Over recent years there has been a surge in research leading to new treatments that utilise the body’s own natural healing capacity to relieve pain and help repair injuries that are not responsive to traditional methods of care. At Cheltenham Podiatry, we have always been passionate in keeping up with the latest developments and proven treatments within the health care industry, allowing us to provide world class support and care for our patients.
These treatments have shown to be safer and more effective in treating numerous podiatric conditions including osteoarthritis, stubborn tendon and ligament injuries and general sports injuries, than in comparison to more conservative methods such as cortisone injections and other oral anti-inflammatories.
Cheltenham Podiatry, in Melbourne has a specialist regenerative clinic with the latest in biological therapies; Autologous Regenerative Therapies (platelet rich plasma and othokine), and Prolotherapy. Jacqueline Kan is proud to be the first podiatrist in Melbourne utilizing Autologous Regenerative Therapy.
Orthokine and PRP are both autologous regenerative therapies used to heal damaged tissues. The patient’s own blood is re-engineered to isolate and magnify it’s natural healing and anti-inflammatory properties (platelets, growth factors, proteins), then reinjected into the affected site using ultrasound guidance for best outcome.
The patients blood is taken, centrifuged, and in some instances incubated to isolate and concentrate the healing and anti inflammatory properties, then injected into the damaged tissues. It is used to promote healing for soft tissue injuries (tendons and ligaments), as well as relieve pain and improve function for osteoarthritic joints. Platelet rich plasma (PRP) and Orthokine are the most popular and well researched biologic therapies that are shown to be safe and effective.
Examples of podiatric conditions treated include:
- Osteoarthritis of knee, ankle, large toe and other painful foot joints.
- Pain relief and healing of stubborn soft tissue injuries that fail conservative treatments – Achilles tendinopathy and plantar fasciitis
- Often combined with other podiatry treatments – prolotherapy, biomechanical adjustments (paddings, tapings, orthotics and footwear adjustments where appropriate) for best outcome.
- severe nerve entrapments
Platelet Rich Plasma
Platelet rich plasma (PRP), is utilized when the normal healing process fails. After an injury, the platelets in our blood are activated, releasing growth factors that help to heal damaged tissues. The process of PRP involves blood collection (venupuncture – akin to pathology for blood tests), which is then centrifuged to separate and concentrate the platelets, and extracted under sterile conditions. The platelet concentration in PRP are 3-5 times above normal levels. This platelet rich plasma is activated and injected using sterile technique into the site of injury. Usually 3-4 injections are required 2 weeks apart. It is an effective treatment for damaged tendons, ligaments and osteoarthritis. A recent study compared a single PRP injection to a cortisone injection to treat chronic plantar fasciitis, which had shown to fail after 4 months of conservative treatment. It concluded, “PRP was more effective and durable than cortisone injection for the treatment of chronic recalcitrant cases of plantar fasciitis”. 
There are many Prp setups that only allow for a one fits all treatment product. However, each condition, injury, and the age of the patient will require varying concentrations of the essential products of Prp for best outcome . For that reason we individualise the process, and engineer the appropriate concentrations of the essential blood products.
Another version of prp – Platelet rich fibrin bio active matrix is a novel application that seeks to accelerate wound healing. In this process, after blood is taken, it is centrifuged, activated, then incubated to engineer a clot. The platelet concentration is aimed at a 2-3 fold increase compared to normal blood, which has been reported to provide optimum benefit. It is applied to the wound, progressively releasing a wide range of growth factors for over 5 days, and is particularly useful for difficult Diabetic/Ischaemic wounds/ulcers that fail to heal through traditional methods. This treatment is required on a weekly basis and incorporated with other ulcer treatments in our clinic.
Orthokine is an autologous conditioned serum, developed in Germany by a molecular biologist and spinal surgeon. It focuses on increasing the body’s natural anti-inflammatory factors. That is, Interleukin 1 receptor antagonist (IL-1RA), as well as growth factors. Osteoarthritic joints have high concentrations of interleukin 1 (IL1) which is understood to damage cartilage in joints. IL-1RA blocks the IL1, preventing damage to the joint while growth factors attempt to heal damaged tissue. Orthokine is similar to PRP, in that blood is taken, but is then warmed in an incubator for 6-9 hours. This process increases the concentration of IL1 receptor antagonist (IL-1RA). It is then centrifuged to separate and concentrate the serum, and extracted under sterile conditions. The serum is then injected into the site using sterile technique. Often, up to 6 injections are required fortnightly. Orthokine has a particularly high level of research (Level 1 evidence) for greater than 50% pain reduction in mild to moderate osteo-arthritis.  It is also used to treat persistent tendon and ligament injuries.Due to its anti inflammatory effect, its the more comfortable injection compared to the other autologous preparations.
Preparation and extraction of our autologous therapies is accomplished safely in a Class 11 bio-safety cabinet. We utilize techniques that maximise safety while minimizing pain. We may also advise to combine Autologous regenerative therapy with prolotherapy, particularly for joints, as surrounding joint soft tissues (ligaments and tendons) are often affected. While theses regenerative techniques alter and improve the internal environment of the joint or tissue, the external environment(mechanical forces) may also need to be adjusted with orthotics , pads, wedges and or approriate footwear to offload the affected tissue. This will likely lead to an improved outcome.
