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Prolotherapy: what to expect

PROLOTHERAPY 2023

Dear Patient:

Thank You for your interest in Prolotherapy, to make an initial consultation effective and informative please follow the steps below.

* Read all available information about Prolotherapy online, and the information provided in this packet

* Prepare a list of questions you may have for the doctor.

* Please obtain a copy of any radiological images (XRAY, CT SCAN MRI). You should be able to request a copy of the radiology imagines from the Radiology Department.

* Please obtain a copy of your latest blood test results including complete blood count (CBC) & Basic metabolic panel (BMP)

* Please provide a list of current medical conditions including any allergies and/or food sensitives.

* Please provide a list of current medications along with the dosage and frequency. Along with any over the counter medication/supplements you may be taking.

What You Can Expect:

The initial consultation will be focused on taking detailed history and conducting a musculoskeletal physical exam to assure the appropriateness of Prolotherapy. Your diagnostic test/s will be reviewed and taken into consideration along with any medications and/or supplements you are taking. Patients are encouraged to bring a family member or friend to the consultation to ensure that all possible questions have been addressed during the consultation.

*PLEASE NOTE: Treatment will not be performed the day of consultation.

*The cost of the initial consultation is $375.00. Insurance does NOT COVER PROLOTHERAPY.

Absolute Contraindications for prolotherapy:

  1. Hardware from prior surgical procedure in the affected area
  2. Currently undergoing treatment for cancer
  3. Currently undergoing treatment for autoimmune condition and taking “immune modulating therapies”
  4. “Full thickness” tendon tears
  5. Any evidence of infection
  6. Pregnancy

FACTS REGARDING PROLOTHERAPY:

Prolotherapy (Regenerative Injection Therapy) was originally used by Hippocrates over 2500 Years ago to heal a javelin’s shoulder injury. This concept was investigated, utilized, and refined by Dr. George Hackett, MD over 70 Years ago.

The cause of a great deal of musculoskeletal pain is related to chronic laxity or relaxation of the connective tissues (ligaments and tendons), which normally control joint movement and provide support for standing, sitting, and locomotion. These tissues are moist commonly damaged by trauma and overuse and the initial healing response may not adequately “weld” the structures back together.

Furthermore, anti-inflammatory medications (Ibuprofen, naproxen) also interfere with the body’s natural healing process, which may result in chronic weakness/ laxity of these ligaments. These once elastic ligaments and tendons “lose” their elasticity. Other contributing factors to ligamental laxity are hormonal changes, such as pregnancy. This is physiologic in preparation for childbirth. However often times the ligaments and/or tendons do not restore their elastic properties fully. Other individuals are predisposed because of genetic variations such as Ehlers Danlos Syndrome or other connective tissue disorders resulting in joint hypermobility or “double jointedness.”

The result of reduced structural stability is a chronic sprain of the ligament and tendon fibers which are connected to the extremely sensitive periosteum of the bone which through nerves sends pain signals to the brain. To compensate for the instability, the corresponding muscles go into spasm resulting in pain and stiffness. There lies the paradox: muscle stiffness is the result of joint hypermobility.

Prolotherapy Injections contain dextrose, local anesthetic, and sterile water. Injections are targeted into the joint space as well as around the joint space (where ligament/tendon connect to bone – enthesis). The solution is hyperosmolar, causing a controlled injury and healing response, which results in growth (Proliferation) of the tissues. In other words, we are injuring the area to stimulate your body to heal. Over time, the weakened tissues get stronger resulting in increased stability, less muscle tension/spasms, improved range of motion and eventually less pain.

Numerous studies have shown a success rate of 80-90% over thousands of patients with success judged as at least 50% reduction in pain.

Typically, injection treatment sessions are administrated 4-6 weeks apart with an average number of 4-6 injection sessions required per patient. This is very much a case by case basis. It is important to remember that everybody heals differently and we will go into your specific situation during the consult. However, the response is directly related to the speed of healing within our bodies. Generally, young, healthy people who good nutritional status will heal faster than someone in poor health.

Publications Describing Prolotherapy

  1. 1)  Hackett, George A., and Henderson, Donald G., “Joint Stabilization: An experimental, Histologic Study with comments on the Clinical Application in Ligament Proliferation” American Journal of Surgery, 89 (May 1955), PP.968-973.
  2. 2)  Klein, Robert G. Proliferation Injections for Low Back Pain: Histologic Changes of Injected Ligaments and Objective Measures of Lumbar Spine Mobility Before and after Treatment”, Journal of Neurology, Orthopedic Medicine, and Surgery, 1989, 10:141-144
  3. 3)  Klein, Robert G., Mooney, Vert, ET AL “A Randomized Double-Blind Study of Dextrose-Glycerin-Phenol Injections for Chronic Lower Back Pain”, Journal of Spinal Disorders, 1993, 6:23-33.
  4. 4)  Lui, Y Kinget Al., “An in-Situ Study of The Influence of Sclerosing Solution in Rabbit Medical Collateral Ligaments and it’s Injection Strength”, Connective Tissue Research, 11 (1983), PP 95-102
  5. 5)  Ongley, Milne J., “A New Approach to the Treatment of Chronic Low Back Pain”, The Lancet (July 18, 1987), PP 143-146
  6. 6)  Dorman, Thomas A, Editor, Prolotherapy in the Lumbar Spine and Pelvis Spine: State of Art Reviews, Volume 9 Number 2, Philadelphia, Hanley and Belfus, Inc., 1995

