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Ankylosing Spondylitis, Hip Pain, PRP treatment

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A fairly common question I get asked by colleagues is how do I use regenerative medicine treatments in the setting of my autoimmune and inflammatory patients. It’s a great question and I have a case that I think helps to explain and give some details in that regard. Specifically a man with Ankylosing Spondylitis and treating his right hip pain with platelet rich plasma.

 


I have a patient who is in his early fifties, he is a gentleman that has Ankylosing Spondylitis. In patients that have systemic inflammatory issues, meaning inflammation throughout the body, that have joint issues, my first take is always if they have total body inflammation you really need a solution that’s total body. And that generally does not mean injectable option into a specific joint or tendon. So things you can consider, you can certainly consider things like over the counter supplements like omega-3 curcumin glucosamine. As well as dietary changes which can be helpful. For most of these people though, they end up requiring medication to control their overall symptoms. And rather than using just anti-inflammatory medications it’s more medications that work on the immune system to help calm things down and modulate it. So that’s always first line. For some of these people they do great. They don’t need anything else.

For a lot of these people, however they may still have some residual joint issues. If somebody has one or two joint issues you can still treat that with some of the regenerative treatments rather than relying on steroid injections or anti-inflammatory medications or chronic narcotics. In the case of my patient, he has Ankylosing Spondylitis. In general he is doing quite well with overall control of his condition with medication. He does, however, still have some residual hip issues. He has pain in the right hip along the side of the hip that also goes down the leg. On his imaging he has very mild arthritic changes in the right hip. The most important thing in his imaging is that he has fused SI Joints on both sides.

The sacroiliac joints sit in between and connect the pelvis to the lumbar spine, is a key support in the pelvis, offers significant stability, and offloads the stress that goes through the hip and the pelvis. So if somebody has a fused SI Joint they’re prone to not only lower back pain they can also be prone to hip pain as well. In this gentleman’s case, my sense has been that a lot of his pain is actually coming from his SI joint being fused and then secondarily developing stress in the hip. Not only the hip joint, but also the hip ligaments and the hip tendons as well. That is based on clinical examination, diagnostic ultrasound, and clinical feel and experience.

In this case what I recommended was platelet-rich plasma where we’re taking a sample of his blood, concentrating into a high concentration of his own platelets called platelet-rich plasma, and then injecting that into the hip joint. Specifically injecting 14 times concentration platelet-rich plasma into the hip joint then injecting platelet lysate into the hip joint as well and ligaments around the hip. He also has hip flexor symptoms as well and I injected platelet-rich plasma into the hip flexor tendons. And then lastly also injecting around the ligaments of the SI joints. You can not actually inject into his SI Joints in this case because the joint is fused. I can, however, inject into the SI ligaments improving support and stability, which will then also help his overall pain symptoms.

So that is how I would approach someone who has an autoimmune or inflammatory condition. Control the systemic issues and then start dealing with the residual remaining things as well to get somebody better. Hopefully he gets a good result and hopefully that’s gives you a better sense for how to treat these kinds of situations.

 


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MEDICAL ADVICE DISCLAIMER: All content in this message/video/audio broadcast and description including: infor­ma­tion, opinions, con­tent, ref­er­ences and links is for infor­ma­tional pur­poses only. The Author does not pro­vide any med­ical advice on the Site. Access­ing, viewing, read­ing or oth­er­wise using this content does NOT cre­ate a physician-patient rela­tion­ship between you and it’s author. Pro­vid­ing per­sonal or med­ical infor­ma­tion to the Principal author does not cre­ate a physician-patient rela­tion­ship between you and the Principal author or authors. Noth­ing con­tained in this video or it’s description is intended to estab­lish a physician-patient rela­tion­ship, to replace the ser­vices of a trained physi­cian or health care pro­fes­sional, or oth­er­wise to be a sub­sti­tute for pro­fes­sional med­ical advice, diag­no­sis, or treatment. You should con­sult a licensed physi­cian or appropriately-credentialed health care worker in your com­munity in all mat­ters relat­ing to your health.
 

Sausage Digit in Psoriasis

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What is a Sausage Digit in Psoriasis?

In this video, you’ll learn what it means to have a sausage digit if you have psoriasis.

Hello, this is Siddharth Tambar from Chicago Arthritis and Regenerative Medicine, where we specialize in evaluation and treatment of arthritis, tendonitis, injuries, and back pain.

