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Month: August 2015

We no longer offer PRP and Stem Cell procedures until further scientific evidence of its efficacy. We do PROLO Therapy for specific orthopedic conditions.

Achilles Tendinopathy

Regenerative Injection Therapies for Achilles Tendinopathy

Achilles tendonitis is one of the most common overuse injuries seen by orthopaedists.  While there are several different known causes of Achilles tendonitis, overuse and degeneration are two of the most common reasons.  In the truest sense, Achilles tendinopathy more accurately describes the condition.  Tendinitis means inflammation within a tendon whereas, tendinosis refers to micro tears commonly as the result of overuse. Collectively tendinopathy incorporates both of these findings.

Those who suffer from Achilles tendinopathy typically complain of pain either along the midportion of the tendon or at the insertion site at the heel.  Stiffness in the morning and increasing pain with activity is common. Thickening of the tendon can result from injury or from degenerative changes seen with age.  For some, swelling and redness may also be present.

Historically, the normal treatment course for Achilles tendinopathy has focused on activity modification including rest, ice, non-steroidal ant inflammatory medication (NSAID), and stretching exercises. In rare cases, corticosteroid injections have been given for Achilles tendonitis, but there is concern for risk of tendon rupture associated with this.

Unfortunately for some, Achilles tendinopathy can become a chronic condition in which adhesions can may form between the tendon and tendon sheath.  This is a much harder condition to treat. There are several different surgical approaches to address this problem however, recovery can be prolonged and return to certain activities may be limited on a long term basis.

Beyond the standard treatments mentioned above, regenerative injection therapies including Prolotherapy and PRP also may also have a place in the management of Achilles tendinopathy.   On the Prolotherapy side, a randomized clinical trial that was conducted in Australia (Yelland et al 2011) showed that Prolotherapy when combined with specific exercises was very effective early at reducing stiffness and allowing for increased activity.   Several studies have evaluated the use of PRP for Achilles tendinopathy.  A European study that is due to publish this month in Foot and Ankle Surgery, reported on 83 Achilles tendons that were followed for an average of 50 months after a single PRP injection. Statistically significant score improvements were seen on the Victoria Institute of Sports Assessment – Achilles (VISA-A) questionnaire. 91.6% of the patients were satisfied with the treatment at final follow-up. No tendon ruptures were seen.

A similar study by Filardo et al (2014) showed a positive outcomes for 27 cases of chronic Achilles tendinopathy treated with leucocyte positive PRP with an average of 54 months of follow-up.

The published data on the use of regenerative injections for Achilles tendinopathy is very limited at the present time. This is an area that is presently being investigated. The results do appear to be promising so far.


Is Platelet Rich Plasma (PRP) effective for knee osteoarthritis?

Traditional treatment for knee osteoarthritis has been focused on knee strengthening, the use of non-steroidal anti-inflammatory medication (NSAIDs), and corticosteroid injections. Additional non-surgical options including viscosupplementation is also a treatment option for some with mild to moderate joint degeneration and have failed other first line treatment options.

Several studies have been published this year in regards to looking at the efficacy of PRP injections for patients who suffer from knee osteoarthritis.

A meta-analysis published by Campbell et al (May 2015), looked at the use of PRP versus corticosteroid injections, viscosupplementation injections, NSAIDs, and placebo. The findings from the literature searches did show that PRP injections led to significant improvements in pain and function at 6 months and maintained effect until 12 months post-injection. Those with milder findings of osteoarthritis radiographically appeared to have greater benefit from PRP injections.

A more recent double-blinded randomized clinical trial by Forogh et al (July 2015), evaluated one injection of PRP versus an intra-articular corticosteroid injection for symptomatic osteoarthritis of the knee. Patients with grade II/III osteoarthritis were randomly divided into two groups. Outcome measures included the Knee injury and osteoarthritis outcome score (KOOS), 20 meter walk test, knee range of motion, flexion contracture, and Visual Analog Scale (VAS) for pain assessment. Patients treated with one PRP injection had greater relief of pain compared to the corticosteroid group. A greater percentage of those treated with PRP were symptom free following injection, had improved activities of daily living and quality of life scores at follow-up.

