Thanks Alan. We can have time for some more questions at the end of the session. We'll now invite up Kristen Oliver who will go through PRP and muscle injection techniques. Kristen. Good morning. So I have a couple slides before I play the video just to kind of go through some things and then I just voiced over the video so you don't have to listen to me talk. So we're talking a little bit about injecting muscle and I also again hit on tendon here. So I just wanted to first bring up this little case that we had. This was a 28 year old soccer player. He had obviously a pain, a sudden injury with pain in the middle anterior thigh after falling during play. He ended up having a partial thickness tear of the rectus femoris muscle sort of right distal to the myotendinous junction and it was a grade two strain. And you can see here and I have here a little picture of the actual injury and I made some notations on it. You can see the arrows that point towards the hypoechoic area and that on ultrasound is the hematoma that was associated with this. So this gentleman was an elite level player and wanted this taken care of immediately. So we went ahead and evacuated that hematoma and then injected the actual muscle itself. So I'm going to play a little video of that. It's not the greatest and then I made this was kind of a last minute add on for me to do. So I made a video of kind of muscle injection technique as well for you to look at. So you can see in the middle this is a transverse view the actual muscle itself and then you can see around it the hematoma. Just for comparison of course this is a little bit apples and oranges here but you can see that's a normal transverse view of a rectus femoris versus here where you can see the hematoma around it and the abnormal heterogeneic muscle itself. And this was the longitudinal ultrasound of the injury. So we also got an MRI on this to make sure it was just a grade 2 and not a 3. And on this I don't know if you can appreciate or not with the lights on but you do still see here as you come up there is a portion about 25% of that was still intact so it wasn't a complete rupture. And here's the MRI findings, both views on MRI. So this is the video, should just play I think. There you go. Oh, there's someone smarter back there than me. So you'll see me try to evacuate the majority of this hematoma. Some of it's more organized and it's difficult and once that is completely removed then I will inject, now you see me starting to inject the PRP, this is actually the PPP I'm injecting in this area. Now unfortunately I didn't save my transverse views but on this just like yesterday when I was describing I'll move down the muscle and you'll see that in my next video. So this video, so a couple of just little pearls, if there's a hematoma obviously aspirate it first. I like to use a CC, one CC of PPP per centimeter of muscle injury and about a CC of PRP and again I'll use leukocyte rich PRP for the tendon. And I say there's no need to immobilize, I rarely immobilize my patients although some people have quite a bit of pain after the injections so if they're uncomfortable I might give them, let them partial weight bear on crutches just for pain, just for pain only, nothing else. And I usually take them out for at least four weeks depending on the level of the athlete. This short video is to demonstrate the injection technique of tendon and muscle using PRP and PPP. Here on my tray I have two 10 CCs of PPP, two 10 CC syringes of a dilute lidocaine. I like to dilute my lidocaine to .25% so it's less toxic to the tenocyte and myocytes. Here are three syringes of leukocyte poor PRP. Now normally for tendon I like to use a leukocyte rich PRP but today we're injecting one of my assistants, her name is Amanda, and Amanda has to work the rest of the day and she said she really doesn't want a lot of discomfort afterwards so we're going to use a leukocyte poor product. And if she decides she doesn't get a good enough result we can always repeat the treatment without charge since she works here for us. I had to actually make this video like the day before I left to come here so I, she was the only person I could find with an injury. Using a curvilinear probe and some sterile ultrasound gel. The patient has already been sterilely prepped and draped. And today we're injecting the semi-tendinosis, both tendon, myotendinous junction, and muscle. So I take my curvilinear probe and I orient it and on the ultrasound screen you're going to be able to see the ischial tuberosity and then the semi-tendinosis tendon as it comes off the ischial tuberosity. So this is where we're going to inject our platelet-rich plasma. I usually start with my dilute anesthetic and I will fan the dilute anesthetic out through the tendon from superficial to deep. I like a transverse approach. We're going to do a little anesthetic here, topical ethyl chloride. And then I'm going to inject first my dilute anesthetic. One, two, three, big stick. And on the screen you can see the dilute anesthetic as it fans into the tendon from superficial to deep. And I'm trying to hit all those layers there. I'll go a little more proximally so I can get near the tenoosseous junction. Then I'll switch my syringes out so my platelet-rich plasma is now on my syringe. And you're going to see me injecting the platelet-rich plasma into the tendon as well, superficial to deep. So there I'm injecting. And I use about a cc of PRP per centimeter of affected tendon. We're going to then move our curvilinear probe from