Inflammation and Instability in Joints and Tendons
Weekly Education meeting 20200810
Topics
-Inflammation and Instability. Addressing both at the same time in patients.
-3 cases
- Chronic Sacroiliac joint instability in a Chrons disease patient.
- Chronic hand pains in a rheumatoid arthritis patient.
- Chronic wrist pain in a sjogrens patient.
-Personalization in regenerative medicine treatment based on someone’s medical history.
-Knowing when to pause on treatment, treat mildly, and when to treat more aggressively.
Content- Weekly Education
Live Weekly educational meeting for the team at Chicago Arthritis and Regenerative Medicine where we discuss the basics of what we do for arthritis, tendinitis, injuries, and back pain.
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Hello, this is Siddharth Tambar from Chicago Arthritis and regenerative medicine. It’s August 10th, 2020. Welcome to our weekly educational meeting that we broadcast live. On this meeting I am essentially discussing questions that either my team is discussing with me kind of live in person or questions that they have, that they’re bringing to my attention either from themselves or from patients. Where we’re focused on musculoskeletal conditions. So at Chicago Arthritis, our expertise and focus is on evaluation and treatment of arthritis, tendonitis, injuries and back pain. Utilizing the most current and up-to-date treatments available to treat these conditions, to improve your pain, improve your function, and get you back to doing the things that you enjoy with the people that you care about. So– You know, I think a lot about inflammation and instability. That is literally my sort of bread and butter, what I’m doing every single day at work. And that’s partly because what I, you know, I am trained as a clinical rheumatologist and see a lot of inflammatory arthritis patients. And because I’m also have a focus and expertise in regenerative medicine where we’re constantly focused on degenerative arthritis, tendonitis, injuries, and instability issues. And frequently, you know, from a mental framework, I think about these things as separate issues. But the reality is that they’re frequently very intertwined and connected. And it’s helpful to think about them separately because there are different issues for each one of these. On the other hand, they’re frequently intertwined as well. And so while inflammation really requires a very dedicated and specific way of looking at things in stability has a completely different way of looking at things. And what’s interesting is that when you sort of bring them together, you get a more comprehensive understanding of the musculoskeletal system and when and how to treat them. Because each one of them has a very different focus and approach to treatment and a very different treatment set of algorithms and tools that we can utilize. But what’s interesting is that I do have patients on the inflammatory end that also have a lot of those instability issues. And so we know that inflammatory arthritis patients such as rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis patients, that they do also have much higher rates of degenerative arthritis, tendonitis, tendinopathies as well. And so these are frequently intertwined. And I’ve had, I think three cases last week that really helped to explain that, or, sort of exemplify that. Where you can have inflammation and instability issues and some of the subtleties involved with how you look at that. So the first case I’ll mention a is patient I’ve known for about a year and a half, where she has an underlying Crohn’s inflammatory bowel disease, meaning inflammation in her gut. That’s also caused inflammation in her SI joints in the past, and some other kinds of tendon related issues. So I saw her about a year and a half a year ago, and her Crohn’s disease was still a bit active, but she was having a lot of hip, SI, lower back pain symptoms. And at that time I told her, because she was already taking a medication for her Crohn’s disease, was you really need to sit down with your gastroenterologist first and foremost, because if you do have active inflammation in your body in your gut, you really need to treat that first before we even start to evaluate anything going on in your SI, hips, lower back area. So she went through that process and it literally has taken her about a year to kind of help to resolve those issues, work through them, sort through what is actually inflammation in the gut versus not inflammation in the gut. And changing her diet, changing her medications, working really in a dedicated fashion with her gastroenterologist, try to figure this out. And finally, after about a year, she’s been able to sort it out and she still has this residual SI, hip, lower back pain symptoms. And now that she’s kind of gone through that process of working through the inflammation component, now that she still has some of the instability issues in her SI joints that are driving her pain, she’s got some mild early arthritic issues in her facet joints, some instability in the lower back, as well as some instability in the hips. We were now able to then progress to the next level of treatment. In her case based on various factors, we ended up utilizing Bmac, as well as, which is bone marrow aspirate concentrate stem cells as well as adipose, some platelets to help treat some of those issues for her. I think she’ll do well now because we treated the inflammation issues first. And it’s taken a little bit longer to get to that, but it’s the right way to do it, right. Treat the bigger issue first, the inflammation, then get to the instability issues. Case number two, is a colleague of mine based on the west coast had asked about a patient of his whose got rheumatoid arthritis and was coming to him