The science behind PRP and Prolotherapy for knee pain

Two alternative solutions we offer for knee pain in our Los Angeles office is Prolotherapy and Platelet Rich Plasma Therapy performed under ultrasound guidance.

These are injection techniques that do exactly the opposite of surgery. They rebuild and strengthen damaged tissue as opposed to removing them.

UPDATE: Platelet Plasma Therapy BEFORE Cortisone!
Research in the International Journal of International Orthopaedics say Platelet Rich Plasma therapy BEFORE ethoxysclerol, cortisone, and/or surgical treatment!

Researchers in the Netherlands evaluated the outcome of patients with patellar tendinopathy treated with platelet-rich plasma injections (PRP) and whether certain characteristics, such as activity level or previous treatment affected the results.

What they found was: “After PRP treatment, patients with patellar tendinopathy showed a statistically significant improvement. In addition, these improvements can also be considered clinically meaningful. However, patients who were not treated before with ethoxysclerol, cortisone, and/or surgical treatment showed the improvement.” (1)

The Use of Ultrasound
Research in the Journal of Clinical Rheumatology says that “(Ultrasound) Sonographic needle guidance reduced procedural pain and improved the clinical outcomes and cost-effectiveness of intra-articular injections of the osteoarthritic knee.”

The researchers found that ultrasound guided injection over conventional palpation-guided methods resulted in 48% reduction in procedural pain, a 42% reduction in pain scores at outcome, 107% increase in the responder rate and with higher accuracy, less need for procedure, significantly reducing patient cost. (2)

The Use of Prolotherapy
Recent medical studies on both treatments support that articular cartilage and meniscal tissue can regrow with treatment. (3,4)

The Use of PRP
New research suggest PRP can be a very effective treatment for knee defects: Researchers writing in the International Journal of the Care of the Injured wrote: “(this treatment) is a simple, low-cost, minimally invasive way to apply PRP growth factors to chronic patellar tendinosis…20 male athletes with a mean history of 20.7 months of pain received treatment, and outcomes were prospectively evaluated at 6 months follow-up. No severe adverse events were observed, and statistically significant improvements in all scores were recorded. The results suggest that this method may be safely used for the treatment of jumper’s knee, by aiding the regeneration of tissue which otherwise has low healing potential. (5)

In the medical journal International Orthopaedics, researchers noted: “Histological examination and study of angiogenesis showed that the application of PRP enhances and accelerates the tendon healing process.” (6)

Prolotherapy works as an irritant using dextrose (a simple sugar) is introduced in the knee. This causes the immune system of the body to accelerate the inflammatory process. More inflammation? The body’s natural healing response is inflammation. Only when complete healing does not occur does inflammation become chronic and problematic.

What this new inflammation does is bring fribroblast and condrocytes, those cells necessary to rebuild the collagen matrix of the tissue, strengthen and restoring them to preinjury form in many cases.

In Platelet rich plasma therapy, blood is drawn from the patient and is used instead of dextrose. The principle is the same except PRP is usually reserved for patients with more damage to the knee area or for high level athletes needed for a big game.

1. Gosens T, Den Oudsten BL, Fievez E, van ‘t Spijker P, Fievez A. Pain and activity levels before and after platelet-rich plasma injection treatment of patellar tendinopathy: a prospective cohort study and the influence of previous treatments.Int Orthop. 2012 Apr 27. [Epub ahead of print]

2. Sibbitt WL Jr, Band PA, Kettwich LG, Chavez-Chiang NR, Delea SL, Bankhurst AD. A randomized controlled trial evaluating the cost-effectiveness of sonographic guidance for intra-articular injection of the osteoarthritic knee. J Clin Rheumatol. 2011 Dec;17(8):409-15.

3. Kon E, Buda R, Filardo G, Di Martino A, Timoncini A, Canacchi A, Fornasari PM, Giannini S, Marcacci M. Platelet-rich plasma: intra-articular knee injections produced favorable results on degenerative cartilage lesions. Knee Surg Sports Traumatol Arthrosc 2010; 18(4):472-479.

