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.
5 Things You Want to Know If You Have Knee Pain
/Three factors play a role in knee pain: structural, biomechanical and environmental. Structural means damage, biomechanical means abnormal tracking or loading within a joint or tendon because of misalignment, weakness, and/or inflexibility. Environmental typically means inflammation within the joint or tendon. When formulating a treatment plan for you, we typically want to address one or two of these factors initially. Unless you have major damage, we’re normally not treating structure initially, as that results in a surgery.
Age often plays a role in these different factors: in the absence of injury, in patients under 20 years of age, the problem tends to be biomechanical. In patients ages 20 to 40, the problem tends to be biomechanical and inflammatory. In patients older than 40, structural, biomechanical and inflammatory are typically all playing a role.
Being proactive in the care of your knee problem usually produces better outcomes than being reactive. This means integrating treatments early on and not waiting until you have major pain or disability to see a physician. We term this “PIO,” Proactive Interventional Orthopedics.
Meniscus tears are commonly found on MRIs and may or may not be a source of pain. For decades, the trend was to treat these surgically, typically arthroscopically, removing the torn piece of meniscus. There’s now a trend towards repairing the meniscus tear, when possible, but only about 10% can be successfully repaired. Thus, surgery for meniscus tears, especially those age 40 and above, is becoming less popular. On occasion, surgery is the better choice, but treating these initially nonsurgically is usually the best way to start. We often tell patients “a little torn meniscus is better than less meniscus,” especially long term. Less meniscus often equals greater arthritis.
Three types of injections can be used for most knee problems: steroid, hyaluronic acid, and orthobiologics. Orthobiologics include platelet-rich plasma (PRP) and stem cell injections. Each of these injections can be reasonably good choices, but for long-term success, PRP is likely your best option in terms of producing favorable outcomes, modifying the disease process, and these are often the most cost-effective option. Now, we are adding protein concentrate to many PRP injections, utilizing your excess plasma that we previously would just discard. Stay away from “stem cell” injections that are ordered by physician’s or chiropractic offices and do not come from you own bone marrow or fat. These are often being used inappropriately, and patients are charged exorbitant amounts of money to have these injections.
As always, let us know if we can be of assistance to you!
F. Clarke Holmes, M.D.
PRP: Natural/Holistic, Preventative & Effective
/The trend we are seeing is in so many patients is their desire to treat their medical conditions with something more natural, less invasive, safe, effective and preventative. Well, platelet-rich plasma injections really check all of these boxes.
PRP injections have been a part of our treatment regimen for many conditions now for 15 years! Thus, PRP is not some trendy, gimmicky, unproven type of therapy.
If you have knee osteoarthritis and it’s not to the point of requiring a knee replacement, then PRP is probably your most effective option to relieve pain, improve function and stop or slow the deterioration of cartilage in your joint. Unfortunately, steroid (cortisone) and hyaluronic acid (the “gel” injections) do not have this preventative benefit of protecting your cartilage.
Of course, we believe in total body care, so physical therapy, bracing, weight loss, a customized exercise regimen, an anti-inflammatory pattern of eating and certain supplements can all play a very valuable role in treating your pain and osteoarthritis.
If you have a chronic tendon problem such as of the rotator cuff, the Achilles tendon, tennis or golfer’s elbow or plantar fasciitis, then PRP can actually heal these conditions. Steroid injections, on the other hand, often provide more rapid pain relief for these conditions, yet are almost always inferior to PRP injections in studies looking at these patients 6-12 months after these injections. Meaning, if your long-term goal is healing and persistent pain relief, then PRP is the better option.
Want to know more? Check out some of our blogs:
Insurance Companies Say PRP Is Experimental…We Sigh — Impact Sports Medicine & Orthopedics (impactsportsnashville.com)
Five Keys to Successful Outcomes with PRP Injections — Impact Sports Medicine & Orthopedics (impactsportsnashville.com)
PRP And The Three "Es" — Impact Sports Medicine & Orthopedics (impactsportsnashville.com)
If you want to take the next step to help yourself in 2025, then let us be of assistance to you!
