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 Post subject: Persistent knee issues??
PostPosted: Thu Apr 24, 2008 5:09 pm 
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Q: I am writing on behalf of a patient with persistent knee issues due to a ski injury 5 years ago. She complains of profound soft tissue instability, which has not been resolved through 3 surgical interventions. Her original MRI revealed a complete tear of the ACL and medial meniscus tear. The initial injury triggered painful, burning nerve symptoms from knee to foot, which were diagnosed as RSD. Following resolution of the RSD, she had ACL reconstruction and both medial and lateral meniscectomy 4 years ago. Due to continuing complaints of instability, rotation, and misalignment in the knee, a second arthroscopic surgery was done to clean up a lateral meniscus tear and œtake a look inside the knee. There was no improvement. In fact, her condition worsened. Ultimately, a PLC (postero-lateral corner) reconstruction was done in an attempt to stabilize the knee, along with repair of a hyper-mobile lateral meniscus. This was done over 2 years ago. She still lives with tremendous instability and uses crutches. MRI™s and other diagnostics have not been helpful, as they are œstatic procedures, and doctors have agreed she has a œdynamic problem “ occurring with weight-bearing, sitting, driving, etc. This patient has been diligent with PT, working with therapists a total of about 3 years and maintaining a continuous home program. Post-surgically, she claims to worsen over time with PT, rather than seeing improvement. She has also given time to prolotherapy, chiropractic, and acupuncture, with no long-term positive effects. Due to constant shifting, rubbing, pinching, snapping, and popping, she has experienced significant diffuse nerve irritation in the back of her knee. A pain specialist (M.D.) has worked with her, and ultimately, Cymbalta has been the most effective for her nerve pain. Other medicines tried, but not helpful, were Neurontin, *, Naprosyn, and a topical Ketoprofen rub.

Dr. Marsha Prudden


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PostPosted: Fri Apr 25, 2008 8:43 am 
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A1: I and others, including Frank Shallenberger, have had great results with ozone (Prolozone) into the knee for a myriad of joint problems. I am now using a powerful infrared laser, 7000mw. It has been outstanding for pain in the several patients we have used it on. I have not yet used it on a knee, but I suspect it will do great there as well. Feel free to contact me directly for more information on the latter. For RSD, look for interference fields as well. The interference field could be coming from previous surgery or the injury itself.

Robert Jay Rowen, MD
http://www.secondopinionnewsletter.com


Last edited by Health Dr-1 on Fri Apr 25, 2008 8:47 am, edited 1 time in total.

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PostPosted: Fri Apr 25, 2008 8:44 am 
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A2: i can virtually promise you that 90% of all chronic knee pain cases, no matter what the cause, can be permanently cured using a few intra-articular injections of ozone...i have been doing this for over 15 years...i teach docs how to do this two times a year....check out my next seminar at http://www.ozonecourse.com ....by the way, i get the same results from painful shoulders (rotator cuffs, capsulitis, etc.), osteoparthritics hips and spines, and chronic neck and low back pain....

frank shallenberger, md


Last edited by Health Dr-1 on Fri Apr 25, 2008 8:48 am, edited 1 time in total.

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PostPosted: Fri Apr 25, 2008 8:45 am 
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A3: She needs a Stand-Up MRI scan of the knee where they can do a scan when she is in the position of the pain and instability. There are centers across the country. I just checked the following website http://www.sumamri.com to see if knee scans can be done, and yes, they can be. They show good photos and have some good info. I can't imagine that any alternative techniques would work, except possibly prolotherapy, which she has already had. She may need another surgery. But first, a diagnosis.
Linda Wright, MD, MD(H)


Last edited by Health Dr-1 on Fri Apr 25, 2008 8:48 am, edited 1 time in total.

