Physician Led • Outcomes Centered • Patient Focused

Ten Things You Should Know About Chronic Orthopedic Pain

1. Chronic tendonitis is not a problem of inflamed tissue.  It is a problem of painful scarring within the tendon that usually will not get better on its own.

Tendons are strong, yet flexible bands of tissue that connect muscle to the bones around your joints.  Tendons and muscles work together to create a pulling force that enables you to move your joints.  This allows you to bend, walk, jump and move in many different ways.  When tendons are damaged, movement in a joint can be very painful and limit your range of motion.  Tendons are injured by either outright trauma or by repetitive injury (damage to the tendon from overuse in work, exercise or activity).  When tendon is traumatized, it tries to heal itself, but often scar tissue eventually forms within it.  This scar tissue causes pain.  As it worsens, the injured tendon will limit your ability to move the joint and do the activities that you need or like to do.  If something doesn’t change, the pain in your joint will likely become worse over time.

Surgical treatments for chronic tendon pain are often unsatisfying and carry long recovery times.  Nonoperative management is the recommended approach, and more often than not is successful.  In general, conservative treatments that are effective are the ones that damage the involved tissue in a controlled way and jump start the body’s healing processes to promote normalization of the damaged tissue.  This approach might seem counter-intuitive, but research supports it.  Options at Stadia Sports Medicine for management of chronic tendon pain include:

  • Physical therapy with ASTYM – a form of soft tissue massage that promotes healing.  Stadia was the first clinic in the city of Des Moines to offer ASTYM as a treatment tool, and Dr. Carlson trained with the founder of the technology.  Patients considering ASTYM should consider Stadia, which has the most experience with this approach of any clinic in Des Moines.
  • Guided injection therapy with minimal pain.  Options include:
    • Corticosteroid (cortisone) injections
    • Platelet-rich plasma injection (see below)
    • Prolotherapy (using dextrose, or sugar water).  Prolotherapy involves the injection of a safe irritant substance at the area of soft tissue injury.  There is evidence that this is a useful treatment approach to help control or eliminate chronic pain.
    • Stem cell therapy (coming in 2015)
  • Tenotomy (see below) – a minimally-invasive technique that helps physically eliminate scar tissue within a tendon.  This approach preserves healthy tissue and results in more rapid recovery times in comparison to standard surgery.


2. There are good treatment options for chronic tendon and joint pain that don’t involve surgery.

    Nobody wants to have surgery if they don’t need it.  At Stadia, our bias is to find the most appropriate treatment for you.  In most cases, this does not involve surgery.  Over 90% of all orthopedic problems never require surgery, so we spend most of our time finding inventive and effective ways to manage the 90% of cases that can avoid surgery.

    Our therapy staff eliminates the pain from tendonitis about 80% of the time using tools like ASTYM and directed exercise.  We also keep patients on their own at home with home-based therapy protocols when appropriate and when the patient desires it.  We offer patients multiple options for procedures that can reduce or eliminate their pain.  See below for more information on some of these.


    3. Ultrasound technology has revolutionized outpatient orthopedic care by reducing pain and improving accuracy of guided procedures.

    Many research studies have documented increased accuracy and better clinical response when ultrasound is used for injection guidance.  For example, in one study, injections of the shoulder joint were successful in only 55% of blind injections and 72% of x-ray guided injections, but were successful in 94% of injections done with ultrasound.  Acromioclavicular joint (the joint between your collar bone and shoulder blade) injections are successful in 45% of blind injections, vs. 100% of ultrasound-guided injections.  Statistics are similar in other joints of the body.  Procedural pain has been shown to be lessened by approximately 50% with the use of ultrasound.  Having this technology in place allows doctors to inject joints in the office that cannot routinely be reached without imaging guidance.  This allows us to easily access virtually any joint in the body with ease and precision, and with a minimum of patient discomfort.  In-office hip injection, for example, significantly decreases work-up time in patients presenting with hip pain.  Ultrasound guidance also expands treatment offerings for chronic tendonitis, including tenotomy for conditions such as epicondylitis, achilles or patellar tendonitis and plantar fasciitis.  Even carpal tunnel syndrome can be managed with the use of ultrasound in the office.   Finally, the use of ultrasound in the office for diagnostics is extremely cost-effective relative to more expensive tests such as MRI.  In many cases, ultrasound is as, or more accurate than MRI for soft tissue diagnosis.  It is particularly effective in the shoulder and elbow.


