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12 Articles in Volume 16, Issue #10
2016 Practical Clinical Advances: Ketamine and Metformin
Case Challenge: Amniotic Allograft Reduces Joint and Soft Tissue Pain
Challenges of Treating Young Patients With a Terminal Prognosis
Defining Palliative Care
Discussing Benefits of Palliative Care
Evaluation of Antiemetic Pharmacotherapy in the Setting of Opioid Withdrawal
Fibromyalgia, Chronic Fatigue, and Chronic Fatigue Syndrome
Gabapentin Dosing for Neuropathic Pain
IV Acetaminophen Reduces Need for Opioids in Burn Patients
Opioid-Induced Constipation: New and Emerging Therapies—Update 2016
Osteopathic Treatment Considerations For Head, Neck, and Facial Pain
Tips From the Field: Deconstructing the Art of Headache Medicine

Case Challenge: Amniotic Allograft Reduces Joint and Soft Tissue Pain

Two case presentations demonstrate the use of injectable micronized dehydrated amniotic/chorionic membrane allograft (mDHACM) to help reduce pain and enhance healing for patients with foot and ankle pain.
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Foot pain is one of the most common orthopedic complaints; it affects more than 1 million people per year.1 The diagnosis of foot pain is based on the patient’s symptoms, which are characterized by classic signs of inflammation—pain, swelling, and loss of function.1

Foot pain can be caused by repeated trauma or overuse that creates microtears in the affected joint, concurrently damaging the immediate surrounding soft tissue.2,3 Additional diagnostic modalities, including  musculoskeletal ultrasound, computerized tomography (CT) scans, magnetic resonance imaging (MRI), and electromyography (EMG) studies may be used to rule out related pathologies.

An injection containing AmnioFix is being prepared. Photo courtesy of Mimed Group Inc.

Common treatment options available for foot pain include rest, stretching exercises, orthotics, cryotherapy, oral analgesics, corticosteroid injections, phonophoresis, and local injections of platelet-rich plasma.4-6 No single treatment is guaranteed to relieve pain.7 Traditional nonoperative management can lead to a temporary abatement of symptoms—during which the degenerative process related to repetitive microtearing and inflammation continues to occur.2,3,6,8

A recent study has shown that locally injected amniotic-derived mesenchymal cells aid in the recovery of injured peripheral nerves.9 A treatment that reduces inflammation of soft tissues and nerves, and that allows for rapid return to pain-free activities is highly desirable and the basis for the use of dehydrated micronized amnion/chorion.  

The purpose of this case review is to present injectable micronized dehydrated amniotic/chorionic membrane (mDHACM; AmnioFix Injectable, Mimed Group Inc, Marietta, GA) allograft as an agent for joint and soft tissue pain reduction in the foot and ankle. Ultrasound-guided arthrocentesis using mDHACM allograft was performed on patients who were still experiencing localized joint and soft tissue pain after 12 months of ineffective conservative care. Both patients received an ultrasound-guided intra-articular, intra-tendon, and periarticular injection of mDHACM. The patients experienced reduced pain on ambulation 2 weeks after the treatment. Following the injections of mDHACM, patients were able to return to their daily activities with reduced pain.

Case 1

A 57-year-old male who was working as a machinist presented with a history of chronic left ankle inversion sprain, which first occurred in childhood, and bilateral pedal stress fractures that occurred while he was in the military. His chronic pain measured 6-10 out of 10 on the Wong–Baker FACES Pain Rating Scale.

The patient had undergone 8 months of conservative care consisting of ankle strapping, wearing high-top boots, and using custom orthotics. He had been taking nonsteroidal anti-inflammatory drugs (NSAIDs), had undergone phonophoresis, and was doing proprioceptive exercises, which had all failed to alleviate his symptoms. The patient was unable to have elective ankle and foot surgery because of job and family responsibilities.

Physical Examination

Upon physical examination, the patient’s dorsalis pedis and posterior tibial pulses were palpable and normal; temperature gradient of the lower extremity was within normal limits in both feet. Skin was supple and hydrated. Feet were not erythematous, warm, or swollen, and muscle power was normal—5 out of 5 for the dorsiflexors, plantar flexors, inverters, and evertors of both feet.

The patient has flexible pes planus (flat feet) with low-average arches. There was tenderness upon palpation along the peroneal tendons at the left ankle consistent with tendinitis. The patient described his pain as sharp shooting pain that radiated both proximally and distally or a dull ache. The pain on percussion was approximately 6 out of 10 on the Wong–Baker FACES Pain Rating Scale for the left ankle. The patient stated that rest alleviates the pain.

Radiographic Studies

An initial x-ray of the left ankle (AP, lateral, and oblique views) demonstrated no acute fracture or dislocation. The ankle mortise appeared maintained. There was a tiny plantar surface calcaneal spur. There were no lytic or blastic lesions and no soft tissue abnormalities.

Subsequently, an ankle MRI was obtained that showed a partial tear involving the left peroneus brevis, and tenosynovitis involving peroneus longus tendons with increased inflammation at the distal fibula, fibular groove, and extending 2 to 3 cm proximally. Also noted were left ligament sprains in the medial collateral ligaments, as well as at the lateral calcaneofibular and calcaneal talar ligaments. Boomerang-shaped peroneus brevis at the level of lateral malleolus was noted, indicating a dislocatable or dislocated peroneal tendon.

Clinical Course

The patient agreed to an ultrasound-guided injection of AmnioFix 40 mg particulate peritendon and intratendon to left peroneal tendon(s) at the distal fibula area (Figure 1). The patient’s ankle was then wrapped in a soft cast paste boot, and he was prescribed a postoperative shoe with instructions to remove the boot in 24 to 48 hours, and then return to usual footwear. The patient was also instructed to take NSAIDs in advance for expected post-injection pain. The Wong–Baker FACES Pain Rating Scale was used to rate average pre-injection pain from 0 (no hurt) to 10 (hurts worst), as well as the pain 8 weeks after the injections.

The patient returned to work after 2 days of weekend rest, with only use of an ankle support and wearing his high-top boots for ankle stability. He was able work a 40-hour week, and his pain level was reported at 1 to 2 out of 10 after 8 weeks. Although the pain was reduced, the patient continued to report tenderness (6-7/10) was present, “but not like it used to be.” Because of the structural abnormality of the boomerang peroneal tendon, it was expected that his pain may increase if the lateral ankle was not protected. Follow-up ultrasound of the same area 9 months later revealed decreased inflammation at the fibular groove and proximally. The patient will require surgical correction (Figure 2).

Case 2

This 40-year-old female veteran has a history of osteoarthritis and cervical dysplasia. She is actively employed as a college registrar. She presented with right foot pain at the right 3rd metatarsal phalangeal joint. Specifically the area is located in the region between the 3rd and 4th metatarsals of the right foot. The patient stated that the pain (7/10) was greatest when she wore high heels or put pressure on her forefoot. The patient stated that rest alleviated the pain, along with wearing a shoe that did not restrict her foot width. Previously, the patient was treated with 8 weeks of physical therapy that included phonophoresis with hydrocortisone ointment. The patient used her prescribed custom orthotics daily.  

Last updated on: December 20, 2016
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