proximal to distal where she has a small amount of muscle strain at the myotendinous junction and then down into the muscle itself. So once I find the area I want to inject, I again use a transverse approach and my curvilinear probe in order to anesthetize. One, two, three big stick. On the screen you'll see me again fan the anesthetic out. And I use as little as possible, probably half a cc, maybe a cc of anesthetic to anesthetize that whole portion of the muscle. I take the anesthetic off and replace it with PPP and I start injecting as well. And I try to hit all those layers, deep to superficial or superficial to deep, whichever way I'm working. Then I fan out both superior and inferior while I keep my needle in the same puncture site. I try to hit all those layers and do as much of that muscle as I can with one puncture site. You can see me fan the product, the platelet pore plasma out through that level. Now again, I'm going to continue a little farther distally on that muscle with a curvilinear probe, dilute anesthetic, and a transverse approach. I'm going to do this again where I inject anesthetic, superficial to deep, and I use as little as I possibly can. And then I'll replace this syringe with the platelet pore plasma and continue to inject the muscle. I continue to do this from proximally to distally until I feel like the whole tendon, myotendinous and muscle structure that's been affected has been injected. I use about a cc of platelet pore plasma per centimeter of injured muscle as well. Thank you very much. Ask questions? Sure. Yeah, I've got time for questions. There's one thing. She did have an injury. I actually had to go through the clinic and try to find someone with a... Does anybody have any muscle pains? I was going to inject my own quad because I've got a little vastus lateralis. I'm like, how would that look on a video if I'm doing the technique on myself? It might look a little weird. Two questions. Yes, sir. Initially, it's been very difficult to aspirate hematoma. So I'm curious how... So if they have sort of that type two signal by MRI, which is my own indication for muscle. And again, I don't do this for everyone. I do it for higher performance people because most everyone has the luxury of time except for someone who's got to get back. So let's say that's the indication. Hematoma aspiration even acutely has been difficult. So any tricks for that? And the second question is, there's some data that I believe came out of Gus Mazzocca's lab that any local anesthetic was somewhat toxic to the platelets. And I'm trying to understand the logic of using local anesthetic, really twofold. It hurts to go through the skin. It may hurt during the injection. The local anesthetic takes a little time to start and you go right to your injection, not giving it much time. I'm just challenging on that. So why use any of it, especially when there's some data that shows that it might be toxic to platelets? So those are my two questions, the hematoma and the local anesthetic, the logic. Sure. So the hematoma question is perfect. And this patient came within 24 hours of injury and they were an elite level athlete and they wanted this taken care of ASAP. They'd been to me before for another unrelated injury. So unless I catch that hematoma within like 48 hours, normally you can't aspirate it. In 99% of my patients, we just have the luxury of time. And then we'll go in and treat it if it doesn't resolve or if they continue to have pain. Tricks on it, I just have to catch it early. Otherwise I can't get the hematoma out. Got to use an 18 gauge. And luckily this individual had great body habitus and I could use a one and a half inch needle versus having to use a longer needle. There wasn't a lot of organized portion. You notice when I tried to aspirate the hematoma, there was still some hypoechoic area left. That was what I couldn't get out. My partner sometimes will try to inject some saline in like to flush it. I don't think that works. I think it just adds more fluid personally. So I don't do that. The second question about local anesthetic. So, you know, you're right. I find that that local anesthetic really takes effect. And I've found this really when you're doing like sutures and things like that back in training, you know, within about, you know, 20, 30 seconds. Now without it, it hurts a lot. So, you know, it's not only painful during the injection. It's very painful afterward. And maybe part of it is just me being a weenie, but they leave your office uncomfortable and unhappy. So you got a way that is the pain and the patient dissatisfaction with the pain versus the possible toxicity of the local anesthetic. Now I can say when we started doing this years, 15 years ago, you know, we used marking. I mean, we didn't really know about the toxicity of anesthetics. And we still had good outcomes. So clinically, I don't think it makes a huge difference. That being said, Chris Santana, who's with Regenexx, gave a presentation at one of the conferences I was at years ago. And he had done a small internal study on local anesthetics. And he had said that he found that the toxicity to tinocytes dropped dramatically if he diluted the lidocaine down to 1% lidocaine to a .25. So that's what we've done. And really, I haven't seen our outcomes get any worse or any better. So that's sort of, to me, a middle road where I'm helping him a little with the anesthetic, but, you know, not causing as much pain. Thanks.

PRP

muscle injections

case study

ultrasound images

hematoma evacuation