PLATELET RICH PLASMA (PRP)

What is Platelet Rich Plasma (PRP)?

PLASMA is the liquid portion of our blood. Simply put, our blood is a solution of numerous proteins and other molecules suspended within plasma. The three main components that make up our blood are red blood cells (RBCs), white blood cells (WBCs), and platelets. In addition to these “big three”, there are many other smaller components present in our blood in much smaller quantities. Examples of these other components include electrolytes, various growth factors, cytokines, hormones, etc. All the components in our blood have important functions to help maintain and support life. Red Blood Cells are important to help deliver oxygen to the various tissues throughout our body. White Blood Cells play critical roles in our ability to fight infections. Platelets are critical in our ability to clot as well as our ability to heal injuries (described in more detail later).


REGENERATIVE MEDICINE attempts to take advantage of our body’s incredible natural healing power. If we are able to collect and concentrate the healing components naturally present in the blood, we can then use (inject) these components in to damaged areas to help promote healing. One form of regenerative medicine that has become very popular is Platelet Rich Plasma. We are able to separate the different components in the blood based on their density by spinning a tube of whole blood in a centrifuge. Spinning blood at a high rate of speed will force the densest components (RBCs, WBCs) to collect at the bottom of the tube. We can then extract the plasma (liquid above the clumped RBCs and WBCs) from the tube and discard the RBCs and WBCs. If done correctly, this plasma will contain a high concentration of platelets, as well as many other important healing molecules, including growth factors and cytokines. This platelet-concentrated plasma is referred to as “Platelet Rich Plasma,” as this plasma is rich in platelets and depleted in red blood cells and white blood cells. If we were to remove the plasma without collecting the platelets, the plasma would be referred to as “Platelet Poor Plasma.”

 

Platelet-Rich Plasma (PRP) is simply a solution of plasma with a higher concentration of platelets than typical whole blood. While PRP is deemed experimental to most insurance companies, it has been used effectively to heal various tissues since the 1980s. It was developed in the 1970s and first used in an open-heart surgery in 1987 in Italy. PRP therapy started to gain popularity in the 1990s as a way to naturally help heal musculoskeletal injuries. There have been literally thousands of research articles that document its safety and efficacy in medicine. PRP can be injected into almost any damaged region of the body to help promote healing. Given the autologous nature of PRP (autologous means derived from the same individual), potential side effects and complications are reduced compared to most other medications (since it is our own body’s product). PRP is basically a method to concentrate our own body’s healing molecules and to re-administer it into an area that requires healing.

How does Platelet Rich Plasma help with Healing?

Normal wound healing involves numerous molecules, including various growth factors and platelets. Since the necessary healing components are transported around the body in our blood stream, the ability of various issues to heal from injury depends greatly on that tissue’s blood supply. There MUST be adequate blood flow to any damaged tissue or else it will be very difficult for these areas to heal naturally.


If the damaged tissue has a great blood supply (such as muscle), then healing happens relatively quickly and easily. An example is a pulled muscle. If you have ever “pulled” a hamstring, you have likely experienced significant pain. “Pulling” a muscle occurs when the muscle stretches past is normal limits, often resulting in tearing of the muscle tissue. This tearing of tissue is very painful. The area over the pulled muscle often bruises, as tearing the muscle will tear many of the small blood vessels that supply the muscle (proof that muscle has great blood supply). While it may take quite some time to heal itself, pulled muscles will almost always heal on their own, if given enough time. This is because of the great blood supply to muscle tissue. All the healing components will flood the area of damage and the muscle tissue will heal.


Other tissues with less of a blood supply (such as tendons, ligaments and joints) have a much more difficult time healing if damaged. When we damage tendons and ligaments, these structures often do not heal on their own. Arthritic joints and cartilage tears do not heal naturally. Injuries to these structures can often lead to the development of chronic pain and dysfunction.

Platelet Rich Plasma (and even Platelet Poor Plasma) may have significant impacts on healing and regeneration of chronic MSK injuries. If we take these super concentrated solutions of plasma, filled with our body’s natural healing cells, and inject this plasma into the site of injury and tearing (especially regions with poor blood supplies), we may give our bodies an improved ability to finally heal chronic, damaged tissue.

What types of Structures can be treated with PRP?

