Online Health Chat with Dominic King, DO

September 22, 2017


Description

Many conditions the orthopaedic team cares for may be treated through non-surgical means. In many cases, patients should first try non-surgical treatment options before considering surgery.

There are several different non-surgical treatment options available that your physician, nurse practitioner or physical therapist may prescribe. Treatment options will vary depending on the condition and the severity of the injury. Here are some common non-surgical treatments:

  • Physical therapy and exercise (rehabilitation medicine) — For some conditions, your doctor may prescribe physical therapy and/or exercises in order to strengthen or increase the mobility of the muscles, ligaments and tissues around the area of the injury or condition. Conditions that may be helped by physical therapy or exercise include arthritis, shoulder instability and lower back pain.
  • Nonsteroidal anti-inflammatory drugs — Nonsteroidal anti-inflammatory drugs (NSAIDs) may be prescribed to reduce swelling, pain or joint stiffness.
  • Corticosteroids (injection and medication) — Corticosteroids are powerful drugs that may be prescribed to reduce inflammation if NSAIDs are not effective. These may be given as a pill or an injection.
  • Resting or stopping activities that cause pain — Sometimes, the best medicine for certain conditions is to stop activities that cause pain to allow the muscles, tendons or joints time to rest and heal.
  • Platelet-rich plasma injections — Platelet-rich plasma (PRP) is the concentration of platelets from a patient's own blood. Whole blood is mainly a liquid (blood plasma) that also contains small solid components: red blood cells (RBCs), white blood cells (WBCs) and platelets. Platelets are best known for clotting blood, but platelets also contain proteins called growth factors. Growth factors are the elements the body uses in the process of healing injuries. PRP is a reasonable step for the treatment of chronically inflamed tendons, ligaments and osteoarthritic joints that have not responded to conservative treatments such as physical therapy, bracing and activity modification.
  • Viscosupplementation or placental tissue matrix injections — This is one of several orthobiologic treatments available. Orthobiologic injections are molecules, cells or tissues that can aid in the healing and reparative process of a musculoskeletal injury or condition. The most common are hyaluronic acid viscosupplement, platelet-rich plasma (PRP) and placental tissue matrix injections. Viscosupplementation is the injection of hyaluronic acid viscosupplement or “gel injection.”

About the Speaker

Dominic King, DO is a staff physician and medical orthopaedic physician in the Department of Orthopaedic Surgery at Cleveland Clinic. He is active in many research projects within areas of orthopaedics and also held several positions, including co-lead for soft tissue application of cell-based therapies for orthopaedics, chair of the Orthopaedic Technology Committee and Major League Baseball (MLB) Independent Medical Examiner for Disability Physicals.

Prior to Dr. King’s appointment at Cleveland Clinic, he performed his fellowship and residency at Cleveland Clinic South Pointe Hospital Sports Medicine and obtained board certification at West Virginia School of Osteopathic Medicine. His specialty interests include nonoperative management of orthopaedic conditions, sports injuries, tendon or ligament conditions, musculoskeletal guided ultrasound procedures and ultrasound procedures.


Let’s Chat About Joint Preservation

Jeopardized Joints

internetkat01: I'm about to have back surgery because there is a cyst on my spine. While the doctor is in there, he will be putting a screw in the two lower bones of my spine to hold them together because they are moving and there is no cartilage left in between the bones. I've stopped taking my steroids weeks before the surgery. He doesn't want me starting my steroids for 12 weeks after the surgery. If I start before, he says the steroid will weaken my bones and the screw will not hold. Do you have any advice on how to not lose the cartilage between your bones?

Dominic_King,_DO: Cartilage loss is the hallmark of osteoarthritis. The main contributors to losing cartilage include some underlying genetics, overload, improper mechanics and injury. Unfortunately, we do not know who will and will not develop osteoarthritis. However, obesity, improper form during work and exercise, and overload all can lead to degeneration and overuse of cartilage. We recently published an article on the Cleveland Clinic Health Essentials page outlining the five best ways to safeguard your joints as you age. Check it out here. https://health.clevelandclinic.org/2017/09/5-best-ways-to-safeguard-your-joints-as-you-age/

PShe14: 1) Are some people more prone to bone spurs in joints? As an aging athlete, I've addressed bone spurs in both my hips and one shoulder. 2) How can aging athletes (who may have incurred more stress and abuse on their joints) best maintain joint functionality? Which exercises, nutrition plans, supplements are best in this scenario?
3) What is the difference between an achy joint versus arthritis in a joint?