Sausage digit, this is a strange but well known condition that you can see in psoriasis. To begin with, what is psoriasis? Psoriasis is an autoimmune condition that affects the skin. By auto immune condition, I mean your immune system, which is meant to normally protect you from anything foreign including bacteria and viruses, is inappropriately recognizing your own body as foreign. In the case of psoriasis, it’s specifically your immune system is recognizing your skin as foreign, and is essentially attacking it causing inflammation which then causes the skin lesions that you see classically in psoriasis.

So in roughly 20% of psoriasis patients, psoriatic arthritis can occur. Psoriatic arthritis is that same inflammatory process that you see in the skin is now occurring in the musculoskeletal system. Including in the joints, the tendons, and ligaments.

So what is a sausage digit in psoriasis? The medical name for it is called dactylitis which essentially means swelling of an extremity or finger, or toe. So specifically dactylitis or sausage digit is essentially inflammation that is occurring throughout an entire digit. And you can see that in the fingers or the toes, the specific structures that get inflamed include the joint, the tendon, and the ligaments. And because it’s all three of those structures that are swollen and inflamed, what you see is a finger or toe that is distended throughout the entire length of the digit. That’s different than what you see if you only have inflammation within the joint where it’ll only be a more specific swelling around that specific joint, rather than throughout the entire digit.

The classic presentation for dactylitis or sausage digit is swelling of a digit and if you have psoriasis. So there are a number of other conditions that can also cause dactylitis including some infections, as well as sarcoidosis, which is another type of autoimmune condition. But the classic presentation for sausage digit is still seen in psoriatic arthritis. So when should you suspect that you could have dactylitis? Well, to begin with, if you have psoriasis or the classic lesions that you see in psoriasis, and if you notice that one of your fingers or toes is completely painful and swollen.

What you should do next is essentially see your rheumatologist or at least see your dermatologist, if that’s who’s been taking care of your psoriasis. Based on an examination, there should be some suspicion that you could have a sausage digit. It has a very characteristic look to it. One that if you’re used to treating psoriatic arthritis patients, is really pretty classic and undeniable. Why I find then to really confirm that diagnosis is if right there, in the exam room, if your physician or rheumatologist can then do a diagnostic musculoskeletal ultrasound, where they specifically look at the finger or toe that is actually swollen and painful, and they can then see whether the joint, tendons, and ligaments are all swollen and inflamed. If your physician is recommending an x-ray or MRI, generally speaking, an x-ray is not going to really show you what you need to see in dactylitis. It’s only looking at the bones. You can sometimes see some chronic changes in the bones that you can see in chronic dactylitis, but it’s really not the right imaging study if you’re looking for active inflammation. An MRI can be helpful as well. But is dramatically more expensive and really unnecessary if your physician has the skills actually look at a musculoskeletal ultrasound and make that diagnosis immediately.

Treatment of dactylitis, is very similar to treatment of psoriasis. Meaning that if you’re not getting better with very conservative treatment for your psoriasis, generally speaking, your physician will escalate you to some of the newer medications that have been around for the last 25 years or so. The newer medications are biologic medications do a better job of treating psoriasis, and they can do a much better job of also treating dactylitis. So if you have a sausage digit where you have that degree of inflammation and pain and swelling, I generally will recommend that you consider one of those medications because it’s really not safe to allow that digit to remain that inflamed. The risk is that you’ll then progressively develop not only pain and inflammation, but eventually damage and more permanent damage in the joint and tendons that are actually inflamed and injured. That’ll then lead to more chronic deformities, more chronic pain, and chronic instability in that joint which then leads to other problems as well. You can treat that when it’s very inflamed with the newer medications which will then do a much better job of treating not only the active inflammation but then also preventing the progression of that condition as well.

Sausage digit, it’s a unique and strange name that we have for this condition seen in psoriasis and psoriatic arthritis. I hope this video has given you some better understanding of what’s involved in that condition, how we evaluate it, and how we can treat it.

If you found any value in this video, please give us a follow up or a like. And until we connect again, have a good day and live well, bye-bye.

