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CASE STUDY: 22 YEAR-OLD COLLEGE STUDENT, SELF-MANIPULATOR WITH SEVERE BILATERAL SHOULDER AND KNEE PAIN AND INSTABILITY
JR, a 22 year-old male college student, came to Caring Medical in April of 2010 for complaints of bilateral knee swelling and shoulder instability. His lateral knee swelling began after he took up running in 2009 in preparation for entering the military upon graduation from college. He stopped running and was evaluated by an orthopedic surgeon who did an MRI and found an oblique tear of his lateral meniscus in both knees. The surgeon recommended arthroscopic surgery but JR looked for an alternative. He received one platelet rich plasma (PRP) injection on three separate visits with only minimal help. He sought a consultation at Caring Medical for Prolotherapy because of the minimal improvement with the PRP injections alone.
His shoulder issues started in 2005 (at age 17) after he tore the labrum in his right shoulder and had surgery to repair the tear. Despite having surgery, he continued to feel instability and pain in his shoulder. Because of his bilateral knee and shoulder pain and instability, even his ability to do non-impact sports like swimming had been affected.
Physical examination revealed joint hypermobility throughout his body, with a Beighton Hypermobility Score of 5. JR admitted that he frequently self adjusts or pops many of the joints in his body. Physical examination of his knees revealed significant bilateral grinding/crepitation with moderate to severe patellar hypermobility. He was instructed not to self manipulate his joints upon starting Prolotherapy, as this could potentially disrupt the connective tissues that are repairing after treatment. Dextrose Prolotherapy with sodium morrhuate was administered around the patella, as well as the various ligaments of both knees. Bilateral intraarticular Human Growth Hormone (2iu/joint) was also given. Because of the improvement in his knee pain with the first treatment, when seen one month later, his shoulders were also treated. He did not return until five months later, because of some continued symptoms, though he was feeling more stability and strength in his knees and shoulders. The knees were no longer swelling and he was back to an active exercise program.
JR returned for three more treatments from October to December 2010. This totaled five treatments to his knees and three treatments to his shoulders. At his last visit, JR reported that he was back to swimming and weight training without limitation, and only had an occasional crepitation in his shoulders but did not have pain. As for his knees, the crepitation was greatly decreased as well as the swelling. He has not yet tested his knees by running.
DISCUSSION
This case shows that some folks, even with Joint Hypermobility Syndrome, may be doing something to themselves to worsen his or her condition. In this case, JR was what we term a “self-manipulator.” He was manipulating himself an estimated hundred times per day. It becomes a habit. He cracks his neck, low back, thoracic, shoulders and other joints. It is imperative for hypermobile patients not to self-manipulate as this just further stretches the ligaments and makes them even more hypermobile. Eventually they are so loose that the only way they can keep in place to is to self manipulate. Obviously, Prolotherapy to the joint and spine instabilities is a better option. In JR’s case, I (R.H.) believe he should get treated until he is back to running.
CASE STUDY: 18 YEAR-OLD FEMALE GOES FROM ANTI-DEPRESSANTS AND ANTI-ANXIETY MEDICATIONS TO PAIN FREE AT 28
When SB came to Caring Medical in March 2009, you would not have believed that this was the same woman who had walked into the office in 2001 as an 18 year-old. She was now a graduate of the prestigious Chicago Art Institute, happily married, and able to exercise. She was taking no medications. This was a far cry to the person seen in 2001 who was in constant pain and on Zoloft, Tylenol #3, Prozac, Clonazepam, Effexor and Soma. From the age of six to 12, SB was active in gymnastics. She had to stop gymnastics when her right hip became painful and, despite lots of therapies and doctors, developed into a constant throbbing pain. Her list of previous therapies to resolve this pain included: physical therapy, prescription medications, deep tissue massage, nerve blocks, acupuncture and Feldenkrais. At the time of her initial consult, she was almost suicidal because the pain was so bad. On physical examination, she had joint hypermobility throughout her body, with a Beighton Hypermobility Score of 6. After a thorough discussion that her prognosis was good but would require a lot of Prolotherapy, she and her mother agreed that SB should start Prolotherapy on her right hip, which was diagnosed as hip joint instability with labral tear.
SB came in somewhat regularly for a two year period, during which time she received dextrose Prolotherapy with sodium morrhuate. She was slowly weaned off of all of her medications. By the time was she was 20, her hip was stable and pain free. She was back to regular exercise and attending college. From the years 2002-2007 she was seen once to twice per year because of joint instability in other areas including the shoulder, neck and elbow. The reason she came to the office in March 2009 was for what she called “tune up treatments” of her right hip and shoulder, at which time she wrote she was forever grateful for Dr. Hauser and the Prolotherapy treatments. She was seen once in 2010 for the same “tune-up treatments.” She noted that the Prolotherapy had gotten her 95% better, but could feel the right hip and neck symptoms recurring.
DISCUSSION
It is important to note for patients with JHS and EDS that, in some instances, Prolotherapy can give permanent relief to an unstable joint. Sometimes, perhaps because of the genetic component to the conditions, patients with JHS and EDS may need what SB calls “tune-up” treatments once or twice a year. While this is not ideal, the patients typically don’t complain because the rest of their lives are extremely “normal.” Even if a joint becomes too unstable, they have the knowledge that Prolotherapy can always be used. There is comfort in this fact. SB has not taken pain medications, except an occasional acetaminophen, in years. She has been off anti-depressants and anti-anxiety medications for over eight years, and has not seen a psychiatrist in over 10 years. She is one of the most delightful people I have ever had the opportunity to meet and treat.