F. Clarke Holmes, M.D.
Harness the Power of Protein Concentrate Added to your PRP
/We are always finding innovative ways to help our patients, especially those with osteoarthritis. Platelet-Rich Plasma injections have been very successful, yet now we have another option to boost the benefits of PRP. We call this “Protein Concentrate.” By filtering the additional plasma after your blood is centrifuged, we are able to trap a high concentration of proteins that can also significantly relieve the symptoms of OA and potentially slow the deterioration of the cartilage in the joint. Two of these proteins are Alpha-2-Macroglobulin (A2M) and Interleukin-1 Receptor Antagonist Protein (IL-1ra).
A2M is the key to slowing the progression of osteoarthritis. A2M is a powerful chemical in destroying proteins that cause arthritis that captures and inactivates the three major chemicals that lead to joint breakdown and cartilage damage. It is also reported that A2M can act as a powerful anti-inflammatory and aid in pain management.
Research on IL-1ra has shown that it also plays a role in slowing the progression of osteoarthritis in joints.
Who should consider adding Protein Concentrate to their PRP injections? We believe that those with repetitive swelling in the joint are the most likely to benefit from the addition of the protein concentrate to the PRP.
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.
“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.
PRP For Knee Pain: Almost A No-Brainer
/Knee pain is often caused by a meniscus tear, osteoarthritis, patellar tendinopathy, low-grade ACL or MCL sprain or some combination of these.
Don’t want surgery, don’t need surgery or already had surgery with a less than satisfactory outcome?
Platelet rich plasma (PRP) has been a star in the world of orthopedics, particularly as it pertains to knee conditions.
Once considered experimental, this innovative, minimally-invasive treatment using your own blood and concentrated growth factors is now is becoming a standard-of-care treatment for many knee conditions.
Over 45 studies have demonstrated clinically significant benefit in the treatment of knee osteoarthritis (OA). The overwhelming majority of studies demonstrate that PRP is more effective in the long-term when compared to steroid or hyaluronic acid injections for knee OA.
Want something safe, natural, effective, and a disease-modifying intervention that will relieve pain, improve function, provide stability and/or healing for tissues that can be done in the office? Then PRP can be a great option for you.
I've been giving ultrasound-guided PRP injections for 15 years. I’ve spent countless hours on the educational process, training and fine-tuning of techniques to make this a excellent option for our patients. I’ve been a patient myself, receiving PRP for shoulder and knee conditions and I've experienced the success firsthand.
Want to know more about PRP?
Learn about the key details of PRP here
How is PRP simple and not-so-simple? Read here
If you think you may be a candidate or want to discuss further, then
come see us. We are always happy to help!
F. Clarke Holmes, M.D.
Do I Need a Knee Replacement?
/Your 55 year-old knee is hurting and your brain immediately asks the question, “Do I need a knee replacement?”
An x-ray demonstrates moderate to severe osteoarthritis and thus, it’s time for a knee replacement, right? Not necessarily. It’s amazing how many patients have severe findings on their x-rays but minimal to mild pain and excellent function. Therefore, we always say, “Treat the patient, not the x-ray.”
Ok, now your pain has been running 5-7 out of 10 for weeks to months. Therefore, it’s time for a knee replacement, right? Well, pain is certainly a factor in this decision; however, we have many nonsurgical tools in the toolbox that will reduce or eliminate pain for extended periods of time.
Finally, you’ve been episodically limping now for several weeks. You suppose it’s time for a replacement, right? Persistent dysfunction is another reason to have a knee replacement, but function can often be significantly improved without the need for surgery.
To overcome the symptoms and dysfunction of knee arthritis, three factors can be addressed: the environment, the biomechanics and the structure. Only surgery can change the structure, yet significant improvements in the environment and biomechanics can often delay or eliminate the need for knee replacement.
How do we do this? The environment is best changed by injections such as platelet-rich plasma, an anti-inflammatory pattern of eating, supplements and occasionally medications.