4. Reeves KD Hassanein K Randomized prospective double-blind placebo-controlled study of dextrose prolotherapy for knee osteoarthritis with or without ACL laxity. Alt Ther Hlth Med 2000;6(2):37-46.)

5. Kon, E. et al.  Platelet rich plasma: New clinical application. A pilot study for treatment of jumper’s knee.  Injury,  International J. Care Injured 2009;40:598-603.

6. (Lyras D, et al.  Immunohistochemical study of angiogenesis after local administration of platelet rich plasma in a patellar tendon defect.  International Orthopaedics 2009;11 February: online.)

PRP, Hyalgan, Supartz, Euflexxa, Orthovisc, Hyaluronin, Synvisc

Autologous (from your own blood) PRP injections showed more and longer efficacy than HA injections (Hyaluronic acid (Sometimes referred to by the brand name) Hyalgan, Supartz, Euflexxa, Orthovisc, Hyaluronin, Synvisc) in reducing pain and symptoms and recovering articular function. 1

Synisc is a commonly prescribed injection for osteoarthritis of the knee. Recently a new version has been approved by the FDA called Synvisc-One. It is not a drug, but an injection solution processed from rooster combs that seeks to mimic the naturally occurring synovial fluid in the knee. The goal is to help prevent bone on bone complications for approximately six months

Synvisc treatments need to be administered three times, the new Synvisc-One, one time.

Is Synvisc for you?
At our chronic pain speciality clinic in Los Angeles we do not recommend Synvisc. The reason? Synvisc, at best, is a temporary fix to a long-standing problem – Knee deterioration. Even in the best case scenario – the synvisc products are promoted as providing UP TO 6 months pain relief.

Although PRP (Platelet-Rich Plasma) Therapy has been around since the mid-1990s many people are still unaware of this beneficial treatment.

Various fields of medicine, including dentistry, neurosurgery, wound healing, and orthopedics, have only just begun to scrape the surface of the long-term and ongoing benefits that can result from employing this valuable therapy.

PRP (Platelet Rich Plasma) Ultrasound-guided injection of the Knee

In a nutshell, a PRP injection delivers a high concentration of endogenous (your own “home-grown”) platelets to an area of injury.

To understand the therapeutic value of PRP injections, you need to have a basic understanding of the make-up of blood. Blood is composed of plasma, red blood cells, white blood cells, and platelets. It’s these platelets that are the injury’s “first-responders” and help revascularize an injured area, construct new tissue, and stop the bleeding.

 

PRP (Platelet Rich Plasma) Ultrasound-guided injection of the Knee

What is it? A Quick Lesson on Blood
In a nutshell, a PRP injection delivers a high concentration of endogenous (your own “home-grown”) platelets to an area of injury.

Because platelets play a significant role in the healing of tissue, reintroducing a high concentration of platelets directly into the injured area may enhance the healing process.

The physiological effects include:
• Increase tissue regeneration (tendon, ligament, soft tissue)
• Decrease inflammation
• Decrease pain
• Increase collagen (base component of connective tissue)
• Increase bone density
• Increase angiogenesis (development of new blood cells)

In the world of high-stakes sports, many stars swear by it. Tiger Woods received PRP injections in his left knee following surgery, and L.A. Dodger’s pitcher, Takashi Saito was able to return to the mound for the 2008 playoffs as a result of this little-known therapy.

Studies have seconded these testimonials. A recent study published in the American Journal of Sports Medicine (2006) reviewed the effectiveness of PRP therapy in patients with chronic elbow pain. Fifteen patients were treated with PRP therapy. The results documented a 60% improvement at eight weeks, 81% at six months, and 93% at final follow-up (12-38 months). There were no side effects or complications reported.

The Trouble with Tendons
Tendon injuries often become chronic because of the poor blood supply to these areas. Athletes and active people tend to have these issues and sometimes a whole career or hobby can be ruined by this ongoing complication. A PRP injection allows a quick and focused action to the area of injury, which allows it to heal more effectively and rapidly.

