PRP: The Details Matter. Give Us 3 Minutes
/More practices than ever are offering platelet-rich plasma (PRP) injections to their patients, especially those with osteoarthritis, tennis and golfer’s elbow, partial rotator cuff tears, Achilles and patellar tendonopathy and plantar fasciitis, just to name a few.
We often say, “not all PRP is the same.” There are so many details that go into the success rate of the injections. On that subject, how do you define success? Less pain, better function, healing of damaged tissue and/or the slowing of the deterioration of cartilage, especially in osteoarthritis. PRP can truly be a disease-modifying treatment, not just something to make you temporarily feel better.
Now, what details really matter?
Experience of the physician: how long has he/she been giving PRP injections
Accuracy of the injection: ultrasound-guidance is paramount
Amount of blood used to produce the PRP: we’ve learned that a higher volume of blood is likely necessary to produce the optimal number of platelets
Creation of the PRP: constructing the optimal amount of PRP to inject for each condition. Creating a mixture either rich in leukocytes (white blood cells) or poor in leukocytes
Providing the best recommendations regarding what medications and supplements should be temporarily stopped before and after the injections
Providing the best recommendations regarding restrictions (use of a boot, crutches, bracing, type of rest) after the PRP
Deciding upon the optimal number and frequency of injections to give
Working with a physician who is frequently involved in medical education on the topic of orthobiologic injections, including PRP
Working with a physician who is transparent and communicative regarding outcomes, expectations and cost
If truth be told, only a few physicians in Middle Tennessee implement all of these details when it comes to PRP injections.
So, if you think you are candidate for this very natural, quite effective, and minimally-invasive treatment, then come see us!
F. Clarke Holmes, M.D.
Why Me? Why So Many Tendon Problems?
/If you are 40 years old or above, it’s probably not “if” but “when” you are going to have a tendon problem. Tendons connect our muscles to bones, but as we age, they become problematic. Common tendon problems include/involve the rotator cuff, tennis and golfer’s elbow, Achilles tendon, posterior tibialis tendon and then the plantar fascia, which behaves like a tendon but technically is a ligament.
Thus, these conditions are usually a disease of the middle-aged and older. What are the causative factors for what we call tendonopathy?
-acute injury to the tendon
-overuse activities
-genetics
-inflammation
-diet
-biomechanics
-weight
So, to treat tendonopathy, we have to address these factors with genetics being an exception, as this can’t be changed.
Thus. we have to modify activities, either temporarily or permanently, especially avoiding overuse situations.
We want to reduce inflammation, and this can be achieved multiple ways: medications, steroid injections, supplements and an improved diet can all play a role. Medications and steroids can be very helpful in the short term but are not always a long-term solution. Platelet-rich plasma injections can be a great option to promote long-term management of inflammation and the actual healing of a tendon.
Biomechanics are often improved through changes in movement patterns, improved flexibility and strengthening. At times, footwear changes and orthotics can play a role as well.
As we often preach, early treatment of a tendon problem usually produces better outcomes than late treatment, but either way, we’ve got you covered. Don’t be discouraged if you have one or more tendon problems, knock on our door and we’ll be more than happy to share our expertise!
F. Clarke Holmes, M.D.
Introducing the Concept of PIO
/As sports medicine providers, we are all about “getting ahead in the game.” Therefore, we have coined the term and are developing the concept of PIO (“pie-o”). PIO stands for proactive interventional orthopedics. You’ve possibly heard of interventional cardiologists or interventional radiologists. These are the physicians that are specialists in their field, but use less-invasive means to treat your condition. For example, the interventional cardiologist will perform angioplasty or a stent procedure, whereas the cardiovascular surgeon would be the physician to do the more-invasive coronary artery bypass surgery, when necessary.
In our field, PIO involves using less-invasive interventions such as injections, weight loss, physical therapy/exercise programs, and various supplements to “get ahead” of your musculoskeletal conditions that either currently are or will soon bring you pain, disability, and dysfunction. The field of orthopedics has typically been “reactive,” meaning you only go to the doctor when you have a significant problem. Unfortunately, when you are only reactive instead of proactive, treatment interventions become more invasive, higher risk, and sometimes less successful.