The biomechanics can be improved through physical therapy, certain forms of exercise, bracing and changes in footwear.
So in summary, knee replacement can be the right option for many patients and produce successful outcomes in most patients, yet in 80-90% of the patients that walk (or limp) into our office, nonsurgical treatment will be quite effective.
As always, let us know if we can be of assistance to you!
F. Clarke Holmes, M.D.
When It Comes to Osteoarthritis, PRP is the Winner!
/Although platelet-rich plasma (PRP) injections remain innovative and the science behind and techniques when using them are evolving, they are trending towards the injection of choice, especially in the case of osteoarthritis. Once considered “experimental,” there are now at least 45 studies validating the success of PRP in the treatment of knee osteoarthritis. So simply put, why would you choose PRP over a steroid injection or hyaluronic acid for knee osteoarthritis?
-Safer and more natural
-Longer-lasting relief of pain with often 6 months to 2 years of benefit for knee OA
-Most likely PRP is disease-modifying, meaning it is slowing the deterioration of cartilage in your knee
How about a study or two demonstrating these points made above:
PRP and Knee OA- Article 1
PRP and Knee OA- Article 2
Want to know more? Here are a couple of our previous blogs on the topic:
https://www.impactsportsnashville.com/blog/2024/2/16/7826kg4vvyebmp8bt2aph72i704hmc
https://www.impactsportsnashville.com/blog/2023/6/17/insurance-companies-say-prp-is-experimentalwe-sigh
As always, we are here to help! Let us know if we can be of assistance to you.
F. Clarke Holmes, M.D.
Proactive Versus Reactive: Which One Are You Choosing?
/We strongly encourage our patients to be proactive with their musculoskeletal health over just being reactive.
Let’s list some examples of the two different approaches:
Proactive
You’re trying to remain in great shape, yet your knee is starting to ache due to mild osteoarthritis. No surgery is necessary, but you want to do something that not only reduces symptoms, but also protects the knee in the long term that is likely disease-modifying. Thus, a series of platelet rich plasma (PRP) injections will meet those goals. PRP injections are one of the best treatment options for the management of osteoarthritis.
You’re starting to have heel pain when you first get out of bed. You suspect plantar fasciitis. Instead of ignoring the symptoms or simply relying on Dr. Google, you decide to consult with a sports medicine physician, so a comprehensive diagnostic and treatment plan can be constructed and customize for you. You realize an inexpensive ultrasound in the office can confirm this diagnosis, determine severity and help with prognosis. At that visit, you’ll be given numerous treatment options and successfully guided on your ability to continue exercising to maintain good health.
You have daily aches and pains, early arthritis and stiffness, but really don’t want to go on daily medications to manage the symptoms. However, you need some help making lifestyle choices as a pertains to diet, supplements and exercise choices. You understand that friends, family, and the Internet are not the optimal resources. Therefore, you decide to move forward with a physician consult so you may receive advice in great detail regarding the best supplements to choose for your particular situation, how to approach exercise and dietary choices. You understand that it is your physician’s to help you decide between what is fact and what is myth.
Reactive
Your heel starts to hurt after some longer walks, especially when you first get out of bed. You talk to friends who recommend rolling the heel, stretching the toes and obtaining non-customized orthotics. You continue to walk, but three months later your heel pain is worse and you limp into the doctor’s office wondering what happened. Bottom line, you now have advanced plantar fasciitis. Unfortunately, the advice you’ve received from well-intentioned others has not been the best for you. Presenting to the doctor when the symptoms first developed would’ve given you a much better outcome, as an entirely different set of treatment options would have been suggested.
Your arthritic knee starts to hurt and you see a bit of swelling, but you decide to keep going to the gym, rubbing Biofreeze on it and you add in some heavy yardwork over several weekends, Ultimately, you can barely bend your very swollen knee, and you’re thinking about canceling that trip to see grandkids. Of course, we are here to help you, but we could’ve avoided this major flare if we would have proactively started some treatment as soon as your knee started to ache.
