they may be implemented.”

Arthritis Drug Good for the Flu?

This is a really interesting study.  A biologic drug that’s used to treat rheumatoid arthritis- a drug that, I might add,  doesn’t seem to be all that effective for RA-  might prove useful in combating the flu.  At least it seems to work in mice.  So if we all develop tails,whiskers, and pink eyes… who knows? This article was published in Science Daily which is an awesome website for new news in science.

Arthritis Drug May Be Effective in Fighting Flu

ScienceDaily (May 26, 2009) — Researchers at the University of Maryland School of Medicine have found that an approved drug for treating rheumatoid arthritis reduces severe illness and death in mice exposed to the Influenza A virus. Their findings suggest that tempering the response of the body’s immune system to influenza infection may alleviate some of the more severe symptoms and even reduce mortality from this virus.

The scientists report in the June 1 edition of The Journal of Immunology, which is now available online, that mice infected with the Influenza A virus responded favorably to a drug called Abatacept, which is commonly used to treat people with rheumatoid arthritis. The mice had been given “memory” T-cells, or white blood cells that have been primed to fight the invading virus as the result of previous exposure to Influenza A.

“We found that treating the mice with Abatacept minimized tissue damage caused by the immune response, but still enabled the body to rid itself of the virus. The mice didn’t become as sick, recovered much faster and had much less damage to the lungs, compared to mice that weren’t given the drug,” says Donna L. Farber, Ph.D., a professor of surgery and microbiology and immunology at the University of Maryland School of Medicine and the study’s senior author.

“Moreover, treatment with Abatacept significantly improved survival for mice infected with a lethal dose of influenza virus,” Dr. Farber says. “The survival rate for the treated mice was 80 percent, compared to 50 percent for the mice that weren’t treated.”

She explains that the drug does not interrupt the immune system’s early, rapid attack in the lungs, which helps to kill the virus, but it prevents “memory” T-cells from overreacting, which produces multiple negative effects. “It’s this overactive immune response that can make you feel sick – and can also lead to pneumonia,” she says.

The study’s lead author, John R. Teijaro, a researcher in Dr. Farber’s lab, notes that tissue damage caused by this vigorous immune response – often most prevalent in young, healthy people – is thought to be the leading cause of death from pandemic strains of flu, such as the avian flu and the 1918 Spanish flu. It is also thought to be true of the early cases of H1N1 “swine” flu.

Dr. Farber says, “We believe that our findings are very significant because they provide a potential new treatment for infection by the influenza virus – one that would dampen the immune response, yet still preserve its protective effects.”

The researchers are now testing Abatacept in mice that have not previously been exposed to the flu virus, trying to determine how well they respond to the drug once they have become very sick. Instead of having “memory” T-cells, these mice have what are known as “naïve” T-cells, which have never been activated by being exposed to influenza previously. Depending on the results, Dr. Farber hopes to one day bring this promising new immunotherapy to the clinic for the benefit of patients.

E. Albert Reece, M.D., Ph.D., M.B.A., vice president for medical affairs, University of Maryland, and dean of the University of Maryland School of Medicine, says, “The results of this study are very promising. Influenza is a significant public health problem, affecting millions around the world each year. We hope that this study – and Dr. Farber’s continuing research – will pave theway for identifying an effective treatment,” Dr. Reece says.

Abatacept, which is manufactured by Bristol-Myers Squibb and marketed under the name Orencia, is already approved by the U.S. Food and Drug Administration for treatment of rheumatoid arthritis. The drug is not approved for treating influenza.

The study was funded by the National Institutes of Health and Bristol-Myers Squibb.

There are three types of seasonal influenza, A, B and C, and a number of subtypes of Influenza A, including a new strain of the H1N1 virus, also known as the “swine flu,” which has recently emerged and caused illness and a number of deaths this year in Mexico, the United States and other countries around the world.

Vaccination is the most effective way to prevent someone from getting the flu or having a serious case of the disease. An antiviral drug, Tamiflu, can help to prevent the flu virus from spreading within the body if it is taken within 48 hours of the first symptoms.

Dr. Farber points out that an immunotherapy with a drug such as Abatacept would be effective against different strains of the virus because the target of the drug would be the immune system, not the virus itself. “We’re very excited about the potential of developing a new therapy, which possibly could be given to people even after they are very sick,” she says.

Journal reference:

  1. Teijaro et al. Costimulation Modulation Uncouples Protection from Immunopathology in Memory T Cell Responses to Influenza Virus. The Journal of Immunology, 2009; 182 (11): 6834 DOI: 10.4049/jimmunol.0803860

Adapted from materials provided by University of Maryland Medical Center.

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