7)Hackett, George S., and Hemwall, Gustav A., and Montgomery, Gerald A., “Ligament and Tendon Relaxation Treated by Prolotherapy”, 5th Edition, 2nd printing, Oak Park, Illinois 1993

8)Houser, Ross, “Prolo Your Pain Away”, Curing Chronic Pain with Prolotherapy”, Beulah Land Pres, Oak Park Illinois 1998.

9)Reeves, K Dean, “Technique of Prolotherapy”, Psychiatric Procedures, Lennard, Ted A., Editor, PP 57-70, Philadelphia, Hanley Belfus, 1995

10)Wilkinson, Harold A., “The Failed Back Syndrome: Etiology and Therapy”, New York, Springer-Verlag, 1992, PP 147-169.

Patient Preparation for Injections:
1)Read the Prolotherapy handout and make sure you have ALL your questions

answered before beginning treatment.

2)You may have a light meal the day of your treatment, however, please do not consume any food within 2 hours of your treatment. The weeks leading up to treatment you want to eat a lot of foods rich protein and vitamin C; this will help with healing. Lots of high quality grass fed beef, pasture raised chicken, wild caught fish, organic vegetables and fruit. You also want to make sure you stay adequately hydrated; at least 64 fluid oz water/day.

3)For your safety it is highly recommended to have someone drive you home after your treatment, mandatory if you are having treatment on your Neck.

4)Please STOP Aspirin and Non-Steroidal Anti-Inflammatory Medications. It is Okay to continue taking “BABY-ASPIRIN” (81MG) unless otherwise told by your doctor.

5)STOP ANTI-PLATELET AGENTS (PLAVIX, TICLID) for 7 days prior. With approval from your doctor.

6)STOP COUMADIN (WARFIN) for 5 days prior to your injection with PRIOR APPROVAL from your DOCTOR and obtain STAT BLOOD

TEST (PT, INR AND PTT) on the morning of your injection. Have any results faxed to our office.

Please contact us prior to your appointment if:

1)You have a significant change in your medical history.
2)You have any questions about your medications.
3)You are taking antibiotics, are being for an infection or are feeling ill.

Thank you and we look forward to seeing you at your next visit.

Jon Trister, MD Diana Trister, DO

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Prolotherapy:Information for patients

Prolo packet questions

Am I a candidate for Regenerative Injection Therapy (Prolotherapy)?

Many problems related to musculoskeletal conditions are can be successfully treated with prolotherapy:

1.Degenerative Joint Diseases (Osteoarthritis) of all locations:
neck, TMJ, shoulders, scapulaes, clavicles, ribs, elbows, wrists, fingers, thoracic and lower back pain, “disc’s problems”, hips, knees, ankles, feet, toes.

2.Consequences of ligamentous and tendinous injuries (with some limitations). Partial tears of tendons, muscles and ligaments can be successfully treated with prolotherapy +/- PRP (platelet rich plasma)

3. Some forms of arthritis may have infectious, allergic, autoimmune or metabolic causes. In such cases we will order special diagnostic tests to help patient in selection of appropriate treatment.

4. Patients with infected joints, non-healing wounds around joints, cancer spread into the bones (metastasis, multiple myeloma, leukemias) are not candidate for prolotherapy

5. Elderly and debilitated patients may not respond well to prolotherapy.

6. Degree of joint damage (stage of the OA), age, weight, smoking status, nutritional status, use of certain medication (Steroids , NSAID) will

negatively affect prognosis of the treatment.

7. Other factors may play role too: anticoagulation therapy, anti-platelets therapy, etc

How much does it cost?

A.: The initial evaluation cost is $375.00. Treatment prices vary by area. Detailed pricing will be given at consultation

Will my insurance pay for this treatment?

A.: No, unfortunately prolotherapy is not covered by insurance

How many treatments will I need?

A.: It is not possible to tell ahead of time how many treatments a patient might need before they are pain-free. The doctor will give an estimated range of the number of treatments that you will need, depending on the severity of your condition. Average 3-6 sessions.

How far apart are the treatments?

A.: Treatments are usually given at 4-6 week intervals. There are exceptions to this, depending on other circumstances.

How soon after treatment can I work out or play sports?

