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This podcast forum is brought to you to share expertise and insights within our integrated delivery system to help us improve the health of the people we serve and achieve world-class accessible care. This is Expert Insights. Here's your host, Melanie Cole.

Melanie Cole (Host): This is Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole. And joining me as Dr. Jonathan Aubry. He's a sports medicine physician at Carle BroMenn in Bloomington, Illinois, and he's here to share the exciting breadth of a sports medicine practice and what's new in the field of in-office orthopedic procedures, ultrasound-guided injections. We have a lot to talk about today. Dr. Aubry, thank you so much for joining us. As we get into this, I just first want you to sort of go over what is the field of sports medicine? Does it only help athletes? What's the difference between a sports medicine physician and an orthopedic surgeon?

Dr Jonathan Aubry: Hi, Melanie. Thanks for having me today. And so, as you've alluded to, I'm a sports medicine physician. I'm family medicine trained. And then I did an extra year of fellowship at the University of Florida in non-operative sports medicine. So you're right, I'm not an orthopedic surgeon as most people tend to think about when they think of sports medicine and orthopedics. And so from a primary care sports medicine standpoint, I like to kind of say that we do more so general orthopedics.

In my practice, I see kids up to adults and elderly folks. So we see kind of the whole breadth of orthopedic injuries, whether it's overuse from athletes, acute injuries from athletes, to arthritis in middle-aged older people, tendon pain, basically anything can bring them to the door with and orthopedic problem or bone, joint, muscle pain. And then our job in my practice is to triage, make sure that we're working up things appropriately with x-rays, MRIs, ultrasounds, things like that to make sure that we're getting people down the right path. So I like to think of it more as non-operative orthopedics versus just sports medicine. But at the back end of this, we see a lot of athletes, we're treating acute athletic injuries, including outside of orthopedics, we're doing lots of concussion care, exercise prescriptions, all those things and really trying to optimize people's fitness on top of just taking care of their bones and joints and things like that.

On top of this, I still do practice primary care for athletes. And so, my partner, Dr. Murphy and I, we spend some time with Illinois State University and some other local places where we will practice primary care and treat non-orthopedic and just general medical problems, but mainly for athletes. And so depending on who you talk to and what the practice looks like, you can have more or less primary care, actual family medical duties in the world of non-operative sports. And, there's certain times where that's mainly what physician does. They mainly just hang out with sports teams or NFL teams, all those things, or in my situation, it's a balance of three and a half days in the clinic treating patients mainly for orthopedic issues and then the rest of my time with athletes in the community. So there can be huge array of different things that a sports med doctor can do.

Melanie Cole (Host): Well, it's certainly a burgeoning field and an exciting field at that. And as you and I were talking off the air, Dr. Aubry, there's so many ways that sports medicine, when we just say sports medicine, that it can go. But one of the interesting things are some of the treatments that are now less invasive that don't require immediate surgery. Tell us about ultrasound-guided injections and things you can do for some of these sports injuries that are really exciting now.

Dr Jonathan Aubry: Yes, it's very exciting time to be a sports medicine doctor. And so over the past 10 years or so, even before I went to medical school, the use of ultrasound to help to place catheters, needles, all kinds of things in the hospital system has translated over to musculoskeletal medicine as well. And so most people know ultrasound from seeing someone that's pregnant, looking at the mother's baby, to check on the size and health of little ones. In this case, we're looking into, we can see joint lines, we can see tendon structure, we can help to diagnose, and then subsequently treat many orthopedic problems that before required an MRI or it was just really difficult to assess. But in this situation, we now have multiple ultrasounds in our office and most sports medicine doctors do utilize this where we're able to, in real time, when a patient is coming through the office, potentially evaluate for joint swelling, for tendon rupture, for damaged musculature tears, things like. And so we can get an idea of, you know, pathology that we couldn't do before. We just were palpating and going from that standpoint. But now, we can get a little bit better diagnostics. And then from that standpoint, if there's something to treat, we can often kind of bring some of those things to the office and do a procedure as needed.

And so when you think of in-office procedures, most people think of injection-type therapy and that's where most of it is done. And we've got some really cool things we do. And the ultrasound has allowed us to be more accurate. And so not only is it a kind of cheap, quick thing that we can have available, its also making us a better injection therapist. The studies are showing that in most cases, I looked at a study this morning it was a review of 12 randomized controlled trials of knee injections, and it was saying that over 95% accuracy was obtained when they were using ultrasound versus nearing 75% to 80% accuracy of getting in the joint capsule when we were just using kind of older school landmark guidance. So I think that 10% to 15% matters. It's low risk, but you're still poking a patient with a needle AND maybe you don't have to do it again. Maybe it's just better for the patient to not have to come back or when we resolve their pain and dysfunction sooner, if that's the real problem.

