PT Classroom - When an “itis” is not an “itis” ׀ by Bryant J. Walrod, MD

Many times in medicine we come across terms that are misnomers or do not accurately reflect the true pathologic process occurring. Unfortunately, our treatments may then be misdirected and not the most appropriate or effective for a condition.

A classic example of this is osteoarthritis. There are true inflammatory arthritic conditions like rheumatoid arthritis and gout, but osteoarthritis for years has been misnamed because there is no inflammation going on in the affected joint. Arthroscopic and cadaveric examinations of osteoarthritic knees demonstrate signs of degeneration and wearing down of the joint with an absence of inflammation. This begs the question, “Why do we treat osteoarthritis with anti-inflammatory medications?” Are we simply benefiting from the analgesic affect of the NSAID and not the anti-inflammatory properties of the medication? This also calls into question the common practice of injecting cortisone into degenerative, worn out knee joints, when again there is no inflammation present and the side effect profile of cortisone can be concerning especially when it comes to chondrocyte toxicity. I much more readily reach for viscosupplementation for injection therapy for osteoarthritis of the knee. It just simply makes more sense to me.
 

This leads to the question, “What we are truly treating in conditions like tendonitis?” Granted, in an acute overuse injury, such as lateral epicondlyitis after a weekend of painting the garage, there is true inflammation occurring. But in the chronic case of refractory symptoms lasting for a month despite rest, there is little, if any, inflammation occurring. In fact, biopsies of tissue in chronic overuse conditions like lateral epicondylosis reveal absolutely no inflammatory cells; instead, simply degenerative and disordered healing of the tissue. Again, this makes me question, why one would inject cortisone into this area. What is the true pathologic process occurring, and what are we attempting to treat?

We also need to look at NSAIDS taken by mouth for chronic overuse tendinoses. The side effects of NSAIDS are numerous, including GI bleeds, renal disease, bleeding, and hypertension. There is also mounting evidence that NSAIDS may be detrimental in the necessary healing process after an acute injury in animals and humans. Some inflammation is a good thing and is needed for proper healing. Too much inflammation can, of course, be detrimental to healing and needs to be addressed, especially in conditions when the inflammation may be causing neurovascular compromise. But the practices of routinely suppressing the bodies own natural response to injury needs to be questioned.

A recent study comparing Tylenol to Advil in the treatment of acute ankle sprains demonstrated no difference in pain, range of motion and return to play. This supports the idea that maybe the key component in treating injuries is treating the pain, allowing for earlier range of motion and mobilization of fluid. This “active rehabilitation” speeds recovery as we work with our bodies to encourage increased blood flow and recruitment of necessary healing mediators to the injury site.

This concept has spurred interest in modalities aimed at trying augment the bodies’ amazing healing potential. In conditions of chronic overuse tendonoses, modalities such as prolotherapy, autologous blood injections, and platelet rich plasma injections have demonstrated much promise.
 

Prolotherapy refers to injecting a pro-inflammatory agent into a chronic non-healing tendonosis to recruit the bodies’ inflammatory process to spur growth of new and stronger ligaments and tendons. I like to inject simple dextrose which “turns on” the bodies’ innate ability to heal. Dextrose is recognized as foreign by the body and it sends inflammatory mediators there to heal it. This process stimulates lying down of Type I collagen in a linear fashion instead of disordered bundle of scarring that is typical in chronic tendonoses. Histological studies demonstrate an increase in thickness and mass in ligaments treated with prolotherapy. Prolotherapy has demonstrated effectiveness in conditions like medial and lateral epicondylosis, piriformis syndrome, gluteus medius and minimus tendonopathy, Achilles tendonopathy, posterior tibial tendonopathy, quadriceps and patellar tendonopathy, and hamstring tendonopathy.

Another exciting concept is injecting one’s own blood to stimulate a healing cascade. Blood is rich with growth factors that assist repairing damaged tissues. The concept is similar to prolotherapy, whereas one injects blood into the area of tendonopathy to stimulate the bodies’ healing cascade.

Finally, the most exciting treatment modality for treating poorly healing tendonopathies is Platelet Rich Plasma (PRP). This is similar to autologous blood injections, but it involves pulling off only the platelets from the blood. Platelets are the portion of blood most densely packed with reparative growth factors. PRP has demonstrated to be an effective treatment for lateral epicondylosis and plantar fasciitis. In professional sports, it has been used to accelerate return to play after medial collateral ligament and rotator cuff injuries. It also can hasten recovery in partial muscle tears.

Increased understanding of the inflammatory process and so-called “inflammatory process” or “itis” has led me to re-examine typical treatment regimens. We need to respect the healing potential of our bodies and augment, not inhibit this amazing process.