for hand pains. And he had questions about, well you know, what’s the right way to approach this? What’s the right way to treat this? And you know, the reality is that inflammatory arthritis or rheumatoid arthritis, he’s not a rheumatologist. So it’s not really in his wheelhouse. And my suggestions were first and foremost, you really need to figure out, is there systemic inflammation, total body inflammation that’s going on? because if there is, that’s the big picture you need to treat that. Whether that’s what diet, supplements, medication, you need to address that first and foremost, because that’s gonna drive more of the problems than anything else. And– You know, he can do that in multiple ways. Obviously probably he should work with a clinical rheumatologist that can help them out with that. But he mentioned that this patient had a lot of hand pains and wrist pains. And so the first thing I suggested was, well, if the patient’s there with you, you’ve already got a relationship with a patient, do a diagnostic musculoskeletal ultrasound, right in the office. If you do a diagnostic ultrasound, you can take a look at the affected joints, the hand and the wrist joints. And you can tell, is there active inflammation or is there really just chronic damage? So how do you tell the difference? Well, there are a couple of things. Number one, if this patient’s complaining of some swelling in her hand, which you can visibly see or feel, you can take under a look under ultrasound, and you can tell if somebody has an effusion, which means fluid in the joint. Or you can tell if they have chronic irritated, joint lining, which is called synovial hypertrophy. So an effusion, which is truly fluid in the joint is an active, generally acute or subacute issue. And on ultrasound, the way that you see that is you see fluid in the joint, and then as you compress it dynamically under ultrasound, if it’s truly fluid, it’ll basically move out of the way. All right. It’s a dynamic finding that you can help to confirm. Synovial hypertrophy on the other hand, which means someone who’s had prior inflammation and now has a chronic irritation of the joint lining that looks distended and swollen in its own regard, but it’s not actually fluid in the joint. It’s just chronic irritation of the joint lining. You can tell that because number one on ultrasound, it has a different look than fluid in the joint. Number two, when you dynamically compress it, you don’t actually move that out of the way, it stays there. It’s a fixed finding, it’ll always be there. So that’s number one. You can tell if something is an acute effusion versus something that is more chronic synovial hypertrophy. The first, which is more fluid in the joint is more inflammation the joint, is a sign that the rheumatoid arthritis is more active. The second, the synovial hypertrophy is more a sign of just prior inflammation. The second thing that he can look at is under ultrasound, does this patient have what’s called Power Doppler uptake on ultrasound? Essentially Doppler is looking at movement. And if you’re looking at joints and tendons, normally you do not find blood flow. So if you look at a joint or a tendon and someone’s at rest, there should be nothing that’s moving. If you do see something moving like a blood vessel, that’s a sign of inflammation in the joint. Now, as a technology has gotten better under ultrasound, you can start to pick up smaller little blood vessels that are not actually in the joint or the tendon that are not actually indicative of inflammation, but are just a normal vessel. Someone who’s experienced with ultrasound will be able to tell the difference, just because they can tell where the blood vessel is. Is it in the joint? Is it in the tendon? Is it normal? Is it abnormal? But that’s a really key subtle finding to help tell if someone has active inflammation versus chronic damage. And in this patient’s case, if she has active inflammation, she really should get that addressed properly in the same ways that I discussed with that prior patient. Meaning controlling the systemic inflammation either with again, meds, supplements, diet. And after that’s been done, then reevaluate and then decide if it makes sense to pursue treatment. His second question to me was what treatment to utilize. So he is someone that specialized in regenerative medicine. And if this patient has chronic arthritic changes, what would be a better fit for her? And so he asked, well, should he use something like alpha-2-Macroglobulin, which is a naturally occurring anti-inflammatory chemical in the blood. Or should he use platelet rich plasma. Or should he use something else. My suggestion to him was that knowing how aggressive rheumatoid arthritis can be that if she does have chronic damage in the joint, and if there is even just a little bit of inflammation, but it’s subtle, that this patient’s better off utilizing her own bone marrow derived STEM cells, rather than a blood based product, like alpha-2-Macroglobulin, like platelet rich plasma. Because it’s just a more aggressive condition. And within bone marrow aspirate stem cells, you do have anti-inflammatory chemicals, including alpha-2-Macroglobulin, as well as interleukin receptor antagonist protein. And so for this patient first and foremost, understand is it active inflammation or chronic damage? Treat accordingly. Number two, utilize the right cell based treatment if you need to in this patient as well. The last one is a longtime patient of mine who’s got chronic Sjogren’s. Which is an inflammatory condition that can cause not only dryness in the salivary glands, dryness in the mouth, the eyes, but can also cause inflammation in the joints. In her case though, she actually doesn’t have significant active inflammation right now, which her presenting