Platelet-Rich Plasma Therapy for Orthopedic Injuries
By Ashkan Alkhamisi, MD, Sports Medicine Physician at HonorHealth Orthopedics-Saguaro
Digital - March 2024
With growing popularity over the past decade, many Sports Medicine and Orthopedic physicians are wanting to learn more about Platelet Rich Plasma (PRP) and its potential benefits for their own patients. There has been an increasing number of high quality clinical research studies suggesting that this can be a safe and potentially efficacious treatment, and it is widely being adopted as a suitable non-surgical treatment option in the world of musculoskeletal conditions. Platelet Rich Plasma (PRP) is an injection of your own blood that has been spun down to increase the concentration of platelets.
The process starts by drawing blood (between 20 mL-120 mL volume depending on the issue) from the arm using a needle into the vein, similar to doing a blood draw. The blood is then processed in a centrifuge machine, which separates blood components into different parts according to their density. The platelets are separated in the blood serum (plasma), while white and red blood cells are separated into different layers and typically not used for the procedure. By spinning the blood, the centrifuge equipment concentrates the platelets and produces what is called PRP.
This concentrated PRP has an increase in growth factors, proteins, cytokines, and other bioactive molecules that initiate and regulate the basic aspects of wound healing via cell signaling. The goal is to change the inflammatory process of the joint or diseased tendon in order to attain proper and long-term healing.
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Phases of the Platelet Cycle
There are 3 phases of the platelet cycle that help stimulate healing. They are:
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Phase 1: Vascular/inflammation, which is the first phase that occurs and which patients will feel the most soreness. This pain is often most intense during the first 48 hours and lessens over the next 5 days post-procedure. I will reassure patients that some soreness is to be expected and to not do strenuous physical activity during this period.
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Phase 2: Proliferation, is the phase involving the majority of the cell signaling pathways to begin tissue repair and can last up to 4-8 weeks post-procedure and increased physical activity can be encouraged during this period.
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Phase 3: Remodeling, is the final phase which involves increased tissue organization and maturation and can take up to 2-3 months post-procedure. For PRP injections involving joint-related issues, then we will do an 8-week follow up post-PRP procedure. For PRP injections involving tendon-related issues, then we will do a 12-week follow up post-PRP procedure. The rationale behind this is that tendons may take a longer period of time to heal than joints, however I express to the patients that they will gradually start to feel better after several weeks.
Evidence for the clinical efficacy of PRP in a variety of musculoskeletal conditions is evolving, PRP is primarily used to treat osteoarthritis and tendinopathies based on various clinical research studies. In my current clinical practice at HonorHealth Orthopedics, my top 3 conditions that I often perform PRP treatments for are the following: Mild-moderate osteoarthritis (hip/knee/shoulder joint), partial rotator cuff tendon tears, and tennis/golfers elbow injuries. I always use ultrasound-guidance to perform any PRP injections, as this is the standard of care when performing these procedures. Additionally, I will try other conservative treatments (steroids and viscos supplementation injections, physical therapy, etc.) prior to pursuing PRP in most patients although it is reasonable to do PRP as a first-line therapy if a patient wishes to do so.
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Candidates for PRP Therapy
When considering appropriate candidates for PRP therapy, it is important to note some considerations. PRP injections are not currently FDA-approved treatments and most insurance companies do not reimburse for these procedures. While the FDA currently considers PRP as an investigational/experimental therapy, PRP injections have been performed in the United States since the early 2000’s and they are deemed safe and reasonable to perform as long as a physician discusses the benefits/risks/alternatives prior to this procedure. PRP cost can vary greatly depending on the Orthopedic practice and location, however in the Phoenix metro area the average price is $700-800 per PRP injection with some places charging more depending on the quantity of the blood draw and machines used.
The number of PRP injections performed per joint/tendon issue will depend on several factors that an experienced physician will discuss with the patient to determine how much is needed. In my clinical practice, I often recommend 2-3 PRP injections per joint/tendon issue, and I explain to my patients that I will consider their PRP treatment to be successful if they achieve a minimum of 9 months of pain relief and improved function. I will also explain to patients that PRP injections can be repeated in the future as needed depending on recurrence of their symptoms.
I advise my patients that they cannot take any NSAID’s one week before and after the procedure as NSAID’s cause platelet dysfunction and we need healthy platelets for optimal results. Likewise, I will ask my patients who are on any blood thinners to discuss with their PCP’s or specialist about discontinuing these medications three to five days before PRP therapy. I will typically avoid performing PRP therapy in severe cases such as bone-on-bone osteoarthritis or complete tendon tears as the evidence for PRP efficacy is much more limited and surgery may be the more appropriate option. One should also avoid PRP therapy for patients with thrombocytopenia/severe anemia, active infection, or active malignancy. For post-procedure considerations, I advise patients to refrain from taking any NSAID’s for one week and give a relative rest period which may include crutches, walking boot, or shoulder sling depending on the issue.
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Continued Education on PRP
PRP is labeled as a type of Ortho-biologic procedure, which is defined as the use of biological substances to enhance biological healing of orthopedic injuries or alter the natural course of an orthopedic disease. It is important to mention that any physician who performs these procedures should be cautious to not market/advertise PRP as a “stem cell” treatment given that there are no mesenchymal stem cells (MSC’s) which are derived from platelets and there are more medical-legal implications. Fortunately, there are few risks to doing
PRP injections such as bleeding, pain, and infection which are no different than performing any other type of injection. PRP is not expected to create allergic responses or increased risks of cross reactivity, as long as the autologous PRP is harvested from the patient’s own body and used only for that person. FDA currently regulates the centrifuge machine/equipment approval process to ensure that physicians are using a reliable machine for various orthopedic issues whenever appropriate. I provide all of my patients with educational PRP handouts that I have created based off my own experience and research to ensure that they are well-informed and adequately prepared prior to pursuing this cash-pay procedure. With the continued interest from the general public regarding PRP therapy, physicians can make an informed and educated decision about whether PRP therapy is appropriate for their respective patients based off multiple factors, as they incorporate this promising treatment strategy into their clinical practice.
About the Author:
Ashkan Alkhamisi, MD, is a Board-Certified Sports Medicine Physician at HonorHealth Orthopedics in Phoenix, AZ. He currently serves as the head team physician to provide sideline medical coverage for Chaparral high school and other SUSD schools in Scottsdale, AZ. He completed his Sports Medicine fellowship at Henry Ford Health in Detroit, Michigan where he worked with the Detroit Pistons and provided medical care to local universities and high schools. Dr. Alkhamisi grew up most of his life in Arizona and wanted to return to his home state to provide Sports Medicine care to his community. Dr. Alkhamisi’s professional interests include comprehensive sports medicine care including acute sports injuries, overuse injuries for patients of all ages, diagnostic and therapeutic ultrasound-guided injections, Ortho-biologics/Regenerative Medicine including Platelet Rich Plasma (PRP), fracture care management, team and event coverage, injury prevention, and return to play protocols.