In another randomized control trial conducted by Filardo et al (July 2015), researchers looked at the potential benefit of PRP injections compared to hyaluronic acid (viscosupplementation) injections for patients with at least a 4 month history of chronic knee pain and accompanying degenerative changes.

For this study, patients had 3 weekly intra-articular injections of either PRP or hyaluronic acid. Outcome measures included the International Knee Documentation Committee (IKDC) subjective score, KOOS score, EuroQol visual analog scale and Tegner score. The findings of the study revealed that both treatments were effective at improving knee functional status and decreasing pain. No significant differences were identified between PRP and hyaluronic acid.

While these studies do show the potential for PRP to be beneficial for those with knee osteoarthritis, it remains unclear as to how many injections are ideal. Furthermore, the preparation methods of the PRP, and the activating agent must also be considered.

Platelet Rich Plasma (PRP) Therapy in Orthopedics

Platelet Rich Plasma (PRP) has been used since the 1970’s. The last decade has seen tremendous focus on PRP applications in musculoskeletal medicine. The potential for PRP to promote tissue healing following injury or disease is attractive to many physicians, researchers, and patients alike. Unlike medications or cortisone injections which suppress or mask the underlying problem, PRP shows the potential to heal. The risk of disease transmission is limited since PRP is derived directly from a patient’s own blood. On the flip side, there is significant variability in PRP concentrations from one patient to another. This combined with different methods of preparing PRP, timing, and the selection of activating agents all present challenges in studying and standardizing treatment protocols.

Published studies of PRP use in adults and in animal models have shown promise for a number of orthopedic related conditions. This is especially the case for tendon and soft tissue injuries. The specific mechanism of how PRP works remains elusive, but several well controlled studies have shown positive outcomes with no significant adverse events.

In simplest form, when an injury occurs, the body’s own platelets release co-factors that stimulate recruitment of mesenchymal stem cells (MSCs) to the site of injury. Additionally, inflammation is reduced during this cascade of events and healing is promoted. Some of the known components of PRP included platelet-derived growth factors, insulin-like growth factor, transforming growth factor-beta, fibroblast growth factor-2. Each of these have differing functions in the healing and reparative process.

To date, many professional athletes have been treated with PRP injections. Success rates that appear in the published literature and across the web vary considerably. Some are reported at greater than 90%. Caution must be exercised in interpreting these results as outcome measures vary. Again it is very difficult to compare studies or even one individual versus another due to the issues described above.

We are just beginning to understand how PRP can be used and how effective it can be in the treatment of certain orthopedic conditions.

Platelet Rich Plasma (PRP) injections for tennis elbow: What is the evidence?

Lateral epicondylitis (“tennis elbow”) is one of the most common conditions seen by orthopedists. It is estimated that 1-4% of the population suffers from tennis elbow. The peak incidence usually occurs between ages 30 and 50. Lateral epicondylitis is classified as an overuse injury to one of the main forearm extensor muscles. The muscle becomes weakened from overuse and microscopic tears develop in the tendon that attaches to the bone (lateral epicondyle). The end result is chronic pain and inflammation.

Treatment has traditionally included bracing, corticosteroid injections, use of non-steroidal anti-inflammatory medications, exercise, and surgery. Acupuncture, cold laser therapy, and extra corporeal shock wave therapy have also been utilized by some with mixed success.

Treatment of tennis elbow with PRP injections has gained popularity over the last ten years. Many studies are being conducted across the U.S… Within the current published medical literature, there are numerous studies comparing the use of PRP to other treatment modalities in the treatment of tennis elbow. Studies range from high quality, controlled clinical trials to single case reports. Of the studies published in the last five years, evidence for the use of PRP has been mixed, but has favored a positive outcome overall.