Here’s how we can use PIO to help you if have arthritis, tennis/golfer’s elbow, rotator cuff or Achilles problems, plantar fasciitis or other chronic conditions: we will customize a plan to reduce pain, improve function and quality of life in a cost-effective manner.
Here are links to two of our other blogs that explain the process and benefits of platelet-rich plasma (PRP) injections, often part of PIO treatment program.
Why Insurance Does Not Pay For Platelet-Rich Plasma Injections, But Why That Should Not Deter You — Impact Sports Medicine & Orthopedics (impactsportsnashville.com)
Five Simple Reasons You Should Consider Platelet-Rich Plasma — Impact Sports Medicine & Orthopedics (impactsportsnashville.com)
If you would like to discuss the concept of Proactive Interventional Orthopedics and how this may be a benefit to you in 2023, then please give us a call. We would love to customize a treatment protocol for you.
Five Simple Reasons You Should Consider Platelet-Rich Plasma Injections For Your Tendon Or Joint Pain
/Let’s make this one quick and easy. Some blogs, we may hit with you great details, information rich in scientific data and opinions full of medical jargon. Today, let’s share some simple information regarding why platelet-rich plasma (PRP) injections should be on your radar if you have OSTEOARTHRITIS, TENNIS OR GOLFER’S ELBOW, ACHILLES TENDONOSIS, PLANTAR FASCIITIS, LATERAL HIP, PATELLAR AND ROTATOR CUFF TENDONOSIS, just to name a few.
1) Most of the time, it works: let’s be real, nothing in medicine works all of the time. If we see a significant benefit in 75% of patients or more, then we are all pretty happy with a treatment. In our patient population, PRP meets this criteria.
2) Most medical studies suggest a clinically significant benefit: do a “pub med” search for PRP as it relates to orthopedic conditions. Although some studies always will be too small or of lower quality, once you start to pool the data, you find that PRP is not really “experimental” any more. There are now hundreds of studies looking at patients receiving PRP for arthritis and chronic tendon problems, and the majority of these studies demonstrate a clinically significant benefit with PRP.
3) It’s both natural and safe: PRP is derived from your own blood. It’s designed to concentrate your platelets that contain your growth factors. These growth factors have many positive effects, ranging from inflammation reduction to slowing down the deterioration process within a tendon or joint. Major side effects are extremely rare, and when compared to steroid injections, prescription medications and surgical intervention, PRP is a safer treatment option with fewer adverse effects.
4) It’s a relatively quick office procedure: 5 minutes to set-up and draw the blood, 5 minutes to transfer the blood to the centrifuge system, 10 minutes to spin the blood, 3 minutes to further separate the blood components and capture the PRP, 2 minutes to prep the patient, and 1 minute to give the injection. In some instances, we may first inject a numbing medication (anesthetic) and then give that 10 minutes to work. So, in total, 36 minutes for this procedure done in the office, all in one sitting.
5) Although typically not covered by insurance, it’s likely a wise investment in your health and may save you money in the long run: the days of insurance always covering the best and most innovative procedures for orthopedic conditions are over. If PRP works for you like we expect it to, then you will potentially save money on doctor’s visits, medications, physical therapy, surgical interventions and other treatments. Not to mention that if you have not yet met your deductible, you will pay out-of-pocket for all of the other treatments “covered by insurance” that may be less effective than PRP.
In an nutshell, PRP is not for everyone and every orthopedic condition. We carefully select those patients who we think can “win the battle” with their orthopedic condition with one or more PRP injections. 20+ years of experience in sports medicine and orthopedics and 10+ years utilizing PRP have given us the knowledge to determine what patients may truly benefit from PRP injections. Come see us if you are curious!
F. Clarke Holmes, M.D.
Impact Sports Medicine and Orthopedics
The Guide to Regenerative Injections
/Dr. Holmes’ Guide to Regenerative Injections
Regenerative injections are those specifically utilized to promote healing of damaged tissue, reduce or eliminate unhealthy inflammation and slow or halt the progression of soft tissue and joint deterioration. We now use them regularly for tendon problems including tennis elbow, golfer's elbow, the rotator cuff, the high hamstring, patellar and Achilles tendons. We also have seen great success in treating osteoarthritis of the knees, shoulders, hips, thumb and great toe joints. Plantar fasciitis, ligament and muscle tears are great candidates for regenerative injections as well.