The Procedure
A patient’s blood is drawn and placed in a centrifuge which separates the platelet-rich plasma from the rest of the blood. This plasma is then injected into the area of injury. It’s a quick procedure with little, if any, downtime. It’s also safe because the platelets are derived from the patient’s own blood, so there is no risk of rejection or reaction.

Not every patient is treated with PRP.
We do not treat every patient with PRP, most often, Dextrose Prolotherapy is used instead of PRP, because of the extra step in drawing your blood, the extra expense in purchasing the PRP kit, and extra time it takes to prepare the platelets. The injections are exactly the same way, but the proliferant, or solution injected is different. For many years we have had great success in healing 1000’s of patients’ and having them avoid surgery with dextrose Prolotherapy.

Your decision to have PRP should be discussed with us to determine which type of Prolotherapy, (Dextrose, platelets, or another proliferant) is best for you.

Not every doctor is proficient in PRP Therapy
Platelet Rich Plasma Therapy has become very popular. Physicians who do not do traditional Prolotherapy are now offering PRP. Unfortunately, these untrained doctors are injecting the platelets in a way that is often painful, debilitating for weeks, and can leave hematomas (collections of clotted blood) in the area injected. We believe that PRP is best delivered by a physician already experienced and well versed in Prolotherapy.

Platelet alpha granules contain potent growth factors necessary to begin tissue repair and regeneration at the wound site. Concentrated autologous platelets contain large reservoirs of growth factors that have the potential to greatly accelerate the normal healing process, naturally. The use of concentrated growth factors is considered by many to be a “new frontier” of clinical therapy

Excerpts in this article from Harvest Technologies Corp

1. Marx, R.E. , et al,“Platelet-Rich Plasma Growth Factor Enhancement for Bone Grafts”, Oral Surg Oral Med Oral Patrhol, 1998;85:638-646.

2. Antonaides, H.N., et al,“Human Platelet-Derived Growth Factor: Structure and Functions”, Federation Proceedings, 1983;42:2630-2634.

3. Pierce, G.F., et al,“PDGF-BB,TGF-ß1 and Basic FGF in Dermal Wound Healing: Neovessel and Matrix Formation and Cessation Repair”, Am J Pathology, 1992;140:1375-1388.

If you are going to have injections in the knee, why not consider a treatment that can provide permanent relief?

 

Avoiding Knee Revision Surgery

Researchers have long noted that weakened ligaments play a key role in the need for a second or “revision” surgery on the knee.

In one landmark study in 2007, Researchers writing in the medical journal Der Orthopäde examined how loose ligaments played a role in the need for follow up (revision) knee surgery.(1)

The researchers examined 135 knee revisions and noted that

-In 32.6 % of all cases, ligament instability was the primary reason for revision.
-In another 21.6%, ligament instability was identified as a secondary reason for revision.

They concluded: Ligament instability is a common reason for revision total knee arthroplasty (TKA).

In other medical literature researchers noted that “Anterior cruciate ligament reconstruction failed to restore normal rotational knee kinematics during dynamic, functional loading and some degradation of graft function occurred over time. These abnormal motions may contribute to long-term joint degeneration associated with ACL injury and reconstruction.”(2)

Prolotherapy and Platelet Rich Plasma TherapySurgery is complex, a second one frequently even moreso. Before the surgical option is considered as the “only course,” patients need to explore Prolotherapy and Platelet Rich Plasma therapy. Our patients have found that these treatments provide excellent results on the previously surgically repaired knee and helped them avoid a revision surgery. Prolotherapy and Platelet Rich Plasma Therapy trengthen and repair the ligaments that remain weak, loose, or damaged following surgery without surgical intervention.

More on our website
Total knee replacement recovery time

Pain and swelling in a knee that had orthroscopic surgery

Watch the treatments
Watch a video of Prolotherapy treatment to the knee

Watch a video of PRP treatment to the knee

References
1. Graichen H, Strauch M, Katzhammer T, Zichner L, von Eisenhart-Rothe R. [Ligament instability in total knee arthroplasty - causal analysis.] Orthopade. 2007 Jun 21;

2. Tashman S, Kolowich P, Collon D, Anderson K, Anderst W.Dynamic function of the ACL-reconstructed knee during running. Clin Orthop Relat Res. 2007 Jan;454:66-73.