Dominic_King,_DO: Bone spurs, also known as "osteophytes" in joints or "enthesophytes" at the insertion of tendons or ligaments on bones, are protrusions of bone that occur because of long-term inflammation or increased traction of tendons pulling on bones. Osteophytes and enthesophytes typically do not hurt, but they are evidence that there is an underlying degenerative or over-use problems. These bony protrusions can become problematic if they are irregularly placing pressure on tendons and other soft tissue such as the rotator cuff in the shoulder. We recently published an article on the Cleveland Clinic Health Essentials page outlining the Five Best Ways to Safeguard Your Joints As You Age. Check it out here. https://health.clevelandclinic.org/2017/09/5-best-ways-to-safeguard-your-joints-as-you-age/

In regard to the difference between an achy joint, arthritis, tendinitis and tendinosis, please check out the following articles: https://health.clevelandclinic.org/2016/06/ok-push-pain-exercise/ https://health.clevelandclinic.org/2016/11/tendinitis-tendinosis-difference-important-treatments-help/

brendanbdavis: I am 43 years old, have had treatment for my right hip and SI joint, and can vouch for physical therapy (and following the suggested stretching and exercises). My range of motion improved from seven to 28 (versus 35 on my left). With a benign tumor on my pelvis over the right hip joint, my right hip is a mess. I still run, bike, ski, etc., and am looking to take on more yoga and swimming. How else can I avoid a hip replacement when I get older?

Dominic_King,_DO: I’m glad to see you are making improvement with physical therapy and are motivated to stay active. Knowing the underlying cause of your hip pain will be essential to giving you a plan for the future. You should have an appointment with a joint preservation specialist to help figure out that cause. We recently published an article on the Cleveland Clinic Health Essentials page outlining the Five Best Ways to Safeguard Your Joints As You Age. Check it out here. https://health.clevelandclinic.org/2017/09/5-best-ways-to-safeguard-your-joints-as-you-age/


Physician Focus

Sandy123: What questions do I need to be ready for at an initial consultation with an orthopedic surgeon regarding long-standing hip pain and recent-onset knee pain? Both conditions have been mostly knocked out by a temporary prescription for meloxicam.

Dominic_King,_DO: You should prepare a written history regarding the hip and knee pain including the length of symptoms, what makes the symptoms better or worse, how much pain you get, how much decreased function you experience, and history of physical therapy, brace use, medications, injections, imaging and surgeries. You should also outline your goals to discuss with your joint preservation specialist. These would include activities you would like to return to doing and any activities you would like to start doing. It is also important to make sure any other medical problems are under control by your primary care physician. Your visit with your joint preservation specialist will go in depth into the complex nature of osteoarthritis and the comprehensive plan that we have created. There are many options available for treatment in the Joint Preservation Center, but a thorough history and physical is a must in order to determine which treatments are appropriate for you.

litvol: How do you find a joint preservation specialist? I have never heard of this term before.

Dominic_King,_DO: While we don't have the information on our website at this time, it is currently being written and will go live very soon. This will share with you the conditions we treat and treatment options available. 

Appointments:
To make an appointment with Dominic King, DO or any of the other specialists in the Orthopaedic and Rheumatologic Institute at Cleveland Clinic, please call 216.518.3444. You can also visit us online at clevelandclinic.org/orthorheum

Moderator: Note: This is the number to the Cleveland Clinic Sports Health Center.

Sandy123: I am looking forward to my appointment the first week in October, my first time with an orthopedist DO/surgeon. I have lots of questions for him. I am interested in PT, proper exercise, weight loss and NSAID's long before any surgery.

Dominic_King,_DO: In the Joint Preservation Center, we love it when patients come excited about their care and interested in all the different options we have available. Joint pain typically is a multi-factorial problem, and joint preservation typically involves a multi-modal approach. We look forward to seeing you and appreciate your enthusiasm.