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PostPosted: Fri Apr 25, 2008 8:45 am 
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A4: Would add level 4 FDA approved K-Laser for pain control, trigger point resolution, and healing at the enthesopathies that are present qod. Consider high quality brace for stabilization while mobile. Maybe candidate for intra-articular HGH/Testosterone for cartilage repair. Finally would persue endogenous stem cell therapy as per Dr Clark, St. Louis, MS.
Great job so far and good luck.
Steve Blievernicht, M.D., FACS

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PostPosted: Fri Apr 25, 2008 8:46 am 
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A5: 2 things may help. One is the BOSU <www.bosu.com> apparatus. This is a proprioceptive piece of execise equipment that hyperstimulates the neuromuscular junction causing regrowth of muscle, ligament and cartilage. Secondly, she should try the pentosan sulfate <http://www.dspharmacy.com> This glycoaminno glycan stimulates chondrocytes to grow new cartilage. Before and after weight bearing plain films show cartilage regrowth even with "bone on bone" anatomy.

Dr Roby Mitchell


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PostPosted: Fri Apr 25, 2008 8:50 am 
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A6: This is a difficult case.

Four possible options that come to mind are:
1. ozone injections into knee to tighten up soft tissue and help tissue regeneration, if not done in prolo
2. scar injections either on knee scars or distant scars that can be related to knee (neural therapy)
3, magnet therapy with the large magnets in Tucson, Northern Ohio, and elsewhere, per Dr. Dean Bonlie's work
4. Bee venom therapy SQ around knee. Can help with pain and neurological symptoms, whether or not Lyme is present intraarticular

Hope this helps

Robert Zieve, M.D.

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PostPosted: Fri Apr 25, 2008 8:50 am 
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A7: Hello Dr Marsha,
I am a holistic dentist, in Australia and you might be surprised that I am responding to you.

I can personally identify with some of the problems your patient is experiencing, as I also had a sports injury 40 years ago, which resulted in the removal of a medial cartilage in my left knee. The joint was also unstable, because most of my joints are hyper-mobile and I was unable to pursue many sports activities afterwards, apart from swimming.

Over the years, I have lived with chronic pain in the knee, as the bone cartilage wore down, and left the long bones ,grinding bone on bone. It was suggested that I consider a knee replacement , about 15 years ago. I did not wish to โ€œgo thereโ€. As a result of trying to protect my knee, I began putting more weight on the opposite hip, which began to get painful as well, especially the gluteal muscles, and I started to develop a sort of waddle , as many elderly people do . I had numerous therapies to relieve the pain, none of which had any lasting effect.

In the last 2 years, while continuing training in specialized areas of dentistry , with a special focus on the TMJ disorders, I discovered that certain types of malocclusions [ the bite, or the way teeth meet] can predispose one, to postural problems, which affect hips, and knees and feet, as well as the cranial bones. So, I began to have treatment, to change my bite, 1 year ago, and also had orthotics placed in my shoes. So, my posture was straightened up, from both ends. I am happy to report, that I no longer have pain in my knee, can walk normally, and my posture is straight. My hip pain has also gone. I am in my 60โ€™s.

There are dentists in your country, who understand this. In fact, I trained with a Dr Steve Olmos, who lives in San Diego, California. He can give you contact names of a suitable dentist, for your patient. It is worth a try, and it certainly worked for me.

Dr Inta Rudajs [ cereus]

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PostPosted: Fri Apr 25, 2008 8:51 am 
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A8: Dear Dr. Prudden:

Obviously not an easy case. However, simply put, I have found that in these types of cases, instability and weakness come from muscular hypertonicity. An extremely simply concept frequently mis-understood.

The error happens when PT's immediately begin a strengthening program after surgery when in fact this is exactly what you should not do.

Injuries induce a natural muscular protection mechanism which is commonly referred to as a spasm, hypertonicity or muscular tightness. You MUST clear out the spam, hypertonicity or muscular tightness before you begin any strengthening program. If you don't, exercises to a tight muscle makes a muscle even more tight which makes it even more weak. This leads to knees or joints popping, clicking, and ultimatley weakness. The general rule is that YOU CAN NOT STRENGTHEN A TIGHT MUSCLE!