complaint was a lot of wrist pains. So she is a longstanding knitter. She knits a ton. That’s just something that she really enjoys doing. She was also a baker in the past. So she’s developed a lot of hand and wrist pains. She has incidentally also had surgery over the tendons of her right wrist in the past for a condition called De Quervain’s tenosynovitis. Which essentially means inflammation over the radial part of the wrist. And she got temporary relief in the past, but she continues to have problems there because she has chronic tendonitis. She’s also developed chronic osteoarthritis in that thumb joint as well. And so the treatment that I’ve done for her two times in the past, once I think roughly four or five years ago, and then another time last year, was prolotherapy. Utilizing a very low concentration of sugar water to inject that into the tendons, the ligaments and the joint, creating a mild inflammatory reaction, which then provides better stability, better optimization of the tendon as well. Which then leads to pain relief and better function. She tends to do pretty well with this treatment every few years, to basically keep her pain at a reasonable, controlled level, allowing her to continue to knit and function at a incredibly high level. Interesting in this case, because I chose not to recommend a more aggressive treatment like platelet rich plasma or bone marrow aspirate stem cells in part because I felt like her underlying other medical issues, she’s got significant diabetes. She’s got some chronic neuropathy associated with that. She’s got some other medical issues as well. My sense was that she’s someone where utilizing a less aggressive treatment but a more mild treatment could still get her pain relief and functional improvement. And her goals were relatively reasonable. Which is she wanted to get 40, 50 percent pain relief, so she could continue to knit. And utilizing a milder treatment rather than a more aggressive treatment, still got her to the place that she wanted to. And understanding the inflammation component here, but understanding the instability component is really what got her to a result that she wanted. Lead me to the last step, which is that a lot of times in medicine these days, we are starting to think of it as almost an algorithmic process. And the reality is that a lot of medicine is very much a can you recognize presenting problems? Can you identify some of the details of this particular person? And then can you utilize a proven effective treatment? And that really makes up 80 percent of medicine. The reality is that there is still personalization required. And so that 80 percent progressively in medicine is being made up or is being filled in the gap instead of with experienced physicians is being filled in the gap with younger physicians, who don’t quite have as much experience. It’s being filled in the gap with mid-levels, nurse practitioners, physician assistants, who can reach a certain high level as well. And it’s even going to be filled in the gap with artificial intelligence. And there’s a role for all of these things, but the reality is that extra 20 percent, 10 to 20 percent, that requires personalization, that requires understanding when something is atypical and understanding when to vary your speed of aggressiveness of treatment an experienced knowledgeable physician adds a huge amount of value to that. Personalization, because for me to tell a patient, listen, yes, you have chronic SI related pain, but you also have Crohn’s disease. Why don’t we make sure that one part is taken care of the Crohn’s part, before we jump into treating the SI. It’s not a here, you got SI, joint pain, let’s treat it with X right away. It’s understanding this particular person and her particular problem and treating it appropriately. Atypical because you look at this individual, her presentation is a little bit different than maybe my typical patient who comes in with SI related pain. So understanding when something is on that same kind of normal trajectory versus something that’s a little bit atypical and off that makes a huge difference. And then lastly, knowing when to maybe pause instead of proceeding with treatment. Knowing when to treat mildly, meaning maybe even just using prolotherapy rather than something stronger. And then knowing when to treat a bit more aggressively. Knowing that, hey, this particular case would do better with bone marrow derived stem cells than with just platelets. There’s a lot of subtlety to some of these things. A lot of times we look at musculoskeletal conditions as very much a hammer and nail kind of issue. But the reality is there’s a lot more subtlety to this and a keen and fine understanding of when inflammation is driving things, when instability is driving things, and when the two are combined together and intertwined. And how to piece them out and treat them both selectively, appropriately, at the same time, in combination, can make the big difference in terms of somebody who has a minimal benefit versus somebody that has a dramatically better benefit. Which then means someone who has a lot less pain, someone who has a much better functional improvement, and someone who’s generally a happier patient. Great. Well, thank you for your time. As a reminder, I do this two times per week, Mondays and Wednesdays. Live both times. You can catch the replay, which will be posted as well as with captions, as well as a written aspect to this on the website. And until next week or until on Wednesday, have a good day. Live well. Thank you for your time. Bye bye.
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About this video
In this video Siddharth Tambar MD from Chicago Arthritis and Regenerative Medicine discusses inflammation and instability in joints and tendons.