Arthritis Approaches

litvol: Can PRP be effective when there is bone on bone in the knee joint?

Dominic_King,_DO: Bone-on-bone arthritis is the same as saying severe or "end-stage" osteoarthritis. At this level of arthritis, we have been seeing that injection-based therapies are not as effective as when they are used for less severe osteoarthritis. However, we have had many patients that note improvement in their symptoms despite the severity of their osteoarthritis. While we are actively researching how PRP works in these types of situations, we do know that it is a safe approach in trying to alleviate the symptoms. Pain can come from several different places and from several different tissues in the knee joint. A joint preservation specialist can help you localize the pain-generating parts of your knee.

Carie: Are PRP injections or hyaluronic acid injections effective in relieving discomfort (six on a scale of one to 10) in bone-on-bone arthritis? Also, do either of these treatments actually do anything to physiologically improve the joint?

Dominic_King,_DO: A level six pain on a scale of one to 10 is the ideal pain score for the types of treatments we provide in the Joint Preservation Center. While we are actively researching how PRP and viscosupplementation (hyaluronic acid) injections work in these types of situations, we do know that they are a safe approach in trying to alleviate symptoms. We believe that both types of injections play a role in helping to manage the chronic inflammation present in some arthritic knees. Not everyone responds to these treatments, mainly because each knee is unique, and the pain from osteoarthritis can come from several different places and from several different tissues in the knee joint. A joint preservation specialist can help you localize the pain-generating parts of your knee.

geewhiz: What can you do to stop the progression of knee arthritis and lower back pain from degenerative diseases?

Dominic_King,_DO: We recently published an article on the Cleveland Clinic Health Essentials page outlining the Five Best Ways to Safeguard Your Joints As You Age. Check it out here. https://health.clevelandclinic.org/2017/09/5-best-ways-to-safeguard-your-joints-as-you-age/


Concurrent Conditions

Ellavin: I have multiple orthopedic injuries and also gastro-esophageal reflux disease. I take pantaprazole and Zantac for the GERD. What are acceptable nonprescription medications to take for orthopedic pain, Tylenol, NSAIDs? Thanks.

Dominic_King,_DO: You should avoid NSAIDs because of your GERD. Tylenol could be effective for your pain; however, I am not aware of other medical problems that you may have that could eliminate Tylenol as an option. You should speak with your primary care physician about the safety and appropriate dosing of Tylenol. In the Joint Preservation Center, we take a very comprehensive look at all of the pain-generating parts of a joint and have several modalities to address this pain. These modalities range from topical NSAIDs, a TENS unit, various injections, hands-on manual therapy, comprehensive strengthening and stabilizing physical therapy, nutrition consultation with anti-inflammatory diet modification and anti-inflammatory supplements such as turmeric and curcumin, orthobiologic injections and cryoneurolysis.

thomp: What might cause someone to be more prone to experiencing labral tears (such as in the hips)? Are there ways to prevent this from occurring in the future and to facilitate functioning when there is already a labral tear?

Dominic_King,_DO: Labral tears, like other connective tissue injuries, occur from a combination of underlying anatomic alignment issues and overuse. Specifically, in the hips, labral tears are more common in people who have FAI or femoroacetabular impingement. If you think of the hip as a "ball and socket joint," FAI is a condition in which the femur (the ball) can become irregularly impinged against the acetabulum (socket) causing irregular mechanics, inflammation and possibly overload and tearing of the labrum. Meeting with a joint preservation specialist can help to determine if this is an underlying cause of your hip pain and if you can help manage this condition through appropriate physical therapy, as well as the next steps in management.

Gail Ann: I have recently been bothered by an issue with the area below my shoulder about one-third of the way to the elbow. The area will crack. It doesn't happen continuously, but it is worrisome. There is very little pain involved, and I have movement of my arm. How will my doctor determine the cause of this cracking? Do you have any idea what could be causing this? Thank you for your time in answering my question.

Dominic_King,_DO: Mechanical symptoms can be worrisome and sometimes quite bothersome. Many times, "cracking and popping" are related to tendons, ligaments and thickened fascia snapping around bones. An x-ray can show the underlying bones, and a musculoskeletal ultrasound (MSK-US) can give a nice, dynamic look at what might be causing the problem. It could be as simple as a benign snapping of two tendons past each other, or it could be something more significant. The good news is it is not painful for you. We would be happy to evaluate this and try to find an answer for you.