 


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***For evaluation and treatment at Chicago Arthritis and Regenerative Medicine:
Determine if you are a Regenerative Medicine treatment candidate:
https://www.chicagoarthritis.com/regenexx-candidate-form/
Contact us for more information or to schedule an appointment:
https://www.chicagoarthritis.com/contact-us/

MEDICAL ADVICE DISCLAIMER: All content in this message/video/audio broadcast and description including: infor­ma­tion, opinions, con­tent, ref­er­ences and links is for infor­ma­tional pur­poses only. The Author does not pro­vide any med­ical advice on the Site. Access­ing, viewing, read­ing or oth­er­wise using this content does NOT cre­ate a physician-patient rela­tion­ship between you and it’s author. Pro­vid­ing per­sonal or med­ical infor­ma­tion to the Principal author does not cre­ate a physician-patient rela­tion­ship between you and the Principal author or authors. Noth­ing con­tained in this video or it’s description is intended to estab­lish a physician-patient rela­tion­ship, to replace the ser­vices of a trained physi­cian or health care pro­fes­sional, or oth­er­wise to be a sub­sti­tute for pro­fes­sional med­ical advice, diag­no­sis, or treatment. You should con­sult a licensed physi­cian or appropriately-credentialed health care worker in your com­munity in all mat­ters relat­ing to your health.

 

Why does my shoulder hurt when playing tennis?

Shoulder pain with tennis
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On this video, you’ll learn about why your shoulder hurts when you’re playing tennis.

Hello, this is Siddharth Tambar from Chicago Arthritis and Regenerative Medicine, where we specialize in evaluation and treatment of arthritis, tendonitis injuries, and back pain. Shoulder pains are a common injury and symptom that people who play tennis experience. And the reason why is because of the above the head activity that’s done when you’re serving and hitting overheads.

To understand this you have to first understand the anatomy that’s involved at the shoulder. To begin with, there’s three different joints, the glenohumeral joint, the acromioclavicular joint, and the sternoclavicular joint. These are supported by multiple different layers of soft tissue structures, including the rotator cuff tendons. That’s four different rotator cuff tendons as well as a biceps tendon that help to provide power and support with the shoulder as it goes through a range of motion. There’s also quite a few different ligaments that help to attach the bones together. These ligaments provide stability as your shoulder is moving through that range of motion. There’s quite a few different nerves involved as well that starts with the nerves that come from the neck, then the brachial plexus, and then the peripheral nerves. These nerves help it coordinate and control your range of motion as your shoulder is in action. When all of this is combined together, your shoulders are able to go through a very wide range of motion with strength and stability and without pain.

If you have pain, it’s a sign that one part of that anatomy or process has been injured or is dysfunctional. The concept of biotensegrity, which means that the overall structural unit is stronger than the individual components, would indicate that if you have even one structure that’s not working optimally, it can then cause significant pain and dysfunction throughout the entire shoulder.

To understand why you can develop pain if you’re playing tennis, it’s important to understand the overall injury pattern that classically develops. Typically when you’re swinging above the head, such as when you’re either hitting an overhead, or with a serve, you are putting additional stress on the structures of the shoulder. As an example, if you have a strain in one of the ligaments of the shoulder, in particular the inferior glenohumeral ligament, that can lead to instability in that shoulder joint, which then leads to more stress on the rotator cuff above the ligaments, which then ends up leading to an injury of the rotator cuff tendons. Which can then either just be a mild injury or even a tear. That injury then can then lead to more stress on the acromioclavicular joint which sits even further above the rotator cuff tendon. All that combined together is what then leads to pain and dysfunction. What’s important to understand is that these are layers of tissue on top of each other that move in a coordinated fashion. As one layer gets injured, the layers above and below that can then also be injured and progressively get damaged.

So what should you do if you have an injury to the shoulder as a tennis player? First and foremost, obviously rest. Alter any of the activities that may be aggravating the pain as well. I would strongly recommend also having your serve videotaped, and the reason why is because if there’s any abnormal motion as you’re serving that’s putting more stress on the shoulder, that’s something you’d want to correct, mainly because if you’re putting additional stress on the shoulder in order to develop power or control during your serve, you need to correct the motion that’s driving that, otherwise you’re going to continue to put unwanted stress on the overall shoulder.