And so we utilize ultrasound for a good amount of our injections here. And then it allows us to actually do some injections that were higher risks such as intraarticular hip or you're trying to avoid some vasculature and things that could be dangerous or some of the tendinous structures where you're trying to get some medicine, some anti-inflammatory medicine into tendon sheath, but you don't want to inject the tendon itself because it has a risk of rupture. So we're able to do these injections where before it was a little bit risky to do so.

When I'm saying injection, most of the time we are using steroid to try to relieve pain and use kind of an anti-inflammatory property to improve function. But we do offer a few other things in our office that can kind of help to relieve pain and hopefully get someone back, you know, more active sooner. And so we have started doing PRP injections, which is platelet-rich plasma where we actually draw some of your own blood, spin it down and we usually get about 5 CCs of plasma with a platelet-rich portion of it. And then we inject that back into whether it's a knee or a muscle tear or something like this to try to increase the growth factors, increase healing essentially of this area. And so that's one cool thing we're doing, and that's a great option for an athlete or someone that doesn't want to do a steroid injection.

And then on top of it, we're doing some of the more basic like viscosupplementation, gel shot injections. That can be really helpful for someone in the mild to moderate arthritis range, specifically in the knees. And so these are some fun things that we're trying to really ramp up and offer some non-steroid options for treatment going forward.

Melanie Cole (Host): How have been your outcomes with these, Dr. Aubry? How long do they last? What are your patients saying about these in-office procedures that saves so much time and invasive procedures and going to the hospital? Tell us what your patients are saying.

Dr Jonathan Aubry: We've had pretty good success. And if we're talking about someone with a severe arthritis, we're hoping that they get to a point where they get a few months of relief and maybe we do this again, because we're trying to stave off a knee replacement or something like that. But with some of the more exciting things like the PRP injections and other things where we can do like tenotomies, kind of poke tendons and poke certain areas and try to increase the inflammation and remodel that tendon, we've had some pretty good results. And so, I would expect from a steroid injection, usually hope to feel better within a few days within that week. But some of the other injections we do are a little bit of a slower burn and require some rest and physical therapy. But within a few months, we're hoping that some things that are dysfunctional are now doing much, much better.

And this reminds me of another thing, I kind of mentioned tenotomies, that's essentially causing some inflammation to a tendon. And so instead of just injecting a fluid into that area, you can just poke holes into the tendon and hopefully cause some damage that hopefully it leads to a secondary healing process. And then from our standpoint, we're also bringing in a procedure called Tenex, which is a waterjet tenotomy device for people that have dysfunctional tendons. We're bringing that to our office here at Carle BroMenn and McLean County Orthopedics. And so the goal there would be it's a little bit more of invasive procedure. You do make about a 4-millimeter incision. But again, it's still ultrasound guided, very minimally invasive. And the goal is in a tendon that has degenerative tissue, we're kind of getting rid of that degenerative tissue with this device. And so it's really cool, cool stuff that's came out in the last few years and I think it's really helpful for people that have chronic elbow pain, chronic foot and Achilles pain, certain types of things that some of the surgeries are not ideal and really haven't proven to be terribly helpful for the pain that hopefully, you know, provides some pain relief and get these people more functional that have had issues for a long time.

Melanie Cole (Host): One-hundred percent. As we wrap up, tell other providers when it's important to refer to the specialists at Carle BroMenn, really for their athletes, their weekend warriors for any sports medicine needs.

Dr Jonathan Aubry: Well, I would say that the moment that you're kind of feeling uncomfortable as a primary care physician that does it all, I would send them over. Because I think that from our standpoint, it's, specializing in sports medicine and orthopedics, we, see it a lot. And when I think of patients in pain or patients not doing well, I want to make sure that they get seen and get out of pain and we make them better as soon as we can. And so, whenever it's getting to be a little bit out of your scope or you don't feel comfortable doing a certain type of injection, or you don't really think that there's other options out there, I would get them over to us and we can usually see them pretty quick.

And so, in that standpoint, I know a lot of family docs and other primary care are awesome at basic injections. And so if you're keeping your stable of patients happy and pain-free, that is amazing. But we're always here to help out. And I'm kind of an open book as well. So, anyone that's listening to this as a physician in the community can always reach out and we can always talk about cases and things like that, because I'm constantly getting pictures of fractured ankles and different things and wanting advice from previous partners and people in the community. So if you're unsure of when to send over, just always give us a call too, because we can kind of help guide treatment at the primary care office or we're always happy to see your patients.

Melanie Cole (Host): Well, it certainly is, as you said, an exciting time to be in the field of sports medicine. Thank you for the overview, Dr. Aubry, and thank you for joining us. For more information and to get connected with one of our providers, you can visit carle.org. Or for a listing of Carle providers and to view Carle-sponsored educational activities, visit our website at carlconnect.com.

That concludes this episode of expert insights with the Carle Foundation Hospital. I'm Melanie Cole.