First, you must clear the muscle of adhesions, scar tissue and hypertonicity. The most effective way is typically hands-on treatment such as deep tissue massage and / or Active Release Technique.

Once the muscle has been restored to normal tension, patients almost always state that their strength has returned and that the pressure or pain on their joints has disappeared. Now, the PT can begin their strengthening program if necessary.

You need someone like a registered massage therapist or Chiropractor trained in Active Release Technique to assess if the patient's muscles are hypertonic. If they are not, then obvioulsy I've been of no use to your case, LOL ! If they are, it's worth a shot.

I have also had cases where patients in similar situations still do not respond to massage and / or Active Release Technique. Some have had good success with Botox injections in the appropriate tight muscles.

Good luck, I'm sorry if I did not provide any insight into your case.

Sincerely,
Paul Biond, D.C. B.Sc.Kin.

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PostPosted: Fri Apr 25, 2008 8:52 am 
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A9; The first thing I would do is test the functional strength of the guadriceps and other knee support muscles to determine if they are working normally. They may test weak despite the prior treatments received. If weak, test for a holmes sign (facet imbrication) which often causes the mm dysfunction. Next I would inject procaine around the patella region (neural therapy) to turn the muscles on. These two treatments should restore some function to the knee so that the other techniques you tried earlier and additional nutritional therapy would have a better chance of working.

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PostPosted: Fri Apr 25, 2008 8:52 am 
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A10: Not sure how the group would take to this idea but I have had some success with Botox injections - 50-100u into the joint. Though the mechanism is not well understood it appears to involve Substance P modulation.
May be worth a try
Andy Brockway MD

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PostPosted: Fri Apr 25, 2008 8:53 am 
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A11: There are some, typical, inconsistencies with the post-op' reports...presumably a partial bilateral meniscectomy if further procedures were done afterwards. Is the surgical video available?

There is no mention of a custom brace. Many advances have been made sicne the old Lennox Hill device Joe Namath used!

Depending upon the location, there are dynamic MRI techniques, that would mostly reveal patella misalignments. (Shellock)

PT that has been 3 years (divided by additional surgeries) without strengthening needs to be drastically changed. It is very difficult to be self-motivated at home to the extent required for recovery. (N.B. Gale Sayers rehab' depicted in the movie "I am Third - the Brian Piccolo story")

It sounds like the ACL repair was inadequate, failing to provide stability. This can still be overcome for everyday activities by strengthening all of the muscles crossing the knee, not just the Quads (hamstrings and Calf!)

Indeed, until proven otherwise, I would suspect a hyper-extending knee as a postural fault and high flexibility, as is common in females. Hopefully, she is no longer following the shoe fashion trends of backless, high heels or flip flops etc.? Orthotics may assist in providing additional stability.
Is the knee still prone to swelling? Traumeel (available from Heel) can be helpful. Elevation must also be undertaken properly.

A natural option for pain relief is California poppy, available from Standard Process.

David Ponsonby

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PostPosted: Fri Apr 25, 2008 8:53 am 
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A12: Contact David A. Tallman, DC., NMD located in Arizona. He does some speciality work, especially with tendons and ligaments. It is better than prolotherapy. Another therapy that may work would be prolozone therapy with trigger point injections if necessary.

Kam Friedrichs DC.

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PostPosted: Fri Apr 25, 2008 8:54 am 
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A13: It's not hard to order and read X-Ray movies. Videoflouroscopy is done by several Chiropractors that I know of. Find one near you. Of course, will your findings suggest a solution? I have no idea.
Dr. Rik Cederstrom DC

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PostPosted: Fri Apr 25, 2008 8:54 am 
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A14: I would recommend having this patient see someone trained in Muscle Activation Technique (http://www.muscleactivation.com/main.html). I have had good success referring tough patients like this one to these practitioners.
Brian Anderson DC


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