· Platelet-Rich Plasma Injections
o Blood obtained from an arm vein is centrifuged for 15-20 minutes, isolating the platelet-rich plasma
o Platelets are very rich in our natural growth factors (healing agents), and are concentrated 6-10 times their natural concentration
o Under ultrasound-guidance, the PRP is injected into the damaged tendon, ligament, fascia, joint or muscle
o Great option for tennis elbow, golfer’s elbow, small rotator cuff tears, small patellar tendon tears, high hamstring tendon tears, Achilles tendon tears, plantar fasciitis, etc.
o Widely-used also for osteoarthritis of numerous joints
o PROS: very natural and safe (your blood); used in orthopedics for ~10 years, Dr. Holmes has used for 7 years; numerous medical studies confirm significant benefit; 2-3 areas can be injected at one time; long-term benefit for most patients
o CONS: these work gradually, over weeks to months; increased pain after the procedure for 2 days to 2 weeks; immobilization required with a splint or boot for some injections
o UNKNOWNS: length of benefit (can be months to years); number and frequency of required injections. 1-2 injections initially for most soft tissue problems; 2-3 initially for arthritis/joint problems
· Amniotic Membrane Allograft Injections (brand- AmnioFix)
o Utilize one of the placental membranes (these cover the fetus during pregnancy) to form a product containing numerous types of growth factors
o Intended to reduce inflammation, reduce scar tissue formation and enhance healing
o The membrane undergoes a rigorous purification and sterilization process, and is stored as a dehydrated powder; sterile saline is added to become an injectable solution
o Great option for plantar fasciitis (#1 use), tennis elbow, golfer’s elbow, small rotator cuff tears, small patellar tendon tears, high hamstring tendon tears and small Achilles tendon partial tears
o PROS: very safe, with no significant reportable adverse effects; Dr. Holmes has used for 5 years; no rejection, despite not being one’s own tissue; no blood draw required; typically less post-procedure pain than PRP
o CONS: probably not as effective for joint pain/arthritis; otherwise, same cons as PRP
· Amniotic Fluid Injections (brand- Catalyst PDA-HAF)
o Very similar to amniotic membrane injections, but often stored in a frozen form and thawed immediately before injection
o Contain over 200 different growth factors
o Great option for soft tissue as well as joint problems such as osteoarthritis
o PROS: theoretically, a more powerful amniotic product than a dehydrated membrane
o CONS: more expensive than the dehydrated membrane product
· Alpha-2-Macroglobulin Injections
o A natural substance found in our bloodstream
o Blood drawn from the patient, centrifuged, manually separated and then placed in a separation pump to further isolate and concentrate the A2M
o 45-minute procedure done in one office visit
o Functions as a “protease inhibitor,” binding the inflammatory proteins that cause the degradation of cartilage in the joint
o Utilized to reduce pain, inflammation, halt the progression of osteoarthritis and provide “longevity” to the joint
o PROS: very safe and natural substance; presumed long-term benefit, less post-procedure discomfort than other injections; two to three injection sites can often be chosen with one procedure
o CONS: newest type of regenerative injection; very few medical studies proving effectiveness thus far, but studies are underway; frequency of injections not known at this point (likely every 6-24 months)
With any of these injections, all forms of ORAL and TOPICAL anti-inflammatories must be stopped for 1 week before and 2 weeks after, as to not interrupt the initial healing cascade initiated by the injections. This includes:
· Advil/Motrin/ibuprofen
· Aleve/naproxen
· Aspirin- any doses above 81 mg
· Mobic/meloxicam, Celebrex/celecoxib, Voltaren/diclofenac
· Fish oils/Omega-3 fatty acids
· Turmeric
· Oral green tea
· Glucosamine/chondroitin
· Arnica
COST: Regenerative injections are rarely ever covered by insurance. Although we closely monitor their coverage status, in the current climate of healthcare and insurance companies reducing their coverage of even typical treatment measures, we do not expect these injections to be covered in the near future.
With rising deductibles, many patients pay out-of-pocket for traditional treatment measures as well. Thus, a regenerative injection may ultimately be a similar out-of-pocket cost to traditional treatments but more clinically effective and cost-effective over the long-term.
A patient should view these injections as an investment into the long-term health of their tendons, fascia, ligaments and joints.
We are here to serve you!
F. Clarke Holmes, M.D.