If you’re not getting better with just conservative management, as I’ve described you then should get evaluated by an appropriate physician who has experience in treating and evaluating shoulder injuries. A good history and exam is a good first step. I strongly recommend doing a diagnostic musculoskeletal ultrasound at the bedside while you’re actually being evaluated. And the reason why is cause you can actually look at the rotator cuff tendons at rest and in dynamic motion to see if there’s any stress. You can also see if there’s any instability or impingement on the tendons as well, which can then pretty quickly give you a diagnosis and then give you a set of steps for helping to get better. MRI can be useful as well. In particular, if you need to look deeper at the level of the joint to see if there’s a labral tear or other kind of joint pathology as well.

First-line medical treatment for a shoulder injury in particular rotator cuff injury would be physical therapy, where they work on scapular stabilization, which then leads to progressive strengthening of the muscles around the rotator cuff tendon. That combined with changing, altering and improving your overall serve as well as overhead motions will help in terms of letting you get back to physical activity and playing tennis again.

If you’re not improving adequately with just that next step of medical care, I would then recommend an injection treatment. I don’t recommend steroid injections in general for shoulder issues because it can damage some of the soft tissue. Appropriate other options would include dextrose prolotherapy, platelet-rich plasma, or bone marrow derived stem cells. The keys there are that they should be treating not only the tissue that’s been injured. For example, let’s say the rotator cuff tendon, but they then should be also treating the other soft tissue and other structures that may be implicated in your pain and overall injury pattern as well. So for example, in that prior injury pattern that I described, they should be treating not only the tendon that’s been injured or torn or that’s causing pain, but they should also be treating that were ligaments originally injured leading to instability in the shoulder to begin with.

Lastly, if your injury is too severe, for example if the rotator cuff tendon is fully torn and blown out, surgery would be an important and next step to consider as well. Keep in mind that even after any kind of reparative process and recovery from that injury, if you haven’t fixed what’s actually driving the pain to begin with, the overall movement pattern or the overall generalized weakness that may be driving that, that you will be prone to that kind of injury again unless you fix what was originally causing the problem.

Thank you for your time. If you found this content to be educational, interesting or useful, please give us a like or follow us. And until we meet again, have a good day and live well, bye-bye.


 

***For more educational content:
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Listen to the Regenerative Medicine Report podcast: 
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***For evaluation and treatment at Chicago Arthritis and Regenerative Medicine:
Determine if you are a Regenerative Medicine treatment candidate: 
https://www.chicagoarthritis.com/regenexx-candidate-form/
 
Contact us for more information or to schedule an appointment: 
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MEDICAL ADVICE DISCLAIMER: All content in this message/video/audio broadcast and description including: infor­ma­tion, opinions, con­tent, ref­er­ences and links is for infor­ma­tional pur­poses only. The Author does not pro­vide any med­ical advice on the Site. Access­ing, viewing, read­ing or oth­er­wise using this content does NOT cre­ate a physician-patient rela­tion­ship between you and it’s author. Pro­vid­ing per­sonal or med­ical infor­ma­tion to the Principal author does not cre­ate a physician-patient rela­tion­ship between you and the Principal author or authors. Noth­ing con­tained in this video or it’s description is intended to estab­lish a physician-patient rela­tion­ship, to replace the ser­vices of a trained physi­cian or health care pro­fes­sional, or oth­er­wise to be a sub­sti­tute for pro­fes­sional med­ical advice, diag­no­sis, or treatment. You should con­sult a licensed physi­cian or appropriately-credentialed health care worker in your com­munity in all mat­ters relat­ing to your health.
 
***About this video***
In this video Siddharth Tambar MD from Chicago Arthritis and Regenerative Medicine discusses why you have shoulder pain when playing tennis.
 

How do I know whether my Hand pains are from Rheumatoid Arthritis?

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A common question I get from patients as well as from referring physicians and colleagues is when should you consider that somebody’s hand pains may be the sign of rheumatoid arthritis. I discuss my approach in this video.


If your hands hurt, when should you suspect that you may have rheumatoid arthritis?

A common question I get from patients as well as from referring physicians and colleagues is when should you consider that somebody’s hand pains may be the sign of rheumatoid arthritis. To start with, what is rheumatoid arthritis? Rheumatoid arthritis is an autoimmune condition which means that your immune system, which is made to protect you from viruses and bacteria, unfortunately recognizes your own body. In this case, your joints as being foreign and then causes a reaction where the immune system is attacking the joints and tendons that it recognizes as problematic. This leads to inflammation, swelling, pain eventually damage and dysfunction in the joints. Classic symptoms of rheumatoid arthritis include pain and swelling in the small joints, meaning the hands and the feet. Typically pains are worse with rest and better with activity.

