PRP Vs. Stem Cell Injections: How to Choose

We often get the question when patients come in looking for nonsurgical treatment of osteoarthritis or a chronic tendon problem: “How do I choose between a platelet-rich plasma (PRP) and stem cell injection?”

First, let’s define the differences: PRP comes from your own blood and involves a simple blood draw from an arm vein. Stem cell injections are prepared after bone marrow or adipose (fat) tissue is extracted from a patient. Obviously, the PRP preparation is simpler, less invasive and lower risk for the patient. Venipuncture takes about 2-3 minutes, whereas obtaining bone marrow involves inserting a larger needle-like device into the iliac crest (bone at top/back of the pelvis) and takes about 10-15 minutes or longer. Obtaining adipose tissue from the lower abdomen is a more complex and time-consuming procedure, often requiring about 30-45 minutes.

Both types of injections have the potential to reduce pain by reducing inflammation and promote healing. PRP uses a variety of growth factors, while stem cells utilize mesenchymal signaling cells and may have a greater potential to regenerate tissue. That being said, we are often using these injections for osteoarthritis, which is a cartilage deficiency problem. At this time, it is debatable whether any type of injection can regenerate cartilage.

What about success rates? Well, the jury is still out regarding which option is better. The good news is that in the large majority of studies, both PRP and stem cell treatments result in less pain and better function. Soft tissue problems like tendons and ligaments often demonstrate an improved or healed appearance on imaging studies. Some studies suggest that PRP and stem cell injections produce equal outcomes in the treatment of knee osteoarthriitis, while some suggest stem cells have better results. For now, we are putting our eggs in the PRP basket exclusively. Why is that?

-PRP is less-invasive, lower risk and faster to prepare

-PRP has a longer track record of use and success

-Although neither are covered by insurance, stem cell injections tend to be 3-10x more expensive than PRP injections. Example: $1000 for PRP on the average versus $5000 for a stem cell treatment.

We often state that PRP injections are like buying a Honda: safe, reliable, and gets the driver from Point A to Point B quite well. Stem cell injections are like a Maserati: fancy, expensive and unique but don’t necessarily get you from Point A to Point B any better or faster.

In summary, we anticipate that the application of stem cell treatments in the U.S. will continue to expand as studies demonstrate increased success and safety, while preparation will become easier, and the cost will decrease. Until then, PRP will be our successful “go-to” orthobiologic injection.

Want more info?

Patients With Knee Osteoarthritis Who Receive Platelet-Rich Plasma or Bone Marrow Aspirate Concentrate Injections Have Better Outcomes Than Patients Who Receive Hyaluronic Acid: Systematic Review and Meta-analysis - PubMed

Bone Marrow Aspirate Concentrate Is Equivalent to Platelet-Rich Plasma for the Treatment of Knee Osteoarthritis at 2 Years: A Prospective Randomized Trial - PubMed

Bone Marrow Aspirate Concentrate Is Equivalent to Platelet-Rich Plasma for the Treatment of Knee Osteoarthritis at 1 Year: A Prospective, Randomized Trial - PubMed

As always, let us know if we can be of assistance to you!

F. Clarke Holmes, M.D.

“Blood” (PRP) Versus “Gel” (Hyaluronic Acid) Injections: How to Choose

The two most popular and common injections we offer patients for knee osteoarthritis are platelet-rich plasma (PRP), utilizing a patient’s own blood, and hyaluronic acid injections, commonly known as the gel, rooster comb, or viscosupplement injections.

Let’s compare the two and discuss pros and cons of each:

Both would be considered “natural“ injections with PRP obviously coming from your own blood and hyaluronic acid is a substance already in your joint, but depleted in joints that have osteoarthritis.

We often describe PRP as that big 100,000 mile service you do on your car, and hyaluronic injections are more like the oil change. Thus, PRP is more comprehensive.

PRP Injections

PROS

-most effective long-term injection we offer patients. Benefits typically seen for 6–24 months, and then PRP can then be safely repeated when necessary.

-very likely disease–modifying, meaning we are stopping or slowing the deterioration of cartilage in the knee. These give patients the greatest opportunity to either delay or avoid knee replacement.

-other than weight loss, probably the best long-term medical and financial nonsurgical investment in the health of your knee.

CONS

-not covered by insurance. See our blog regarding this here

-works gradually, with greatest benefit likely seen 4-6 months after the injections.

-anti-inflammatories of any type as well as blood thinners need to be stopped before and after the PRP procedure for a specific period of time.

Hyaluronic acid Injections

PROS

-authorized by most insurance plans, meaning the cost of these is fully covered, partially covered, or can be applied towards your deductible.

-excellent safety profile.

-the majority of patients see a benefit, often for 4 to 12 months.

-like PRP, injections are not particularly painful when given into the knee joint under ultrasound guidance and only require a few days of rest afterwards.