A.: If your sports or work-outs involve the area that is being treated, you will get the best results with treatment when you avoid exercising or stressing the area until 3 or 4 weeks after the last treatment. If you must continue to exercise the treatment area, it may take a lot more treatments to get the desired result. You may continue to re-injure it with the exercise or sports activity, preventing it from getting strong enough to protect it.

What is in the medicine that is used in the injections?

A.: There is no cortisone used in prolotherapy. The solution is normally a mixture of a very concentrated dextrose (glucose) with a local anesthetic like lidocaine. In some cases we do PRP (Platelet Rich Plasma) which is your own blood product.

What is the success rate with prolotherapy?

A.: Prolotherapy generally has about a 80% good to excellent response among the doctors across the country that keep track of their patients’ responses to treatment. About 10% of the patients are in the poor response, or less than 50% improvement category.

Is there a guarantee that prolotherapy will work for me?

A.: There is nothing in medicine that is guaranteed.

How do I contact the office for an appointment?

A.: Please call our office at 508-754-9950 for an appointment. The staff will be happy to schedule your appointment and give you further information.

What are the office hours?

A.: Our office hours are 8:00 AM – to 5:00 PM, Monday through Friday.

What should I bring to the doctor’s office for the initial evaluation?

A.: Please bring the completed paper work that the office sends to you and any X-ray or films of any other studies that you may have had.

What happens at the first visit?

A.: Medical assistant will greet you, collect your paper work and take you to the examination room. The doctor will review your paper work, ask you questions about your problem, examine you, read your X-rays and explain them to you, give you their opinion about what they believe is causing your pain or other problems, order any new studies that may be needed and make recommendations for treatment. They will explain the treatment and answer

your questions. You will be given Consent form for treatment and estimated cost. No treatment will be performed during consultative visit.

Will I need a driver?

A.: Most of the time patients do need a driver. You will receive a treatment which may affect your ability to drive safely for 12-24 hours.

Will I need to be off work after the treatment?

A.: Most patients do not need to be off work the day after the treatment if it is sedentary work.

What are the risks with prolotherapy?

A.: There are risks with all treatments and medications, if the doctor feels that you are a candidate for prolotherapy, they will explain the risks to you and try to answer all of your questions.

It is important to remember that prolotherapy is a controlled injury. Therefore you should expect to be sore for the following 24-48 hours.

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Prolotherapy: Targets Carpal and Palmar ligaments

By Jon Trister MD

Prolotherapy is an effective treatment for various wrist and hand issues associated with laxity, instability, and altered function in these areas. The following structures are commonly targeted for Prolotherapy injections:

Carpal Ligaments  

The carpal ligaments comprise both intrinsic (connecting carpal bones) and extrinsic (connecting forearm bones to carpal bones) structures.

Transverse Carpal Ligament (TCL)  

The TCL is a thick fibrous band that spans the volar aspect of the wrist, forming the roof of the carpal tunnel. It attaches medially to the pisiform and hook of the hamate, and laterally to the scaphoid tuberosity and trapezium. Its key functions include:

– Formation of the Carpal Tunnel: The TCL creates a fibro-osseous tunnel that houses the median nerve and flexor tendons, protecting these components from external forces while allowing for smooth tendon gliding during wrist and finger movements.

– Biomechanical Stability: The TCL stabilizes the carpal bones by maintaining their arch-like configuration, which helps distribute axial loads across the wrist during weight-bearing activities.

– Pulley Function: Acting as a pulley system for flexor tendons, it ensures efficient force transfer from forearm muscles to the fingers.

  • Muscle Attachment Site: Portions of the thenar (e.g., abductor pollicis brevis) and hypothenar (e.g., flexor digiti minimi brevis) muscles originate from the TCL, contributing to movements of the thumb and little finger.

The transverse palmar ligament (also known as the deep transverse metacarpal ligament) and the carpal ligaments, including the transverse carpal ligament (TCL) and the palmar carpal ligament, play vital roles in maintaining the form and function of the wrist and hand. These ligaments provide stability, facilitate movement, and protect essential anatomical components such as nerves, tendons, and blood vessels.

Transverse Palmar Ligament  

The transverse palmar ligament (also known as the deep transverse metacarpal ligament)

The transverse palmar ligament connects the heads of the metacarpal bones of the second to fifth fingers on their palmar surfaces. It serves several important purposes:

– Stability of Metacarpophalangeal (MCP) Joints: It prevents excessive separation of the metacarpal heads during finger movements, ensuring proper alignment and stability of the MCP joints.

– Facilitation of Grip: By stabilizing the MCP joints, this ligament contributes to grip strength and precision during hand functions such as grasping or pinching.

– Protection of Soft Tissues: The ligament creates functional spaces that house blood vessels, nerves, and intrinsic hand muscles, shielding these structures during hand movements.

Functional Importance 

Together, these ligaments ensure:

1. Structural Integrity: They stabilize both the proximal (carpal) and distal (metacarpal) components of the wrist-hand complex.