Diagnosis is generally made by a combination of classic history, examination findings, imaging findings, and labs as confirmation. So when should you consider that you may have rheumatoid arthritis. First and foremost, do you have the classic symptoms of this condition. Namely, pain and swelling in the hands and the feet. Symptoms that are classically worse first thing in the morning and better with activity. Pains that are generally worse with activity and better with rest, are generally caused by wear and tear arthritis or tendonitis rather than your immune system such as rheumatoid arthritis. In addition, these symptoms tend to be chronic, meaning symptoms that have been ongoing for more than six weeks. They don’t spontaneously resolve on their own.

So if you have these classic symptoms in your hands what are the next steps that you should take? I would strongly recommend seeing a board-certified clinical Rheumatologist. Most physicians, whether that’s your primary doctor, orthopedic surgeon, or other types of doctors who are used to seeing pain, they’re not used to seeing these kind of autoimmune conditions. A Rheumatologist at that point then should be able to take a look at your history of how you’re describing your symptoms. Then doing a thorough examination to look for inflammation in the joints. And then utilizing imaging as well.

The imaging study that I strongly recommend is diagnostic musculoskeletal ultrasound. Unfortunately, most rheumatologists are not using this at the bedside in a routine manner. If they do however, they can very quickly and efficiently see whether or not you have inflammation in the joints rather than having to wait for an MRI. X-rays on the other hand are not very helpful for looking for inflammation. They are helpful if you’re looking for wear and tear arthritis. And MRI can be very detailed and helpful for looking for inflammation. But again, ultrasound can be done at the bedside and is a lot cheaper and a lot faster to help make your diagnosis.

Lastly, the kind of labs that they should be looking for include; do you have the classic antibodies such as the rheumatoid factor and CCP antibody, as well as if you have inflammation on the labs including labs such as your SED rate and CRP test. The last thing is, they should be trying to rule out other conditions such as wear and tear arthritis, if your thyroid number is off, if you have other types of endocrine or hormone-related etiology for pain. If you have nerve-related pain or anything else that could be causing your symptoms at that time.

Based on all of that, they should be able to make a diagnosis or rule out rheumatoid arthritis in a relatively efficient and reliable manner. And then, based on making your diagnosis, they then should be able to put you on the right track for treatment for the cause of your pain and swelling.


***For more educational content:Sign up for our email newsletter: https://www.chicagoarthritis.com/newsletter/
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Listen to the Regenerative Medicine Report podcast: https://www.chicagoarthritis.com/regenerative-medicine-report/


***For evaluation and treatment at Chicago Arthritis and Regenerative Medicine:Determine if you are a Regenerative Medicine treatment candidate: https://www.chicagoarthritis.com/regenexx-candidate-form/
Contact us for more information or to schedule an appointment: https://www.chicagoarthritis.com/contact-us/


MEDICAL ADVICE DISCLAIMER: All content in this message/video/audio broadcast and description including: infor­ma­tion, opinions, con­tent, ref­er­ences and links is for infor­ma­tional pur­poses only. The Author does not pro­vide any med­ical advice on the Site. Access­ing, viewing, read­ing or oth­er­wise using this content does NOT cre­ate a physician-patient rela­tion­ship between you and it’s author. Pro­vid­ing per­sonal or med­ical infor­ma­tion to the Principal author does not cre­ate a physician-patient rela­tion­ship between you and the Principal author or authors. Noth­ing con­tained in this video or it’s description is intended to estab­lish a physician-patient rela­tion­ship, to replace the ser­vices of a trained physi­cian or health care pro­fes­sional, or oth­er­wise to be a sub­sti­tute for pro­fes­sional med­ical advice, diag­no­sis, or treatment. You should con­sult a licensed physi­cian or appropriately-credentialed health care worker in your com­munity in all mat­ters relat­ing to your health.

Why Do I Have Pain Under My Knee Cap?

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Why Do I Have Pain Under My Knee Cap?
Pain under the knee cap, or patellofemoral pain, is a common issue I see. Learn more about this condition, the issues involved, and treatment options in this video.


 

What does it mean if you have pain underneath your kneecap, and what can you do about it?