CONS

-may have an indirect benefit on the long-term health of the knee joint, but are not considered “disease–modifying” like PRP.

-benefits of pain and swelling reduction along with functional improvements do not last as long as PRP.

-although they work a bit more rapidly than PRP injections, typically it takes 6 to 8 weeks after the final injection to see the greatest benefit.

-most brands require a series of 3–4 total injections, given one per week.

Want to know more about PRP?

Learn about the key details of PRP here

How is PRP simple and not-so-simple? Read here

As always, let us know if we can be of assistance to you!

F. Clarke Holmes, M.D.

Our Top 5 Treatments for Knee OA

Whether it be mild, moderate or severe knee osteoarthritis, here are our top 5 treatments. If you can incorporate these into your regimen, then you undoubtedly will see the benefits of less pain, better function and greater longevity for your knees.

1) Weight Loss: for every 1 pound a person is overweight, an extra 4 pounds of force are going through the knees. So, lose 10 pounds, and you have 40 pounds of less force on those knees. Lose 25 lbs, and 100 fewer lbs. of force! A recent study indicated that when those with knee OA lost 10% of their weight, their pain decreased by 50%

2) Healthy Eating with an Anti-Inflammatory Diet: healthy eating doesn’t always result in weight loss, but choosing the right foods often results in less inflammation in our body. This means less pain and a better environment for the joints. Choose fresh foods over processed ones. Reach for the fresh foods in the refrigerator more than packaged food in the pantry. Eat at home more and go out to restaurants infrequently. Fruits, vegetables, whole grains and lean meats should be the staples of your diet. Alcohol in moderation. Red meat, fried foods and processed food only on occasion and when necessary. Sodas rarely and watch out for artificial sweeteners.

3) Injections: these are often a faster path to relief for most patients. Platelet-rich plasma (PRP) injections utilizing your own blood and concentrated growth factors are the star of this category. Long-term benefits are most common with PRP. Hyaluronic acid injections (brand names: Orthovisc, Trivisc, Gelsyn, Euflexxa, etc.) are good options for many. At times, we combine the PRP and hyaluronic acid injections to boost the benefits. Steroid injections are the final option and can have great utility when a patient needs to feel better quickly such as during a flare or before a big trip.

4) Exercise/Physical Therapy: choose exercise you like, you will stick to, a variety and types that do not cause pain in your knee, both during and afterwards. Sometimes, it’s not just the type of exercise, but the intensity and duration. Find your “sweet spot,” meaning your knee might feel great if you walk a one mile but hurts if you go further. You can bike for 30 minutes, but beyond that causes swelling. So, stay below your pain threshold. Lower-impact options like biking, elliptical, rowing and swimming/aquatic exercises are often the best choices for most with knee OA. Physical therapy is often a good starting point to strengthen the muscles around the joints and to improve biomechanics, functional movement patterns and flexibility.

5) Supplements: our favorites are collagen, curcumin (the active ingredient of turmeric) and for more advanced knee OA, glucosamine and chondroitin. Others like fish oil may have benefits for the joints as well. The key here is choosing a high-quality brand and taking these on daily basis. Admittedly, they don’t help everyone, and you need to make sure that your physician knows you are taking these, especially if you are taking other medications and/or will soon have a medical procedure.

As always, let us know if we can be of assistance to you!

F. Clarke Holmes, M.D.

What Does "Being Proactive Over Reactive" Mean?

Proactive Interventional Orthopedics (PIO)…a concept we will continue to promote. What does it mean in orthopedics to be proactive over reactive? Here are some examples and brief explanations:

Choose maintenance and more long-term injections over short-term steroid/cortisone injections: platelet-rich plasma (PRP) and hyaluronic acid injections often produce a more clinically significant and longer duration of benefit than steroid injections. For your knee and hip arthritis, tennis and golfer’s elbow and plantar fasciitis, just to name a few, choose these injections.

A course of physical therapy over exercises you simply found online: patient outcomes are generally better when you work with a physical therapist over Dr. Google or YouTube. We have fantastic relationships with physical therapists across Middle Tennessee and can work with you to find the best fit.

Regular use of supplements over prescription or over-the-counter medications: there’s a time and place for prescription meds when managing orthopedic conditions. However, for long-term management, we prefer options like curcumin/turmeric, collagen, and glucosamine/chondroitin. That being said, it’s always wise to consult with a physician before starting new supplements.

Don’t wait for your pain or disability to reach high levels before you seek treatment: orthopedic conditions treated early after the onset of symptoms and when pain and dysfunction are at a low level typically respond better to less-invasive treatments, and this early treatment can lower the risk of further damage to the joint or tissue.

Choose a specialist over a primary care physician for your orthopedics needs: PCPs work really hard and a do a great job to care for your overall health, but they do not necessarily have the expertise, the tools such as on-site imaging and advanced equipment or the time to dedicate to your orthopedic conditions.