2. Facilitation of Movement: They allow a wide range of wrist motions—flexion, extension, adduction, and abduction—while maintaining alignment.

3. Protection of Neurovascular Structures: By forming tunnels or compartments (such as the carpal tunnel), these ligaments shield critical nerves like the median nerve from compression or injury.

4. Force Transmission: They enable the efficient transfer of forces from forearm muscles to the fingers during activities that require strength or precision.

Damage or dysfunction in these ligaments can lead to conditions such as carpal tunnel syndrome (caused by compression of the median nerve due to TCL thickening) or instability in the MCP joints. Understanding the anatomy and biomechanics of these structures is crucial for accurately diagnosing and effectively treating wrist-related injuries.

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Synergism of the muscles, tendons and ligaments around the glenohumeral joint.(Literature review)

The Supraspinatus muscle collaborates with several structures, including muscles and ligaments, to effectively stabilize and facilitate movement in the shoulder joint. Below is a detailed breakdown:

Muscles that Work with the Supraspinatus

1. Deltoid Muscle: The supraspinatus initiates arm abduction (0° to 15°) and works in concert with the deltoid to continue abduction beyond this range. As the angle increases, the deltoid becomes increasingly dominant in the abduction process.

2. Other Rotator Cuff Muscles:

   – Infraspinatus: Aids in external rotation and stabilizes the humeral head.

   – Teres Minor: Contributes to external rotation and stabilization of the humeral head.

   – Subscapularis: Helps stabilize the humeral head within the glenoid cavity, counteracting forces during movement.

Ligaments that Support the Supraspinatus

1.Inferior Glenohumeral Ligament (IGHL): Provides passive stabilization by limiting superior and anterior translation of the humeral head, enhancing the stabilizing role of the supraspinatus during abduction.

2. Coracohumeral Ligament: Assists in limiting inferior translation of the humeral head, especially when the arm is adducted, supporting the supraspinatus in maintaining joint stability.

Together, these muscles and ligaments ensure both dynamic and static stability of the shoulder joint while facilitating smooth movements such as abduction and external rotation.

The Subscapularis muscle, an essential component of the rotator cuff, also works synergistically with various muscles and ligaments to stabilize and facilitate movement in the shoulder joint.

Muscles that Work with the Subscapularis

1. Rotator Cuff Muscles:

   – Supraspinatus: Helps stabilize the humeral head within the glenoid fossa and complements the subscapularis during shoulder movements.

   – Infraspinatus and Teres Minor: Serve as antagonists to the subscapularis by providing external rotation, balancing its internal rotation force. Together, these muscles form a force couple that stabilizes the glenohumeral joint by compressing the humeral head into the glenoid cavity.

2. Latissimus Dorsi: Works synergistically with the subscapularis during internal rotation and adduction of the shoulder, particularly when the function of the subscapularis is compromised.

3. Pectoralis Major: Aids in internal rotation and adduction of the shoulder, complementing the subscapularis during these movements.

4. Deltoid (Anterior Fibers): Contributes to internal rotation alongside the subscapularis and assists in arm elevation.

Ligaments that Support the Subscapularis

1. Coracohumeral Ligament: Reinforces the area between the subscapularis and supraspinatus tendons, providing added stability to the anterior shoulder.

2. Glenohumeral Ligaments (especially the Anterior Band of IGHL): These ligaments limit excessive anterior translation of the humeral head, complementing the stabilizing role of the subscapularis during shoulder movements.

Functional Synergy

– The subscapularis primarily provides internal rotation and prevents anterior displacement of the humeral head while working in conjunction with other rotator cuff muscles to maintain dynamic stability.

– Additionally, it plays a role in “concavity compression,” where opposing forces from the subscapularis (anterior) and infraspinatus/teres minor (posterior) help stabilize the humeral head within the glenoid cavity.

In summary, the subscapularis muscle synergizes with the other rotator cuff muscles—particularly the supraspinatus, infraspinatus, and teres minor—as well as larger muscles such as the latissimus dorsi and pectoralis major. Ligaments like the coracohumeral and glenohumeral ligaments further support its stabilizing functions. Together, these structures ensure proper shoulder mechanics and joint stability during movement.

The Infraspinatus and Teres minor muscles.

This muscles are components of the rotator cuff, primarily function as external rotators of theshoulder joint. They collaborate with various other muscles and ligaments to stabilize and mobilize the shoulder joint effectively.

Synergistic Muscles

1. Rotator Cuff Muscles:

   – Supraspinatus: Initiates arm abduction and stabilizes the humeral head, complementing the actions of infraspinatus and teres minor by preventing superior translation of the humeral head.

   – Subscapularis: Provides anterior stabilization and counteracts excessive anterior displacement, coordinating with infraspinatus and teres minor to maintain joint stability during movement.

2. Deltoid Muscle: 

   – The deltoid works alongside the rotator cuff muscles during shoulder abduction. Infraspinatus and teres minor counterbalance the upward pull of the deltoid, preventing superior displacement of the humeral head.