In the most recent of studies (Behera et al 2015), PRP was compared to bupivacaine for chronic tennis elbow. Bupivacaine is also known as Marcaine and is a local anesthetic. Twenty-Five patients were studied for up to 1 year following one injection of either PRP or bupivacaine. Those who received bupivacaine had better improvements in pain and functional scores than those treated with PRP. However, at 6 months and 1 year after injection, PRP was far superior to bupivacaine.

In a randomized control trial comparing PRP to an active control group by Mishra et al (2014), 230 patients were studied. A successful outcome was defined as a 25% or greater improvement on the visual analog pain scale. The results of the study showed that there were no differences between groups at 12 months, but at 24 months PRP was superior (83.9% vs. 68.3% in control group).

A doubled blinded, randomized control trial by Gosens et al (2011) comparing PRP versus corticosteroid injections in patients with chronic lateral epicondylitis has similar findings to Mishra et al. In this study, 150 patients were randomly divided into the two groups. Patients treated with PRP were significantly improved versus those who had received a corticosteroid injection after two years of follow-up. No complications were noted.

There are additional published studies looking at PRP use in treating lateral epicondylitis. Evaluating these studies can be challenging as the comparison group (“controls”) and outcome measures often vary considerably. Unfortunately, some studies also have methodological flaws which may invalidate the results.

PRP for tennis elbow does appear to be safe and has so far shown the potential to be effective for a subset of patients.

Prolotherapy for Sacroiliac (SI Joint) Pain

Sacroiliac joint (SI Joint) dysfunction or sacroiliac syndrome as it is sometimes referred to as, can be a potential cause of low back pain. It is a condition that is not well understood as there is no gold standard for diagnosing and treating this problem. The SI Joint is considered a diarthrodial joint and connects the sacrum to the pelvis. Limited motion does occur and the SI joints are supported by surrounding muscles and strong ligaments. While not completely clear, it is believed that SI joint pain can be caused by either too much joint movement or too little movement. Pain can also come from surrounding structures including the discs and facet joints.

Diagnosis of SI joint dysfunction is often made based on tests conducted during a physical examination. Many practitioners also utilize a SI joint injection under fluoroscopic guidance (“live x-ray”) or CT guidance to confirm the diagnosis. If the patient receives relief of pain, even if temporary, then treatment can be focused on the SI joint. Non-surgical treatment options often include corticosteroid injections, manipulative physical therapy, and the use of non-steroidal anti-inflammatory medications. More advanced options include radiofrequency neurotomy and SI joint fusion. Results of a systematic review of the literature (Rupert el al 2009) found evidence for radiofrequency neurotomy use is very limited based on only a few quality studies. The number of SI joint fusions has increased significantly in the last few years including the use of minimally invasive approaches. The indications for a fusion is limited and there are concerns that by removing motion within the joint, more forces will be transmitted across the hips and lower spine leading to further problems.

So what other options exist for those who suffer from pain emanating from the SI joints? Prolotherapy has been suggested and has been used successfully in a number of documented cases. The medical literature is very limited in regards to using prolotherapy for this condition, but the results of some smaller studies have shown that Prolotherapy may be an option to consider. Cusi et al (2010) followed 25 patients with SI joint dysfunction following a hypertonic dextrose solution injection under CT guidance. A positive clinical result was present for 76% at 12 months after injection and 32% at 24 months. In a randomized controlled study, Kim et al (2010) compared Prolotherapy injections to corticosteroid injections. At 15 months post-injection 58.7% of those treated with a Prolotherapy injection had pain relief equal to or greater than 50% versus 10.2% for the corticosteroid group.

Going back to the underlying reason for SI joint pain, the common thinking is pain and dysfunction result from changes in ligamentous laxity. Prolotherapy is aimed at injecting an irritant into the joint and/or weakened ligamentous structures to promote a response by the body to heal the affected area. While limited data to support Prolotherapy for SI joint dysfunction exists, no significant adverse events have been reported in the literature and mostly observational studies have shown the treatment to be effective at alleviating pain for the subset of patients treated.