    4. Platelet-rich plasma is a promising treatment for chronic soft tissue and joint pain.

      Platelet-rich plasma (PRP) involves the injection of a patient’s own blood into an area of tendon (or joint) injury.  Specifically, a patient’s own blood is prepared prior to injection by being spun in a centrifuge so that the platelets can be isolated for injection.  Platelets contain many factors in them that promote wound and tissue healing, allowing injured tissue to regenerate itself.  PRP shows promise as a useful therapy when more conservative measures have failed.  At Stadia we utilize the Harvest PRP system, which provides an optimal concentration of platelets for injection to the injured area – something that has been shown to be important for the best clinical response.  We also use ultrasound guidance for all PRP injections, to increase the likelihood of a good response to treatment.

      Injecting your own blood into an injured area may sound crazy, but there is a growing body of evidence that PRP is an effective treatment tool.  For example, surgical repair of partial tears in the elbow ligaments of pitchers takes an average of a year after surgery to return to full activity.  PRP was shown in one study to return 16 of 17 athletes to throwing within 15 weeks of the procedure.   PRP has been shown to be superior to steroid injections for the management of plantar fasciitis, tennis elbow, Achilles and patellar tendonitis and other soft tissue injuries.  Multiple medical studies also have shown recently that PRP appears to be an effective treatment for the pain associated with osteoarthritis.  Most of these studies involve the knee, but there are also studies confirming effectiveness in the ankle and hip.  A study looking at PRP in the knee by researchers from the Hospital for Special Surgery has shown that PRP improves pain and function, and in up to 73% of patients, appears to delay the progression of osteoarthritis – an otherwise progressive disease.


      5. Tenotomy is a minimally-invasive procedure that is a great alternative to surgery for patients with chronic tendonitis.

        Percutaneous tenotomy is a procedure that can be used to help heal chronic tendon pain that is not getting better with traditional non-operative measures.  It involves the removal of scar tissue from an injured tendon, and can be thought of as a bridge between traditional surgical tenotomy and other non-operative treatments.  Outcomes seem to mimic that of surgical treatment, with less post-procedure pain and more rapid recovery, as well as lower overall costs.  There is a reported 80-90% success rate among patients not responding to conservative therapies, with an ever-increasing number of studies showing this as an effective treatment tool in the properly selected patient.

        Percutaneous tenotomy is done entirely under local anesthesia, with the patient comfortable and alert for the entire procedure.  Ultrasound is first used to identify the area of tendon injury, and then appropriate skin markings are made.  Following this, using a small needle and ultrasound guidance, local anesthetic is injected into and around the area of tendon injury.  Once the area is anesthetized, a special tool is inserted into the scarred tissue.  This tool delivers ultrasonic energy that is specifically designed to break up and remove damaged tissue safely and quickly, without disturbing the surrounding healthy tendon tissue.  Total treatment time for this procedure averages 15-20 minutes.  After the scar tissue is removed, the tiny opening is closed with a steri-strip.

        Following tenotomy, patients are discharged to home, with over-the-counter pain relievers usually adequate to control post-procedure pain.  Restrictions following this procedure are going to be individualized, but in general, following tenotomy, you can expect a return to full activity by about six weeks; and with thousands of procedures performed in the United States, there have been no reports of significant complications to date.


        6. Physical therapy, whether home-based or supervised, often can be used to control or eliminate chronic orthopedic pain.

        We are big believers in the power of physical therapy to take patients who are struggling with chronic pain and make them whole again.  Many, many studies bear this out.  Studies also confirm that properly directed home programs can be effective to achieve pain control in the right patients.

        Stadia Sports Medicine’s physical therapists utilize the latest in therapy techniques designed to speed tendon healing and promote more rapid recovery from injury.  We do not rely on techniques such as electrical stimulation or therapeutic ultrasound which are commonly used in therapy settings but which have not been shown to be effective for these problems.  Our approaches to patients are grounded in the medical literature.  Stadia Sports Medicine was the first clinic in Des Moines to utilize the ASTYM technique with our patients, having used it since our opening in 2006.  ASTYM was developed by Dr. Carlson’s fellowship director at Ball State University in Muncie, Indiana, Tom Sevier, M.D., who went on to found Performance Dynamics –the company that trains clinicians in the ASTYM technique.  Thus, practitioners at Stadia have experience with ASTYM going back to the 1990’s, and our therapy staff has a broader depth of experience with this technique than any other physical therapy group in Des Moines.