So we ask the question: are you going to be proactive or reactive? Not every little ache or pain that last hours to a few days should prompt a visit to the doctor. However, do not ignore symptoms and instead, do realize that early treatment usually provides better outcomes than waiting until symptoms rise to a moderate or severe level.
As always, let us know if we can be of assistance to you!
F. Clarke Holmes, M.D.
I Have Knee Arthritis. Can I Still Run?
/The answer is, “yes,” “maybe” or “no.” Thus, it really depends on your situation, and fortunately, a period of relative rest may only need to be temporary.
Here’s the really good news: several recent studies have indicated that running a reasonable number of miles does not cause knee osteoarthritis and may actually have a protective effect.
If you are a runner and your knee is symptomatic, then our role is to help you reduce or eliminate your symptoms and safely return to running. We know that running has numerous health benefits, not only including protection of the joints, but also calorie burning, weight control, improvement of cardiovascular health and many mental health benefits.
As a patient though, it’s sometimes difficult to know when you need to stop running for a while, what’s a reasonable amount of running for your body and what treatment options may be available to not only reduce your symptoms, but also to protect your knees on a long-term basis.
That’s where we come in! We love treating runners and understand how you think. We typically focus on a nonsurgical and minimally-invasive approach to your care.
Physical therapy, bracing, footwear changes, custom orthotics, medications, supplements, and various injections can all play a role in the treatment of knee osteoarthritis. One of the best long-term treatment options, especially for those with mild to moderate osteoarthritis, would be platelet plasma (PRP) injections. These can have a very protective effect for the knee, and not only by reducing symptoms, but also by slowing or stopping the deterioration of the cartilage within the joint. Only a couple weeks of rest are typically required after these PRP injections.
Check out a few blogs on PRP as well as running as it relates to knee osteoarthritis:
https://www.impactsportsnashville.com/blog/2023/8/5/our-top-5-treatments-for-knee-oa
https://www.impactsportsnashville.com/blog/2023/5/12/five-keys-to-successful-outcomes-with-prp-injections
https://pubmed.ncbi.nlm.nih.gov/36875337/
As always, let us know if we can be of assistance to you!
F. Clarke Holmes, M.D.
I Don't Want Surgery But What Else Can I Do?
/Fortunately, 90% of problems that come into an orthopedic clinic do not require surgery.
Approximately 80% of those conditions treated nonsurgically can be treated with traditional treatment measures: rest, activity modification, physical therapy, medications, supplements, lifestyle changes, brace, splint, a boot walker, steroid injection, etc. This is “bread and butter“ treatment administered by an orthopedic/sports medicine physician.
Now, what about that last 20% of non-surgical treatment? That’s often where we have to think “outside the box.” Let’s say in the case of osteoarthritis and tendon problems, that’s where treatment like platelet-rich plasma (PRP) injections can be very helpful. For example, in the case of knee osteoarthritis, how would you like to have less pain, less stiffness, less swelling and better function? What if we could accomplish that with a treatment that is minimally-invasive, safe, proven and natural? As a bonus, this treatment has preventative benefits, meaning we likely are slowing down the cartilage breakdown in your knee. These are the benefits seen with PRP injections.
In the case of tendon or fascia problem like a rotator cuff partial tear, tennis or golfer’s elbow or plantar fasciitis, PRP is designed to be a healing agent. We are using these growth-factor rich injections to accomplish healing, not just make you feel better like a steroid injection might.
Check out a few of our previous blogs, and let us know if we can help you!
https://www.impactsportsnashville.com/blog/2023/12/8/prp-the-gift-of-health
https://www.impactsportsnashville.com/blog/2023/9/23/5-things-you-have-to-know-if-you-have-knee-pain
https://www.impactsportsnashville.com/blog/2023/8/5/our-top-5-treatments-for-knee-oa
F. Clarke Holmes, M.D.
PRP: The Gift of Health
/As we near the major holiday gift-giving season of the year, consider one the best gifts you can give to yourself: the gift of health! Platelet-Rich Plasma (PRP) injections are a great option for you in 2024 if you are looking to boost your orthopedic health and longevity. Here are 5 great adjectives that apply to PRP injections:
1) Safe: adverse effects and complications associated with PRP injections are exceedingly rare.
