Lecture Questions

[Diane]

Hi Steve,

1. Are the terms myxoid degeneration/mucoid degeneration/ tenomalacia the same thing?
2. Do you use a certain measurement to assess for the ulnar nerve like we do for the median nerve?
3. In the video, do you mean that for some patients you may see kinking of the PIN nerve and this is normal but when it actually produces the same symptoms as what the patient presents with, then this is pathological and you should call it? Do you still mention in the report if there is kinking but the patient has no symptoms?
4. If a patient has myxoid degeneration of the CFO or CEO, which one would you recommend patients to get? A steroid injection or a PRP? I’m not sure about the exact science but what I’ve heard from colleagues is that steroids provide immediate relief of pain but PRP are better in the long term but takes time for the pain relief to kick in?

Thanks!

[Stephen Bird]

1: In my mind myxoid and mucoid degeneration are the same thing and I use it when a cystic area appears in a collagen tendon as part of a degenerative phase tendinosis.
Tenomalacia is different as this refers to the softening of the tendon “compressibility” which occurs during the disrepair phase of tendinosis. With tenomalacia the tendon collagen is still visible, however the tendon is swollen, hyoechoic and soft when compressed.
With myxoid / mucoid degeneration there is no collagen visible, just an anechoic cystic space.

Personally I use myxoid

2: Kerry Thoirs did her Phd on this topic and came up with the same measurement as you use for carpal tunnel and the median nerve (10 square mm)
I also informally use the wrist to forearm ratio from the carpal tunnel as well. I measure the nerve proximally where it is sitting on the medial head of triceps in the Struthers canal area. This is my reference measurement and then I measure it where it is most swollen in the cubital tunnel and if me second measurement is 1.4 times bigger than my first one I call it swollen.

3: Many people have a fibrous band at the arcade of Frohse and I think of this as a normal variant, but it is a predisposing factor for PIN entrapment. If the patient has this variant and then a job or sport that uses resisted supination then they will develop neural oedema and symptoms. I only mention it if there are symptoms. So 2 people can have a fibrous band and on examination we will see kinking of the nerve with resisted supination, however one mat stay asymptomatic and the other mat develop symptoms due tot he activities they choose to undertake.
It is just like a Steide process of the talus or a large os trigonometry. A regular person may never develop symptoms but the ballerina can have her career ended by posterior ankle impingement when she does On Point training.

4: If you are at the myxoid degeneration stage you have degenerative phase tendinosis and the road back is difficult. The pain will burn out but the tendon may never recover to normal.
We have always used steroid for this and I think that times are changing slowly for the better as regenerative medicine starts to become more widely accepted. Personally I think it makes sense to look at an anabolic pathway out of tendinosis with physiotherapy loading exercises and other anabolic interventions like PRP, prolotherary etc.

I think this is the way of the future, however here in Australia we are very well paid by Medicare to stick steroid into and around tendons, however there is no Medicare support for PRP.

I wonder why we do steroid rather than regenerative medicine interventions !!!

In other parts of the world where there is no financial bias toward steroid use there is a greater use of PRP etc. The financial framework does certainly determine the way medicine is delivered to some extent in all countries.

I think we will see a slow and steady drift toward anabolic biased therapies in the future (not likely before I retire !)

Steve.

[Alfredo Ferreyra]

Agree! We tried to stay away from using steroids because eventually it will cause more damage than anything else. Here is the US I focus to use PRP or autologous stem cells and also stem cells derived from fat and all the places that offer this are a cash base clinics. We don’t accept insurance because they don’t cover although they are starting to cover only for Achilles. We use Emcyte kits because we have tested many PRP kits on the market doing quantitative date using a hematology analyzer , many of them are garbage specially the ones using BD vacutainers but the EMcyte kits (using 60ML) of blood we are able to get anywhere from 5 to 12X the concentration! depending on the volume the doctor wants to inject. I inject my knee IA and on the medial meniscus since I had a bucket tear and NO surgery and its been 7 months pain free and Knee is perfect, also you can see sonographic changes after three months.

anyways great talk and take care !

Cheers
Alfredo

[Stephen Bird]

Hi Alfredo,

This is certainly the way of the future with the rise of regenerative medicine starting to make an impact.

Here is Australia we are still fairly lazy and a lot of steroid is used. I think this will change over time, or at least I hope it does. As you mention the fact we no longer have a Medicare rebate for PRP is a problem so patients choose the free government funded steroid injection over PRP or stem cell options.

I am interested in watching this space.

Where I work in Taiwan the regenerative medicine is much more broadly applied than in Australia.

Steve

[Jayeta Choudhury]

Hi Alfredo
Did you inject inside the meniscus? What an interesting therapy!

[Stephen Bird]

Hi Jayeta,

I hope Alfredo will give you some first hand advice,

I will email him now to prompt him,

My understanding is that the PRP is injected directly into the meniscus.

Steve

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