Healthy eating patterns over a fad diet: weight loss is a vital part of the treatment plan when it comes to weight-bearing joint problems like hip and knee osteoarthritis. Through a variety of options, we can help you a structure a plan to gradually lose weight in a manner that the weight will stay off and through means that can be maintained for the long-term.

As always, let us know if we can help you overcome an injury, treat an orthopedic condition or find the pathway to greater wellness with an improved quality of life!

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.

It’s Time To Start Treating Your Arthritic Knee Like Your Car

“Orthopedic Maintenance”…that’s a term you may start to hear, especially in our practice. For years, patients have been led to believe that in the case of their arthritis, there’s “nothing you can do about it” until you want or choose to have a replacement. Also, our medical system has been developed to be reactive instead of proactive, especially again in the setting of arthritis. So, let me ask you this, do you only take your car to the mechanic when you have a problem? If the answer is yes, then you are on the fast track to either a needing a new car or paying your mechanic a pretty penny for all the repairs your car will need! If you are a wise car owner, then you take your car in at regular intervals for the oil change, fluid additions, tire rotation, alignment, brake maintenance and various inspections. So I then ask, should you be doing the same for your arthritic knee? The answer is a resounding “Yes!”

So, what does orthopedic maintenance look like? In very general terms, it means that if your body has aches, pains or dysfunction, then it’s wise to jump on these earlier than later, avoiding the temptation to ignore symptoms, and think, “I’m just getting old.” This translates to seeing your orthopedic/sports medicine physician to confirm a diagnosis and discuss treatment and prevention strategies. Let’s focus on one of the most effective forms of non-operative treatment for knee osteoarthritis: injections

1)     Steroid (cortisone) injections are great for acute pain, when it’s important to reduce symptoms and swelling quickly. Steroids are really a more “reactive” treatment, such as when a patient needs to feel better quickly for a major life event (a trip, visit with the grandkids, have to feel better for work, etc.) but can be proactive for a patient trying to stave off a knee replacement or is not a good candidate for knee replacement. For example, the elderly patient whose risk of knee replacement outweighs the benefit, planning two steroid injections a year for his/her symptomatic knee arthritis may allow the patient to feel less pain, move better, be at lower risk for a fall and have a greater quality of life.

2)     Hyaluronic Acid/Viscosupplement injections (brand names include Orthovisc, Gelsyn, Euflexxa, etc.) have a long track record of excellent safety and provide symptomatic relief in approximately 75% of patients for 4-12 months. They probably work as anti-inflammatories and lubricants for the knee, replenishing the hyaluronic acid in the arthritic knee that is depleted or less effective. These are probably more beneficial for those with mild to moderate arthritis as opposed to more severe cases. There are essentially no side effects except for mild injection-site soreness in some. Most insurance companies will authorize this 3-4 injection series every 6 months, so planning on about two series a year is a very proactive strategy. These are what we often term as the “oil change” injections.

3)     Orthobiologic injections are really your “game-changer” injections. These have been used in orthopedics for 15 years and in our practice for over 10 years. Platelet-Rich Plasma (PRP) is the most commonly used orthobiologic injection. Insurance companies and even some medical providers still like to consider these as “experimental” or unproven treatments for osteoarthritis, yet there are now 39 randomized, controlled trials (studies) that demonstrate that PRP is effective in the treatment of knee osteoarthritis. PRP is derived from your own blood, as we obtain blood from an arm vein, spin this in a centrifuge, remove the majority of red and white blood cells, and concentrate the platelets which are rich in your own growth factors. These growth factors module inflammation, reduce pain, improve function, and most likely have a beneficial effect on the cartilage within the joint. This is how they are “game-changers.” They very likely stop or slow the progression of arthritis by stabilizing the cartilage and potentially improving the quality of the cartilage.

We typically start with two PRP injections 2-6 weeks apart and expect, on the average, 6-12 months of symptomatic benefit. Repeating these at regular intervals is likely the best plan of action in order to see continued, long-term benefits. PRP injections are here to stay, and how we continue to apply them in the treatment of osteoarthritis will continue to evolve.

Primary care providers and dentists have done a great job integrating maintenance evaluations and treatments into a patient’s health regimen. Now, we should likely be doing the same in orthopedics, and the treatment of knee osteoarthritis is a great place to start, as this is the most common medical condition seen in our office today. It is a tremendous source of pain and disability for millions of Americans and contributes to the spending of billions of health care dollars. It’s time for orthopedic physicians and patients to join together to be proactive over reactive and realize that less-invasive preventative strategies are preferred over more-invasive and costly interventions.

As always, we here to help and strive to be your resource for these innovative maintenance strategies!

F. Clarke Holmes, M.D.

Impact Sports Medicine and Orthopedics