3. Teres Major: 

   – Although not a rotator cuff muscle, teres major aids with shoulder adduction and internal rotation, complementing the stabilization provided by infraspinatus and teres minor.

4. Trapezius and Serratus Anterior: 

   – These muscles stabilize the scapula, providing an optimal base for infraspinatus and teres minor to act on the humerus effectively during external rotation and other movements.

Synergistic Ligaments

1. Glenohumeral Ligaments: 

   – The superior, middle, and inferior glenohumeral ligaments provide passive stability to the shoulder joint. They work alongside the active stabilization role of infraspinatus and teres minor to limit excessive translation of the humeral head.

2. Capsular Mechanoreceptors: 

   – Mechanoreceptors within the glenohumeral capsule interact with rotator cuff muscles through reflex arcs, enhancing their synergistic action to stabilize the joint during dynamic movements.

Functional Roles

– Infraspinatus and teres minor work together to externally rotate the humerus, stabilize the glenohumeral joint by compressing the humeral head into the glenoid cavity, and counteract anterior or superior translation forces during arm movements.

– During overhead activities, these muscles help clear the greater tuberosity from impinging under the coracoacromial arch by externally rotating the humerus.

In summary, infraspinatus and teres minor synergize with other rotator cuff muscles (such as supraspinatus and subscapularis), larger movers like the deltoid and trapezius, and passive stabilizers like the glenohumeral ligaments to guarantee stability, mobility, and proper biomechanics of the shoulder joint.

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Key Components of the Elbow Joint literature review by Jon Trister MD

Key Components of the Elbow Joint

Bones: Humerus, Ulna, Radius 

Ligaments:

Ligaments are tough connective tissues that stabilize the elbow by connecting bones to bones. The primary ligaments of the elbow include:

  • Medial (Ulnar) Collateral Ligament (MCL): Provides stability on the inner side of the elbow, resisting valgus forces.
  • Lateral (Radial) Collateral Ligament (LCL): Stabilizes the outer side of the elbow, resisting varus forces.
  • Annular Ligament: Encircles the radial head, holding it against the ulna and allowing smooth rotation during pronation and supination.
  • Joint Capsule: A fibrous capsule reinforced by ligaments that encloses the elbow joint and contains synovial fluid for lubrication.

Tendons

  • Biceps Tendon: Attaches the biceps muscle to the radius, enabling flexion and forearm supination.
  • Triceps Tendon: Connects the triceps muscle to the ulna, enabling extension of the elbow.
  • Forearm Muscle Tendons: Attach to the medial and lateral epicondyles of the humerus.

Muscles

Muscles crossing the elbow provide dynamic stability and enable movement:

  • Biceps Brachii: Facilitates flexion and supination.
  • Triceps Brachii: Enables extension.
  • Forearm Flexors (e.g., Flexor Carpi Ulnaris): Attach to the medial epicondyle, aiding in wrist flexion.
  • Forearm Extensors (e.g., Extensor Carpi Radialis Brevis): Attach to the lateral epicondyle, aiding in wrist extension.

Synergy Between Ligaments, Tendons, and Muscles

  1. Stabilization:
    • Ligaments act as static stabilizers, maintaining joint congruency and preventing excessive motion. For example, collateral ligaments resist side-to-side instability during activities like throwing or lifting.
    • Muscles serve as dynamic stabilizers, contracting to counteract external forces. For instance, forearm muscles stabilize the elbow during gripping or lifting tasks.
  2. Movement Coordination:
  3. Tendons transmit muscular forces to bones, enabling precise movements such as flexion, extension, pronation, and supination. The biceps tendon works with the biceps muscle for bending and rotating the arm, while the triceps tendon facilitates straightening
  4. Stress Dissipation:
  5. The enthesis plays a important  role in dissipating mechanical stress. This reduces wear on individual structures during repetitive or high-stress activities such as throwing or lifting.
  6. Load Sharing:
  7. Structures like tendons and ligaments often merge or overlap at their attachment sites. For example, components of the lateral collateral ligament complex share loads with adjacent tendons like those of the extensor muscles.During dynamic activities like pitching or racquet sports, specific muscle groups (e.g., forearm flexors) activate to counteract valgus stress on ligaments like the MCL. This synergy minimizes strain on static stabilizers while maintaining joint integrity.

Clinical Implications

In summary, ligaments provide static stability while tendons and muscles dynamically control movement at the elbow joint. Their synergy ensures a balance between mobility and stability, enabling efficient function during complex activities while protecting against injury.

Supinator Muscle  and Ligaments in the elbow: functional synergy

The supinator muscle and the ligaments of the elbow joint work in functional synergy to enable and stabilize forearm supination, a key movement that rotates the palm upward. This coordination involves both dynamic and static elements, ensuring effective motion while maintaining joint integrity.