2) Effective: 80-90% of our patients that receive PRP injections have very good outcomes and are satisfied with their results.
3) Natural: these injections use your blood, specifically your platelets and your growth factors to exert their positive effects.
4) Proven: once considered experimental, there are now hundreds of studies that demonstrate clinical benefit with PRP injections.
5) Preventative: PRP injections are touted in their ability to prevent many degenerative joint and soft conditions from further deterioration.
Want to know more? Check out some of our blogs:
Insurance Companies Say PRP Is Experimental…We Sigh — Impact Sports Medicine & Orthopedics (impactsportsnashville.com)
Five Keys to Successful Outcomes with PRP Injections — Impact Sports Medicine & Orthopedics (impactsportsnashville.com)
PRP And The Three "Es" — Impact Sports Medicine & Orthopedics (impactsportsnashville.com)
As always, let us know if we can be of assistance to you!
F. Clarke Holmes, M.D.
5 Things You Have to Know If You Have Knee Pain
/1. Three factors play a role in knee pain: structural, biomechanical and environmental. Structural means damage, biomechanical means abnormal tracking or loading within a joint or tendon because of misalignment, weakness, and/or inflexibility. Environmental typically means inflammation within the joint or tendon. When formulating a treatment plan for you, we typically want to address one or two of these factors initially. Unless you have major damage, we’re normally not treating structure initially, as that results in a surgery.
2. Age often plays a role in these different factors: in the absence of injury, in patients under 20 years of age, the problem tends to be biomechanical. In patients ages 20 to 40, the problem tends to be biomechanical and inflammatory. In patients older than 40, structural, biomechanical and inflammatory are typically all playing a role.
3. Being proactive in the care of your knee problem usually produces better outcomes than being reactive. This means integrating treatments early on and not waiting until you have major pain or disability to see a physician. We term this “PIO,” Proactive Interventional Orthopedics.
4. Meniscus tears are commonly found on MRIs and may or may not be a source of pain. For decades, the trend was to treat these surgically, typically arthroscopically, removing the torn piece of meniscus. There’s now a trend towards repairing the meniscus tear when possible, but only about 10% can be successfully repaired. Thus, surgery for meniscus tears, especially those age 40 and above, is falling out of favor. On occasion, surgery is the better choice, but treating these initially nonsurgically is usually the best way to start. We often tell patients “a little torn meniscus is better than less meniscus,” especially long term. Less meniscus often equals greater arthritis.
5. Three types of injections can be used for most knee problems: steroid, hyaluronic acid, and orthobiologics. Orthobiologics include platelet-rich plasma (PRP) and stem cell injections. Each of these injections can be reasonably good choices, but for long-term success, PRP is likely your best option in terms of producing favorable outcomes, modifying the disease process, and these are often the most cost-effective option. Stay away from “stem cell” injections that are ordered by physician’s or chiropractic offices and do not come from you own bone marrow or fat. These are often being used inappropriately, and patients are charged exorbitant amounts of money to have these injections.
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.
Knee Replacement Soon? Hit the Pause Button...
/So many patients with knee osteoarthritis ask me the question “well, if I’m eventually going to require knee replacement, shouldn’t I go ahead and have it done now?”
Well, there’s not just one answer to that question, but here are some of my replies:
-Most knee replacements only last 15 to 25 years. After that, the implants start to loosen, creating pain, swelling or a sense of instability.
-Most patients are at higher risk for surgical complications at the time of a second surgery, known as a “revision,” simply due to their age and likelihood of having more significant medical conditions.
-Surgical techniques are improving with breakthroughs every two or three years. Robotically-assisted replacements and having replacements as an outpatient surgery are two recent examples. More advancements are sure to come.
-One should never base the need to have knee replacement on the appearance of the x-rays. Some patients with “bone-on-bone” arthritis have minimal pain and excellent function. These patients don’t need a replacement.