The knee has an amazing capacity to heal itself – so why remove the cartilage?

Removing tissue from your knee through surgical intervention can only make your knee weaker in the long run and prone to arthritis because removal of tissue decreases the shock absorption capabilities built in to protect the knee.

Why remove tissue then? Because some physicians believe that the meniscus, the piece of cartilage between the femur and the tibia, does not have the ability to be repaired, either by regular body repair mechanisms or surgery. So it is shaved, smoothed, or partially removed. Years ago, when a meniscus was injured, the standard protocol was complete removal. Many of these patients were forced to have knee replacement years later because of the severe pain from the meniscus removal.

The meniscus or menisci are the thick, strong, cartilage-like shock absorbers that cushion and pad the knee between the thigh (femur) and shin (tibia) bones. Shaped like the letter “C,” the meniscus of each knee provides stability in carrying the weight of the body or in gliding through the knee’s many range of motions.

The meniscus can become problematic either through traumatic injury, or age and wear and tear.

Wear and tear can occur in runners, people who have jobs that require a lot of physical activity where stresses to the knees are applied, or in older people where the degeneration of the cartilage causes tearing in the meniscus.

Meniscus injuries in sports are often caused by impact or in sharp cutting or turning when the meniscus can become trapped between the femur and the tibia. Typically an injury to the meniscus will occur in combination with ligament injuries, especially the MCL (medial collateral ligament).

Prolotherapy and Platelet Rich Plasma injections have been instrumental in avoidance of needless knee surgeries in my Los Angeles clinic. Many of my patients have already had one or two or three knee surgeries by the time they see me in hopes of avoiding a knee replacement.

Prolotherapy and PRP knee injections should effectively regenerate all damaged areas.

PRP as an alternative for Total Knee Replacement

Two alternative solutions we offer for knee pain in our Los Angeles office is Prolotherapy and Platelet Rich Plasma Therapy performed under ultrasound guidance.

These are injection techniques that do exactly the opposite of surgery. They rebuild and strengthen damaged tissue as opposed to removing them.

We receive many emails each week that typically begin with “I have no cartilage…” or “My doctor says that there is little or no cartilage left..”. Then the emails will continue with a date or waiting list for a joint replacement. Joint replacement should always be considered AFTER non-surgical treatments have been explored.

We cover this extensively in these articles:
On a waiting list for knee replacement?

Unstable Knee Replacements

Hip and Knee Replacement Long-Term Survival of the artificial joint and the patient!

The emails we get are from patients looking to avoid the surgery, whether because of costs, time away from work, or other fears. This is where PRP can offer patients a possible choice.

How exciting is PRP in knee repair?
“At the beginning of the new millennium, there was a breakthrough in platelet-rich plasma (PRP) therapy for tissue repair…they have shed light on new avenues of management because of their effects on repair functions.”

Andia I, Sánchez M, Maffulli N. Joint pathology and platelet-rich plasma therapies. Expert Opin Biol Ther. 2012 Jan;12(1):7-22.

“Presently, PRP use in tendon and ligament injuries has several potential advantages, including faster recovery and, possibly, a reduction in recurrence, with no adverse reactions described.”
Taylor DW, Petrera M, Hendry M, Theodoropoulos JS. A systematic review of the use of platelet-rich plasma in sports medicine as a new treatment for tendon and ligament injuries. Clin J Sport Med. 2011 Jul;21(4):344-52.

Let Dr. Darrow explain the benefits of PRP

Platelet Rich Plasma Therapy has become very popular. Physicians who do not do traditional Prolotherapy are now offering PRP. Unfortunately, these untrained doctors are injecting the platelets in a way that is often painful, debilitating for weeks, and can leave hematomas (collections of clotted blood) in the area injected. We believe that PRP is best delivered by a physician already experienced and well versed in Prolotherapy.

Call our office if you would like to speak to one of our staff about PRP 310-231-7000

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