Supinator Muscle and Its Role

The supinator muscle is a spiral-shaped muscle located in the posterior forearm. It wraps around the proximal radius and is primarily responsible for forearm supination. Unlike the biceps brachii, which also assists in supination but requires a flexed elbow, the supinator can perform this action regardless of elbow position. It originates from multiple structures around the elbow, including:

  • Lateral epicondyle of the humerus
  • Radial collateral ligament
  • Annular ligament
  • Supinator crest of the ulna

Its insertion on the proximal radius allows it to rotate the radius laterally during supination. The muscle is innervated by the deep branch of the radial nerve (posterior interosseous nerve) and is most active during slow or unresisted supination, while the biceps brachii takes over during forceful or resisted movements.

Ligaments, Lateral elbow:

Several ligaments in the elbow joint contribute to stability during supination:

  • Annular Ligament: Encircles the radial head, securing it against the ulna while allowing rotational movement. This ligament provides a stable axis for the radius to rotate during pronation and supination.
  • Jaap van der Wal, a Dutch anatomist, provided a unique perspective on the anatomy of the annular radial ligament. According to his observations, the so-called “annular ligament” is not an independent structure as traditionally described in anatomy. Instead, Van der Wal argued that it is an integrated part of the aponeurotic connective tissue layer through which the fibers of the supinator muscle insert into the lateral epicondyle of the humerus. He suggested that most collagenous fibers in the proximal lateral cubital region are interposed between skeletal tissue and muscle fascicles, making it difficult to identify separate ligamentous entities such as the annular ligament or even the radial collateral ligament as distinct structures.
  • Van der Wal’s connective tissue-focused dissections highlighted how these anatomical components are interconnected within the lateral ligamentous complex of the elbow. This perspective challenges traditional anatomical descriptions and underscores the functional integration of ligaments, muscles, and connective tissues in this region. His work sheds light on how these structures collectively contribute to elbow stability rather than functioning as isolated components
  • Radial Collateral Ligament: Works with the annular ligament to stabilize lateral elbow structures and prevent excessive varus forces.
  • Quadrate Ligament: Located distal to the annular ligament, it limits excessive supination and helps maintain alignment between the radial head and ulna.

Functional Synergy

  1. Stabilization During Supination:
    • The annular ligament anchors the radial head, ensuring smooth rotation within the radial notch of the ulna.
    • The radial collateral ligament supports lateral stability, preventing dislocation or misalignment during rotational movements.
  2. Force Transmission:
  3. The supinator muscle generates rotational force on the radius for forearm supination. Its attachment to ligaments like the annular ligament integrates muscle action with ligamentous stability, ensuring efficient motion without compromising joint integrity.
  4. Load Sharing:
  5. The close anatomical relationship between the supinator muscle and ligaments like the annular ligament allows these structures to share mechanical loads. For instance, parts of the supinator originate from or are embedded in collagenous tissue associated with these ligaments, creating a functional unit that stabilizes and moves the joint simultaneously.
  6. Prevention of Excessive Motion:
  7. Ligaments such as the quadrate ligament act as passive restraints against excessive rotational forces, complementing the dynamic control provided by muscles like the supinator.
  8. Developmental Interplay:
  9. During fetal development, parts of the supinator muscle are closely integrated with collagenous tissue forming ligaments like the annular ligament. This suggests a developmental synergy where muscle contraction may influence ligament formation, although excessive ligament growth can impair some muscle fibers.

Clinical Relevance

The interplay between these structures highlights their importance in maintaining elbow function:

  • Injuries to ligaments (e.g., annular ligament tears) or nerve compression affecting the supinator can impair forearm rotation.
  • Conditions like “pulled elbow” (radial head subluxation) involve entrapment of structures such as the annular ligament and may disrupt normal synergy between muscles and ligaments.
  • Rehabilitation often focuses on restoring both dynamic (muscle) and static (ligament) stability to ensure proper joint mechanics.

In summary, the supinator muscle works synergistically with elbow ligaments to facilitate controlled forearm supination while stabilizing joint structures. This collaboration ensures smooth movement and protects against injury during complex rotational tasks.

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Immune support by Renata Trister DO

Orange Peel Tea for Immune Support
During these uncertain times, supporting your immune system and the microbiome is important. You can drink this tea throughout the day and swish it around your mouth (unsweetened) to support the oral and gut microbiome.
Ingredients:
Orange or any citrus peel (from 4-5 fruits)1/4 Onion1 inch Ginger2-3 Sprigs of Rosemary2 tsp Whole Cloves2-3 Star Anise1-2 tbs Fennel seeds
8-10 cups water. Bring to a boil & simmer for 20 minutes (or up to an hour)
Keep in mind that you don’t have to have every single ingredient.  There is no way to do this wrong.  A simple tea of citrus peel is helpful.  The other ingredients can be rotated.  The goal is to use what you have on hand and get lots of polyphenols from these plants.  Boiling these plants in water helps get the nutrients out.  You can use a vegetable peeler to peel the citrus and save the peels in a bowl as you go in your fridge.  Once you have enough, you can make tea.  If you are having digestive issues, prioritize the ginger and fennel after the citrus peel.  The onion provides quercetin, a flavonoid, useful for immune support, and is very antimicrobial.  You don’t taste it in the tea, but it provides benefits.  The spices all function to support the gut flora.  Star anise contains shikimic acid and is used as a base material for the production of Tamiflu.