        At Stadia, we strive to keep a patient’s therapy course as short as possible while still achieving treatment goals.  Although we love treating our patients, and we would love having you in our office, we know that you would rather be doing other things.  We respect that by insisting that a patient’s therapy always be moving toward a defined goal, and then redirecting if progress is not being made.   Finally, having M.D.’s and P.T.’s in the same office together provides a unique, collaborative atmosphere that makes for optimal patient care.


        7. Back pain is usually controllable.

          Back pain is one of the most common problems that presents to any sports medicine or physical therapy office.  Fortunately, it benefits from a systematic approach to evaluation and treatment.  Based on the age of the patient and their appearance in the exam room, we can usually send a patient home with a plan to address their back pain.  If the patient fits a certain pattern in the office, home exercise might be suggested.  Home exercise in this case is always done with direction, supplying the patient with a specific program and reviewing proper technique with the patient prior to their leaving the office.  In other cases, obtaining additional diagnostic studies or bringing a patient in for in-office, supervised physical therapy might be deemed appropriate.   Regardless of the approach taken, the assumption is always that we can get a patient’s back pain under control, without the use of chronic medication.


          8. Your biomechanics (the way your body moves and works) usually lead to chronic pain problems, and properly evaluating and addressing this helps treatment.

          Chronic pain problems don’t just spring up out of nowhere.  The groundwork for them is usually laid over a long period of time.  One of the things that often contributes to breakdown of a tendon or joint is faulty mechanics (in the body, “biomechanics.”).  Causes of faulty biomechanics run the gamut from chronically tight muscles, which can place undue strain on joints, to flat feet, which can place strain on the legs, knees and back.  Muscle weakness patterns tend to develop in people over time, leading to ways of compensating for this weakness that are ultimately self-defeating.  It is important that physicians who are seeing patients with orthopedic pain be aware of these weakness patterns and look for them when patients present to their office.

          When patients at Stadia are evaluated, their biomechanics are always taken into account.  This information is used to help formulate an individualized treatment approach that works for the patient.  This gets to individual root causes and helps reduce the likelihood of pain becoming a chronic problem.


          9. Sports Medicine is not just for athletes.

            Since 1989, the American Board of Medical Subspecialties has recognized Sports Medicine as a distinct non-operative physician specialty.  Since only 10% of all musculoskeletal problems ultimately go to surgery, the idea of training clinicians whose focus is optimal treatment for the other 90% is sound.  Moreover, when problems that are being evaluated by a Sports Medicine physician ultimately are found to require surgery, Sports Medicine physicians can direct patients to the most appropriate surgeon for the job – something that is difficult for patients to determine on their own.  In this sense, we feel that it is best for Sports Medicine physicians to practice in an independent setting, where what drives referral to a surgeon is expertise and not institutional affiliation.  Stadia Sports Medicine is the only independent Sports Medicine Practice in Des Moines.  Sports medicine physicians typically offer the following services within the context of their practice:

            • Office-based diagnosis and care of musculoskeletal injury (joints, bones, muscles, spine)
            • Consultation for medical problems that relate to exercise (asthma, bone density problems, exercise-associated abdominal pain, anemia, concussion injury, etc.)
            • Evaluation of endurance athletes to help establish training zones for optimal training.
            • Establishment of exercise prescription protocols for patients desiring to start exercise for the management of established medical problems.
            • Nutritional advice pertaining to sports participation/exercise


            10. You still have time to address your pain, but you have to act now.

              If you are on a high-deductible health insurance policy and have met your deductible, or if you have flex funds to use prior to the end of the year, you still have time to look into treatment options this year.

              No matter what your age, if you are having orthopedic pain, physician-directed Sports Medicine can help.  Stadia Sports Medicine is Des Moines’ first Sports Medicine practice, founded in 2006.  If you want your pain eliminated, give us a call today.  We’re here to help.


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