CASE STUDY: ACTIVE 61 YEAR-OLD FEMALE WITH JHS
In January 2009, BB, a 61 year-old skier, came to Caring Medical saying she “didn’t want anything to slow her down.” BB always knew she had a tremendous amount of joint flexibility, and thus, excelled at yoga as well.
She had a significant past medical history with five years of suffering with bilateral hip, knee, and elbow pain. She continued to be active, including skiing with a very restrictive knee brace, despite her right knee MRI showing a medial meniscus tear, and her right hip MRI showing a high-grade partial-thickness tear involving the gluteus minimus insertion onto the right greater trochanter as the dominant finding with paritendonitis and trochanteric bursitis; low-grade tenoosseous strain of the iliopsoas insertion the lesser trochanter without tendon tear; more substantive iliopsoas bursitis. BB was a strong natural medicine advocate and exclaimed that “No orthopedic surgeon is doing surgery on me!” She was told by a skiing friend to look into Prolotherapy.
BB was diagnosed with JHS and like SB, had evidence of hypermobility throughout. Her Beighton Hypermobility Score was only 4, but many joints had excessive mobility. She was told that she was an excellent Prolotherapy candidate, but because so many joints were involved it would require some time for all of the instability to resolve.
BB was seen at Caring Medical on 10 occasions over the course of the next two years for treatment. Her elbow responded after four treatments, allowing her to get back to exercise, which included weights and push-ups. Her right knee needed five treatments, and her hips each needed nine treatments. Now BB is back to cycling up and down the hills of Colorado and skiing at a high level without braces and without pain.
DISCUSSION
Some patients with JHS and EDS can function at a high level for most of their lives without needing a lot of medical intervention. In BB’s case, her body didn’t start to suffer the effects of her hypermobility until she was in her mid 50’s. She is an extremely motivated and active person who tried everything she knew to stabilize her joints. When the orthopedic surgeons in Colorado started talking about various “potential” surgeries for her, she looked into Prolotherapy. I suspect that with her extreme sports mentality I may be seeing her periodically for a while. But I am happy for her being able to get back to all of her activities without braces, and look forward to her having an extremely “active” retirement!
CASE STUDY: 48 YEAR-OLD NATIONAL CALIBER ATHLETE WITH PELVIC FLOOR DYSFUNCTION AND JHS
JD came to Caring Medical in extreme distress because she was no longer able to work as a physiotherapist, athletic trainer and Pilates instructor. She was a 48 year-old wife and mother from Ontario, Canada and her pelvic pain had completely disabled her. She explained that her previous life as an athlete included Canadian National rhythmic gymnastics team, international level dragon boat and outrigger paddling, recreational triathlons, cross country skiing and water skiing.
JD always had what she called “extreme flexibility.” She had a series of injuries including the following:
- 2004 – plantar fascia pain
- 2006 – severe hip pain on the greater trochanter
- 2007 – inguinal pain, requiring inguinal hernia repair x 2
- 2008 – right groin exploratory surgery and inguinal nerve ablation. Her right groin pain did not resolve. MRIs at this time revealed a torn rectus abdominus, right hip dysplasia, and labrum tear.
- 2009 – right rectus abdominus repair and removal of mesh. Re-injury of right inguinal area. Another right inguinal hernia repair with mesh.
JD’s first appointment at Caring Medical was in August 2009. She had multiple complaints but her primary pain areas were the pelvic floor, pubis, groin, left knee and left ankle. She received some Prolotherapy in Canada previously, but because she did not feel the technique used was aggressive enough, she was not happy with the results. JD said her main goal was get to back to teaching Pilates full time. The pain was completely disabling her from working and driving, and she was becoming very depressed. Her pain was increased with most movements and activities including sitting, standing and walking. She was diagnosed with JHS with her main problem being subluxation of the pubic symphysis. She was felt to have pubic instability and this was causing the majority of her pelvic pain. She had instability of the left knee and left ankle. These areas were treated with dextrose Prolotherapy with sodium morrhuate every four to six weeks. When JD came for her third visit in December 2009 she noted that she was feeling much better. Her groin pain had improved to the point that she was water jogging two to three times per week and doing some core workouts. She started working again, two mornings per week, and was able to drive short distances. On this third visit, she started treatment on her right hip because of popping, clicking and pain from hip joint instability. She was feeling much stronger and less pain overall until she re-injured her right oblique abdominal muscle and this started her right pubic/groin pain again.
At her February 2010 visit, the pubic symphysis was treated again, as well as the right hip. At this visit, JD noted a new pain in her lower right back which was also treated with dextrose Prolotherapy with sodium morrhuate at that time. Over the course of the next year, JD was seen in the office three times (including seven months between two of the visits) necessitating treatment to her left knee, right hip, and new-onset metatarsalgia of her left foot. To date, her disabling groin pain is down to a manageable level, but feels that some of the pain is secondary to the two meshes she has in her. JD is back to work, but not full time like we had hoped.
DISCUSSION
When writing case studies, it is often difficult to illustrate the extreme disabling effects of JHS and EDS. I included the case of JD to show that a national caliber athlete can be broken down by these conditions to the point where she could not even work as a full-time athletic trainer/Pilates instructor. In her case, she was on the verge of a nervous breakdown prior to Prolotherapy, and shed many tears at her first consultation. When she was most recently seen, in February 2011, it was primarily because she had fallen on the ice and re-aggravated her right hip and left knee pain. Her groin was not treated, which was the original disabling injury for which she first came to Caring Medical. JD no longer suffers anxiety about when her next joint is going to sublux, because she knows she can get Prolotherapy to treat future injuries. The peace of mind that comes with Prolotherapy for JHS and EDS patients goes a long way.
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