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Tensegrity and immunology part 2. Jon Trister MD

Cellular components of the organs and tissues, vascular and neurological structures are parts of tensegrity arrangement; Microbiome is an equal part of this ecosystem. Tensegrity is influenced by the microbiome. At the same time, mechanical properties of the connective tissue will influence microbiome composition and pathogenicity.

Cellular components of the organs and tissues, vascular and neurological structures are suspended in the tensegrity network and actually part of this network. Their form and function regulated by mechanical properties of the ecosystem they reside (Pre-stress).

Pre-stress  is  influenced by  microbiome and microbiome is regulated by pre-stress.

 Microbiota are ecological communities of commensal

symbiotic and pathogenic microorganisms

 found in and on all multicellular organisms. Microbiota includes bacteria, archaea, protists, fungi and viruses. Microbiota have a  crucial role for immunologic, hormonal and metabolic

 homeostasis of their host. The synonymous term microbiome describes either the collective genomes of the microorganisms that reside in an environmental niche or the microorganisms themselves

Microbiome  persist in nearly every human body site, including tissue and blood. The genomes of these microbes continually interact with the human genome in order to regulate host metabolism.

Many components of this microbiome are capable of both commensal and pathogenic activity. This activity is determined by environment they reside (viscoelasticity -pre-stress): immunological cells responsible for innate and adaptive responses. They are additionally able to persist in both “acute” and chronic forms. Inflammatory conditions historically studied separately (autoimmune, neurological and malignant) are now repeatedly tied to a common trend: imbalance or dysbiosis of these microbial ecosystems.

Collective activity of the microbiome that drives inflammatory processes via complex microbe-microbe and host-microbe interactions. Many microbes survive as polymicrobial entities in order to evade the immune response. Pathogens in these communities alter their gene expression in ways that promote community-wide virulence. Other microbes persist inside the cells of the immune system (Cell Wall Deficient bacteria -CWD), where they directly interfere with host transcription, translation, and DNA repair mechanisms. The numerous proteins and metabolites expressed by these pathogens further dysregulate human gene expression in a manner that promotes imbalance and immunosuppression. Molecular mimicry, or homology between host and microbial proteins, complicates the nature of this interference. When taken together, these microbe-microbe and host-microbe interactions are capable of driving the large-scale failure of human metabolism characteristic of many different inflammatory conditions.

Microbiota are “ecological communities of commensalsymbiotic and pathogenic microorganisms” found in and on all multicellular organisms. Microbiota includes bacteria, archaea, protists, fungi and viruses. Microbiota have been found to be crucial for immunologic, hormonal and metabolic homeostasis of their host. The synonymous term microbiome describes either the collective genomes of the microorganisms that reside in an environmental niche or the microorganisms themselves

Microbiome  persist in nearly every human body site, including tissue and blood. The genomes of these microbes continually interact with the human genome in order to regulate host metabolism.

Many components of this microbiome are capable of both commensal and pathogenic activity. They are additionally able to persist in both “acute” and chronic forms. Inflammatory conditions historically studied separately (autoimmune, neurological and malignant) are now repeatedly tied to a common trend: imbalance or dysbiosis of these microbial ecosystems.The collective activity of the microbiome that drives inflammatory processes via complex microbe-microbe and host-microbe interactions. Many microbes survive as polymicrobial entities in order to evade the immune response. Pathogens in these communities alter their gene expression in ways that promote community-wide virulence. Other microbes persist inside the cells of the immune system, where they directly interfere with host transcription, translation, and DNA repair mechanisms. The numerous proteins and metabolites expressed by these pathogens further dysregulate human gene expression in a manner that promotes imbalance and immunosuppression. Molecular mimicry, or homology between host and microbial proteins, complicates the nature of this interference. When taken together, these microbe-microbe and host-microbe interactions are capable of driving the large-scale failure of human metabolism characteristic of many different inflammatory conditions. (Amy D Proal)

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Tensegrity and Immunology.Part 1

Mechanical properties of the skin are changed with time. Altered pre-stress changes first defenses of the immune system-physical barriers-Epidermis and dermal layers of the skin. Reduced functional capacity and increased susceptibility of the skin with development of dermatoses such as dry skin, itching, ulcers, dis-pigmentation,  wrinkles, fungal infections, as well as benign and malignant tumors are the most common skin conditions in aged population. In turn altered appearance, dry skin, chronic wounds, and other conditions decrease general health and reduce the likelihood for healthy and active aging. Ability of the skin to carry out multiple and wide-ranging roles is very closely related to its structure, which is composed of an outer epidermis overlying an inner dermis, separated by a basement membrane.