Prolotherapy was first developed by a surgeon George Hackett in the U.S.A. in the 1930’s to treat chronic pain. Prolotherapy is a safe and effective regenerative treatment, also known as a proliferant. It is an injection of a natural solution( dextrose) into damaged tissue, producing a cascade of events at the site of injury, stimulating growth factors and regenerating ligaments, tendons and cartilage,and improves nerve function, relieving pain.
Cheltenham podiatry in melbourne suburb of highett utilises two forms of Prolotherapy:
Classical Hackett Prolotherapy
Is a 15-20% glucose with anesthetic solution is injected into the damaged tissue. It triggers an inflammation and wound healing cascade, so that fibroblasts encourage new collagen production. As the new collagen matures it increases the strength of the ligament. Microscopic studies have shown increase in collagen fibril size and number.When introduced in a joint , it releases growth factors that can help increase cartilage growth. It can be utilized to strengthen damaged ligaments ( eg.weak ankles), repair damaged tendons and utilized in treating osteoarthritic joints. Fortnightly to monthly injections are required for Hackett’s prolotherapy, usually 4 – 9 sessions.
Lyftogt’s Perineural Prolotherapy
John Lyftogt’s perineural prolotherapy ( otherwise known as P.I.T.- Perineural injection therapy ) is an exciting and innovative advancement in the field of Regenerative Medicine.
It is a shallow 5% medical grade dextrose- D5W (a form of glucose) injection just under the skin with a small fine needle (no anesthetic is required), that is used to treat pain. 
The theory behind Neural Prolotherapy is based on “Hilton’s Law”, named after British surgeon Dr. John Hilton. An extraordinary anatomist, Dr. Hilton noted that the nerves that innervate a joint also innervate the skin overlying that joint and the muscles that move that joint. From this, Dr. Lyftogt hypothesized that irritation to a nerve that supplies sensation to the skin over a joint may also cause dysfunction and pain to the muscles and tissue around that joint.
It has long been known that dextrose in traditional prolotherapy promotes healing in connective tissues such as ligaments and tendons. Because nerves also contain connective tissue, Dr. Lyftogt postulated that dextrose could allow for the same healing in nerves. He injected small amounts of dextrose under the skin which resulted in decreased swelling, reduced pain, and improvement of function in many musculoskeletal conditions.
Dr. Lyftogt postulated that restoration of subcutaneous nerve function (those just beneath the surface of the skin) will lead to healing of deeper structures and reduction in pain. This method to treat musculoskeletal injuries and neuropathic pain has been achieving remarkable results.
It decreases pain almost immediately as well as improving function. Between 1- 6 sessions are required for permanent pain relief, although often 1-3 sessions are sufficient. An immediate reduction in pain after the first injection is experienced by most patients, which may last anywhere between hours to days. Pain is generally reduced by 20-40% with each subsequent treatment as the tissue progressively heals. As nerves feed all our tissues, it can also be used to help heal chronic musculo skeletal conditions, as Achilles tendonopathy.
Injured tissues cause the release of pro-inflammatory substances (e.g. Bradykinin, Prostaglandins) that activate a channel on nerves called the “Transient receptor potential V1” (TRPV-1) cation channel, also known as the capsacin receptor. When activated, this channel results in the nerve releasing substances that cause inflammation (substance P and calcitonin gene related peptide (CGRP)) leading to leaky blood vessels (swelling), hypersensitivity, and painful sensations. It is thought that the dextrose used in the injections for Neural Prolotherapy bind to and inhibit the TRPV-1 nerve receptors, preventing this inflammatory process and restoring normal nerve function.
Examples of podiatric conditions treated with these therapies include:
- Osteoarthritis of knee, ankle, large toe and other painful foot joints, bunion pain
- Pain relief from stubborn soft tissue injuries – Heel pain, weak ankles, Achilles tendinopathy and plantar fasciitis, ligament damage and weakness (weak ankles), ankle pain, cuboid syndrome, runners knee, jumpers knee, ITB syndrome.
- neural/nerve pain- morton’s neuroma, nerve trauma after surgery, nerve entrapments and constriction.
It may be combined with other podiatric treatments – Autologous Regenerative Therapy (PRP/Othokine), orthotics, footwear adjustments, padding’s and exercise. Nutritional supplements are often advised with Prolotherapy to encourage healing of the tissues.
Nerve Hydrodissection under Ultrasound Guidance
This specialised field of regenerative medicine has moved ahead with improved techniques for recalcitrant nerve entrapments. Their a growing body research utilising ultrasound guided nerve hydrodissection (freeing entrapped nerves with injectants). This is a simple safe technique using either 5% dextrose, or platelet rich plasma for conditions such as tarsal tunnel syndrome , Morton’s neuroma, and other deep nerve entrapments.
 Monto, Raymond Rocco. “Platelet-rich plasma efficacy versus corticosteroid injection treatment for chronic severe plantar fasciitis.” Foot & ankle international 35.4 (2014): 313-318.
 Baltzer, A. W. A., C. Moser, S. A. Jansen, and R. Krauspe. “Autologous conditioned serum (Orthokine) is an effective treatment for knee osteoarthritis.” Osteoarthritis and Cartilage 17, no. 2 (2009): 152-160.
. Wu YT1, Ho TY, Chou YC, Ke MJ, Li TY, Tsai CK, Chen LC.Six-month Efficacy of Perineural Dextrose for Carpal Tunnel Syndrome: A Prospective, Randomized, Double-Blind, Controlled trial . Mayo Clin Proc. 2017 Aug;92(8):1179-1189