Pain underneath the kneecap, also known as patellofemoral joint pain, is frequently described as pain underneath the kneecap, in front of the knee, around the knee as well. It’s typically pain that’s worse with prolonged standing, as well as if you’re going up and down stairs.

The patellofemoral joint is the articulation between the patella, also known as the kneecap, and the femur, the thigh bone. The structures that are involved there include the cartilage in between those two structures. Generally, there’s not very much fluid within that knee joint. There’s a normal alignment where the kneecap fits in the middle of the femur, along the trochlear groove. There are a number of soft tissue structures that are very key as well, including the ligaments, such as the medial patellofemoral ligament, lateral patellofemoral ligament, as well as the plica, that help to stabilize the lateral, or right and left motion of the kneecap. There’s also the quadriceps tendon and the patellar tendon above and below the knee that help to stabilize the kneecap as well. It’s also important to remember that the structures above and below the knee make a big difference in terms of what happens in the knee as well. So that would include at the ankle, the hip, and the lower back as well.

When there’s pathology or dysfunction in the patellofemoral joint, people are frequently complaining of pain in front of the knee, behind the knee, and around the knee. They frequently also describe swelling. Those symptoms, as well as classic examination findings, help to make a diagnosis of patellofemoral pain. Classic examination findings include the patellar compression test, where you compress the patella and have an individual contract their quadricep, and if they have significant pain, that can indicate that they have patellofemoral-related pain.

Imaging can make a big difference as well. X-rays can show whether the kneecap is properly aligned within the knee groove. In addition, it can also show if there is significant narrowing within the patellofemoral joint. Diagnostic musculoskeletal ultrasound is also helpful for looking for alignment. It’s also very helpful for telling if there’s any significant instability within the joint. You can also detect very small amounts of fluid that people may not actually be complaining of. MRIs are generally not to make this diagnosis. However, you can find swelling in the bone, also known as a bone marrow lesion, that can be seen if there’s significant stress within the patellofemoral joint.

Treatment for patellofemoral-related pain includes a number of different things. First and foremost, weight loss and ideal body weight can make a big difference. As much as possible as you can reduce excess body weight will help to reduce stress on the knee as well. Alignment is a big part of helping with knee pain as well, in particular, patellofemoral pain. Bracing, knee bracing can be helpful in that regard. Also in that regard, instability and alignment can also be improved with physical therapy. Strengthening the appropriate muscles of not only the thigh but also of the hip, can make a big difference as well in terms of patellofemoral-related pain. I frequently recommend over-the-counter supplements such as glucosamine, omega-3, and curcumin for knee related pain in general. That can certainly be helpful in patellofemoral-related pain also.

There are a number of different types of injections that can be helpful for patellofemoral-related knee pain. Steroid injections are most commonly given. It can give pain relief. Typically does not give longer term pain relief. It’s also not also very helpful and healthy for the joint long-term, so I generally try to get people to avoid that if possible. Hyaluronic acid injections can be useful for pain relief, in particular, if somebody has mild to moderate osteoarthritis. Dextrose prolotherapy is the first-line regenerative medicine treatment that’s helpful for mild to moderate patellofemoral osteoarthritis. It can help with not only pain but also instability due to hypermobility and chronic instability in the knee cap and the knee joint. Platelet-rich plasma is also helpful for moderate level osteoarthritis in the knee. Bone marrow derived stem cells are also helpful for more moderate to advanced level knee osteoarthritis and patellofemoral osteoarthritis. And also consider radiofrequency ablation, where you’re basically treating the nerves that cause pain around the knee as well.

The results to expect from these sorts of injection treatments generally include pain relief and functional improvement and getting back to a high quality of life. It’s not necessarily going to significantly improve what your imaging looks like on x-ray, ultrasound, or MRI. But if your goals are to feel better and to live a better lifestyle, then these kind of treatments can certainly make a big difference.

Surgery is generally not recommended for patellofemoral knee pain. Certainly arthroscopy does not make sense if you have knee pain from patellofemoral osteoarthritis in large part because there’s no evidence that it will actually help in terms of longer lasting pain relief in comparison to just physical therapy. Knee replacement, however, may be needed if you’re failing the above treatments that I’ve already mentioned.

I hope that gives some explanation and understanding of what’s going on if you have pain underneath the kneecap. If you found this content interesting and helpful, consider subscribing, giving us a like, and until we connect in the future, have a good day and live well. Bye bye.