-What often produces the most pain is an unhealthy environment within the knee joint, some of which may be controlled with injections like platelet-rich plasma (PRP).
-We also believe that PRP may put a stop sign or at least a yellow light on cartilage deterioration. We do not make guarantees about cartilage regrowth, but if we can stabilize a patient’s current cartilage and slow or stop the deterioration, then we are slowing the process of osteoarthritis and perhaps delaying the need for knee replacement.
-For a joint condition like arthritis, we often think of PRP as a maintenance treatment, not just a one-time application. Much like the maintenance for your car, you don’t just take it to the mechanic once or twice and then get a new car. This is an ongoing process.
-Assuming a patient is in that 80% success group with PRP treatments, one should plan on likely having repeat PRP injections every 1 to 2 years. This is a great long-term investment in the health of your knee.
-Want to know more about PRP? Check out this blog:
Five Simple Reasons You Should Consider Platelet-Rich Plasma — Impact Sports Medicine & Orthopedics (impactsportsnashville.com)
In summary, for some individuals, knee replacement is inevitable, but there can be great value in delaying this surgery to increase the odds that it is required just once in a patient’s lifetime. For others, treatments like PRP can eliminate the need to have a replacement.
As always, let us know if we can be of assistance to you!
F. Clarke Holmes, M.D.
Five Keys to Successful Outcomes with PRP Injections
/Quality Equipment- we’ve chosen a PRP system created by one of the industry’s leaders in orthobiologic injections.. This is our 5th PRP system to use over the past 12 years. Thus, we are always searching for the best option to produce a high-quality PRP solution.
Appropriate Selection of Patients- we attempt to choose patients and conditions that are excellent candidates for PRP injections. Admittedly, not every patient is an ideal candidate, yet their options may be limited in terms of other forms of treatment, or they are willing to have PRP due to its excellent risk-benefit and cost-benefit ratio compared to more invasive treatments. Partial tendon tears, plantar fasciitis and osteoarthritis of the knee, hip and shoulder comprise 95% of our PRP injections.
Appropriate Pre-Procedure and Post-Procedure Instructions and Compliance-little things can be the difference between PRP succeeding or not succeeding or between a good outcome and a great outcome. For example, it’s important for a patient to be off any anti-inflammatories at least a week before and 2 weeks after a PRP injection. It’s also important to rest the treatment area, and this form of rest really varies depending on the patient and their area treated. A patient’s timetable for return to exercise and/or rehabilitation must be carefully outlined.
Quality Preparation of the PRP solution- not all PRP is the same. The platelet concentration and number of platelets can vary and are important aspects of the potential success of PRP. How much blood we take from the patient and the PRP system dictate these numbers. Also, we typically create a leukocyte-poor (low numbers of white blood cells) for joint injections and leukocyte-rich (higher white blood cells and the highest number of platelets) solution for tendon injections.
Accuracy of the Injection, Preferably with Ultrasound Guidance- using ultrasound for the injection often results in less pain, lower risk, and greater accuracy. We place the PRP exactly where it needs to be and avoid hitting other structures like bone, cartilage, nerves and blood vessels. We often say, “if you’re going to invest your time and money in this procedure, don’t you want it done as precisely as possible?”
More medical professionals are performing platelet-rich plasma injections than ever. This innovative treatment is not going away and will only evolve in the years to come. If you think you are a first-time or repeat candidate for a PRP injections, then come see us!
F. Clarke Holmes, M.D.
PRP And The Three "Es"
/This sounds like the name of a band, right? Well, we’re referring to platelet-rich plasma (PRP) injections and three important words that start with an “E” when discussing these procedures.