Relevant Histology:

Stratum Corneum

Stratum Granulosum

Stratum Spinosum

Stratum Basale

Skin perform barrier function for invaders:

Physical barriers: terminally differentiated epidermal keratinocytes. 

Biochemical barriers: acidic, hydrolipidic nature of the skin, as a result of sweat, sebum, lipids, and antimicrobial peptides (AMPs).Any changes in lipid composition and epidermal differentiation lead to a disturbed skin barrier, which plays a role in the pathogenesis of several immune-mediated skin  pathologies, such as atopic dermatitis and ichthyosis vulgaris .

The epidermis is a host to keratinocytes, melanocytes and immune cells such as Langerhans cells (LCs) and T lymphocytes, nerve-ending cells (Merkel cells).The dermis is composed of an upper papillary (stratum papillare) and lower reticular (stratum reticulare) dermis containing thin and thick collagen fibers, respectively. The collagen fibers offer a mechanical barrier as well as a structural environment  in which to host blood vessels and many immune cells such as dermal dendritic cells (DDCs), ab T cells, gd T cells, natural killer (NK) cells, B cells, mast cells, and macrophages can perform their function.

More recently, it was proposed a sentinel role in health and disease for a spectrum of skin-resident cells ( with keratinocytes involved in sensing pathogens and danger signals, migratory DCs capable of initiating a diverse range of immune responses, and tissue-resident memory T (Trm) cells performing crucial effector functions.

Skin-associated lymphoid tissue (SALT) participates in  trafficking of immune cells between the skin, draining lymph nodes (LNs), and the peripheral circulation (Streilein, 1983).

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Updates from CDC as of 3/29/2020:

  • There is currently no vaccine to prevent coronavirus disease 2019 (COVID-19).
  • The best way to prevent illness is to avoid being exposed to this virus.
  • The virus is thought to spread mainly from person-to-person.
    • Between people who are in close contact with one another (within about 6 feet).
    • Through respiratory droplets produced when an infected person coughs or sneezes.
  • These droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into the lungs.

Take steps to protect yourself

Clean your hands often

  • Wash your hands often with soap and water for at least 20 seconds especially after you have been in a public place, or after blowing your nose, coughing, or sneezing.
  • If soap and water are not readily available, use a hand sanitizer that contains at least 60% alcohol. Cover all surfaces of your hands and rub them together until they feel dry.
  • Avoid touching your eyes, nose, and mouth with unwashed hands.

Avoid close contact

Take steps to protect other

Stay home if you’re sick

Cover coughs and sneezes

  • Cover your mouth and nose with a tissue when you cough or sneeze or use the inside of your elbow.
  • Throw used tissues in the trash.
  • Immediately wash your hands with soap and water for at least 20 seconds. If soap and water are not readily available, clean your hands with a hand sanitizer that contains at least 60% alcohol.

Wear a facemask if you are sick

  • If you are sick: You should wear a facemask when you are around other people (e.g., sharing a room or vehicle) and before you enter a healthcare provider’s office. If you are not able to wear a facemask (for example, because it causes trouble breathing), then you should do your best to cover your coughs and sneezes, and people who are caring for you should wear a facemask if they enter your room. Learn what to do if you are sick.
  • If you are NOT sick: You do not need to wear a facemask unless you are caring for someone who is sick (and they are not able to wear a facemask). Facemasks may be in short supply and they should be saved for caregivers.

Clean and disinfect

  • Clean AND disinfect frequently touched surfaces daily. This includes tables, doorknobs, light switches, countertops, handles, desks, phones, keyboards, toilets, faucets, and sinks.
  • If surfaces are dirty, clean them: Use detergent or soap and water prior to disinfection.

To disinfect:

Most common EPA-registered household disinfectants will work. Use disinfectants appropriate for the surface.

Options include:

  • Diluting your household bleach.
  • To make a bleach solution, mix:
    • 5 tablespoons (1/3rd cup) bleach per gallon of water
    • OR
    • 4 teaspoons bleach per quart of water
  • Follow manufacturer’s instructions for application and proper ventilation. Check to ensure the product is not past its expiration date. Never mix household bleach with ammonia or any other cleanser. Unexpired household bleach will be effective against coronaviruses when properly diluted. 
  • Alcohol solutions.
    Ensure solution has at least 70% alcohol.
  • Other common EPA-registered household disinfectants. 
  • Products with EPA-approved emerging viral pathogens pdf icon
    [7 pages]external icon
     claims are expected to be effective against COVID-19 based on data for harder to kill viruses. Follow the manufacturer’s instructions for all cleaning and disinfection products (e.g., concentration, application method and contact time, etc.).
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