Gail Ann: Thank you so much for answering my question. I live in Northern Ontario and am unable to have an evaluation at Cleveland Clinic. I will share with my doctor your comments and hope he will be able to send me for the suggested x-ray and ultrasound.

Dominic_King,_DO: The great news is that Dr. Miniaci is here in Cleveland and also at Cleveland Clinic Canada. Here is a link to his profile and number to make an appointment: https://my.clevelandclinic.org/staff/5017-anthony-miniaci.


Steroid Situations

internetkat01: I have osteoporosis and lupus, and I take Rayos, which is a steroid. I take a low dose (10mg), but I take it daily. Is the steroid weakening my bones?

Dominic_King,_DO: Corticosteroid injections, also known as steroid or cortisone injections, primarily decrease inflammation. Inflammation in the body can be harmful if not controlled. However, inflammation is also what the body uses to heal damaged tissue. Therefore, corticosteroid injections can have a role in alleviating pain, but the trade-off is an increased risk of damage to cartilage and connective tissue if misused or used too often. The same goes for oral steroids; however, oral steroids act systemically and affect the entire body. Injected steroids typically remain local and only affect the joint or tissue they are injected into. Your physician should be able to describe the most appropriate route of using steroids and how often a steroid should be used. He or she can also discuss the risks of that steroid for your specific condition.

At the end of the day, if you are not receiving significant relief of your symptoms from the administration of an oral or injected steroid, a more comprehensive look at the underlying problem and other treatment options should be pursued. With osteoporosis, your bones are at risk for injury and fracture because they are more brittle. Steroids used in a prolonged fashion can have effects on weakened bones, but that risk has to be weighed against the positive effects they can have on managing your lupus. This is a conversation you should continually have with your treating physicians to help you balance the risks versus rewards of this medicine.

Sandy123: I have heard that steroids or other injections may alleviate pain, but the effect eventually wears off and they can cause more damage to the joint. Is this true, always, sometimes?

Dominic_King,_DO: Corticosteroid injections, also known as steroid or cortisone injections, primarily decrease inflammation. Inflammation in the body can be harmful if not controlled. However, inflammation is also what the body uses to heal damaged tissue. Therefore, corticosteroid injections can have a role in alleviating pain, but the trade-off is an increased risk of damage to cartilage and connective tissue if misused or used too often. The same goes for oral steroids; however, oral steroids act systemically and affect the entire body. Injected steroids typically remain local and only affect the joint or tissue they are injected into. Your physician should be able to describe the most appropriate route of using steroids and how often a steroid should be used. He or she can also discuss the risks of that steroid for your specific condition.

At the end of the day, if you are not receiving significant relief of your symptoms from the administration of an oral or injected steroid, a more comprehensive look at the underlying problem and other treatment options should be pursued. This is where a joint preservation specialist can discuss the next steps in management, especially in dealing with the complex issue of knee osteoarthritis.


Tomorrow’s Treatments

magilla: I am not familiar with the name of the procedure that came out of Europe and I believe is being used in the US. The method, as I understand, uses stem cells on something like cheese cloth. Apparently, they can grow new cartilage in this manner that can be placed in a joint area that has lost the cartilage. Do you know about the procedure to do this, and are you using it at Cleveland Clinic?

Dominic_King,_DO: In the Joint Preservation Center, we are constantly evaluating the best approaches to the treatment of acute and chronic joint pain. There are hundreds of different orthobiologic companies offering many different solutions, and hundreds more on the way. When you meet with your joint preservation specialist at Cleveland Clinic, he or she will discuss the research efforts that are underway and why research is important in critically evaluating the use of these types of products.


Closing

That is all the time we have for questions today. Thank you, Dr. King, for taking time to educate us about Joint Preservation.

On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative. If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at http://my.clevelandclinic.org.

For Appointments

To make an appointment with Dominic King, DO or any of the other specialists in the Orthopaedic and Rheumatologic Institute at Cleveland Clinic, please call 216.518.3444. You can also visit us online at clevelandclinic.org/orthorheum.

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