First, a quick reminder that we use your own blood obtained from an arm vein, a special kit, a centrifuge and a precise separation process to create the PRP. PRP is then a great treatment choice for osteoarthritis of the knee, hip, shoulder and other joints. It’s also an effective treatment for tennis and golfer’s elbow, plantar fasciitis, Achilles and rotator cuff tendon problems, just to name a few. When considering who will perform your PRP injection, you absolutely need to consider the three Es:
Experience: At Impact, Dr. Holmes has been performing PRP injections since 2009. Very few physicians in the Nashville area can claim that level of experience. In addition, we are giving more PRP injections than ever as more and more patients are realizing the benefits of this procedure. Thus, in 2009, we may have given 1-2 PRP injections a month, and now, we give 12-15 a month on average.
Expertise: With experience comes expertise, yet expertise also comes with putting in the work. This means attending conferences, reading and interpreting studies, participating in webinars and interacting with peers who are also experts in the field. Hardly a week goes by that we don’t spend some time fine tuning our expertise in this field. Next, we’ve been pioneers in the sports medicine industry through our ultrasound-guided injections. 14 years of experience with ultrasound and over 10,000 injections later, we consider this to be an area of expertise.
Equipment: PRP is not just PRP, meaning some kits, equipment and the preparation process are better than others. Novices in the field tend to choose lower cost and lower quality PRP systems which often produce fewer numbers and a lower concentration of platelets. At Impact, we are on our 5th PRP system over the past decade. These systems continue to improve, and you deserve a high-quality option. Finally, ultrasound-guidance is paramount when having a PRP injection. Don’t you want this high-powered solution to be injected into the precise location? Without ultrasound guidance, you are proceeding “blindly” and can only hope the injection makes it to the intended location.
Considering a PRP injection for your orthopedic condition? Remember the 3 Es and let us know if we can be of any 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.
BEING PROACTIVE, NOT REACTIVE, WHEN IT COMES TO PLATELET RICH PLASMA (PRP) INJECTIONS
/I am a 28 year-old nurse practitioner and former competitive athlete, and I am strongly considering getting platelet-rich plasma (PRP) injections for my knees. Why? For one, as a provider, I have witnessed many improved patient outcomes. Two, this procedure is safe, has relatively no side effects, and is minimally-invasive. Lastly, we are seeing that by being proactive with PRP versus reactive when symptoms are present shows even further benefit.
After many years of intense volleyball training, games, and working out without any downtime throughout the year, I developed bilateral knee pain. Although I have no x-ray evidence of osteoarthritis at this time, based on my symptoms, there is no doubt I have cartilage damage. Because of this, I feel that PRP injections, in addition to other conservative treatments I’ve used, will boost the longevity of my knees.
PRP helps soft tissue, joint, and cartilage pathology. It is a great way to use your own body’s healing system to improve musculoskeletal problems, and there is minimal risk because it uses your own blood.
What’s our process?
Obtain blood from a vein.
Spin it in a centrifugation system in our office. This separates the components of the blood and concentrates the platelets.
We take the plasma that has platelets that are rich in growth factors to create the PRP injectable solution.
The PRP is then injected under ultrasound guidance in the targeted area.
When injecting the PRP solution to the targeted area, it creates an espresso shot-like effect for your body’s growth factors and repair cells to travel to this area. The main goal is to help repair the damaged area, decrease pain, and improve function. Keep in mind that this is a slow and methodical approach that can take up to 6 months to see maximum benefits. Sometimes more than one PRP injection is needed. How long does PRP last? It varies based on the severity of the patient’s condition, a patient’s activity level, and incorporation of other conservative treatments. Cost can vary per practice. We typical charge $800-$950 (*subject to change) depending on how many locations we are injecting and which centrifugation system we use. Keep in mind that PRP injections are NOT stem cell injections.
My goal with this blog is to change the thought process that PRP injections should only be used reactively to treat orthopedic conditions and their accompanying symptoms to one instead that utilizes PRP in a proactive approach to slowly repair and stabilize conditions.
So, why haven’t I had PRP injections in my knees already? Honestly, the only thing holding me back is my nervousness when it comes to needles.
Interested to see if PRP injections would be helpful for you? We would love to have a consult with you to discuss these in detail!
Taylor Moore, FNP
Impact Sports Medicine and Orthopedics