Shoulder

  • Joint Pain

    • Glenohumeral Joint (Connects the Shoulder to the Arm) Arthritis

    • Acromioclavicular Joint (Connects the Collar Bone to the Shoulder) Arthritis

    • Shoulder Labral Tear (Cartilage on the interior of the Shoulder Joint)

  • Ligament Pain

    • Shoulder Ligament Sprains

  • Tendon Pain

    • Rotator Cuff Tendon Tear/Tendinitis

    • Biceps Tendon Tear/Tendinitis

  • Bursa Pain

    • Subacromial Bursitis (Bursa between the Shoulder and Rotator Cuff Muscles)

Elbow

  • Joint Pain

    • Elbow Joint Arthritis

  • Ligament Pain

    • Ulnar Collateral Ligament Injuries

  • Tendon Pain

    • Lateral Epicondylitis (Tennis Elbow)

    • Lateral Epicondyle Tendon Tear

    • Medial Epicondylitis (Golfers Elbow)

    • Medial Epicondyle Tendon Tear

  • Bursa Pain

    • Olecranon Bursitis (Bursa on the back of the Elbow)

  • Nerve Injury

    • Ulnar Nerve Injury

Hand & Wrist

  • Joint Pain

    • Wrist/Finger Arthritis

  • Ligament Pai

    • Wrist/Finger Ligament Sprain

  • ​​Tendon Pain

    • Wrist/Finger Tendon Tear/Tendinitis

  • Nerve Injury

    • Carpal Tunnel Syndrome

Hip/Pelvis

  • Joint Pain

    • Hip Joint Arthritis

    • Hip Joint Labral Tear

    • Pubic Symphysis Pain

  • Ligament Pain

    • Iliotibial Band Syndrome

    • Hip Ligament Sprain

  • Tendon Pain

    • Piriformis Syndrome/Tendonitis

    • Hamstring Tendon Tear/Tendinitis

    • Iliopsoas Tendon Tear/Tendinitis

    • Gluteal Tendon Tear/Tendinitis

  • Bursa Pain

    • Trochanteric Bursitis (Bursa on the outside of the Hip)

    • Ischial Bursitis (Bursa on the back of the hip at the Hamstring Tendons)

    • Iliopsoas Bursitis (Bursa on the front of the hip at the Hip Flexor Tendons)

  • Nerve Injury

    • Sciatic Nerve Injury

Knee

  • Joint Pain

    • Knee Joint Arthritis

    • Knee Meniscus Tear

  • Ligament Pain

    • Medial/Lateral Collateral Ligament Sprains/Tears

    • Anterior Cruciate Ligament (ACL) Sprains/Tears

    • Posterior Cruciate Ligament (PCL) Sprains/Tears

  • Tendon Pain

    • Patella Tendon Tear/Tendinitis

    • Quadriceps Tendon Tear/Tendinitis

    • Hamstring Tendon Tear/Tendinitis

  • Bursa Pain

    • Knee Bursitis (Numerous Bursa)

  • Nerve Injury

    • Peroneal Nerve Injury

Foot & Ankle

  • Joint Pain

    • Ankle/Foot Arthritis

  • Ligament Pain

    • Ankle Sprain

    • Plantar Fasciitis

  • Tendon Pain

    • Peroneal/Posterior Tibialis Tendonitis

    • Achilles Tendon Tear/Tendinitis

  • Nerve Injury

    • Tarsal Tunnel Syndrome

What is a Joint?

Human Joints are a point of the body at which two parts of the skeleton are fitted together. Different joints in the body have different functions. Some joints have lots of movement, such as the shoulder joints. Other joints move very little, such as the sacroiliac joints. All joints in the body degenerate with time, a condition commonly referred to as ARTHRITIS. Joint Arthritis may (but not always) cause pain. There are many possible treatments for arthritis, including anti-inflammatory medications, physical therapy, exercise, etc. However, if these treatments do not provide adequate relief, there are a variety of injections that can provide benefit for joint pain.

What is a Ligament?

Ligaments are strong bands of fibrous, connective tissue that connect two bones together. They provide stability to the joint. Because of their role in providing stability to the joint, ligaments can often become stressed and sprained. The most well know ligament sprains occur in the ankle, a condition with which most athletes are very well aware. Some sprains are severe enough that the ligaments will tear. Ligament sprains can cause significant amounts of pain and swelling. Like joints, there are many possible treatments for ligament injuries, including anti-inflammatory medications, physical therapy, exercise, etc. Ligaments can also be treated with a variety of injections that can provide benefit for swelling and pain.

What is a Tendon?

Tendons are strong cords of tissue that connect muscles tissues to bones. Tendons are vital to normal movement of the body. Tendons can be stressed and strained through injury trauma and normal wear and tear. Over time, many tendons in the body can start to develop microtears. Some tendons may develop significant tearing. Inflammation of the tendon is commonly caused tendonitis. Like joints and ligaments, tendon injuries can result in significant amounts of pain. There are many possible treatments for tendon injuries, including anti-inflammatory medications, physical therapy, exercise, etc. Tendons can be treated with a variety of injections that can provide benefit for inflammation and pain.

What is a Bursa?

Bursa Sacs are little sacs of fluid located throughout the body, designed to reduce friction between muscles and bones. As the body moves, tendons move back and forth over bones, which can cause damage and tearing to the tendons. Bursa lie between the tendons and bones to reduce the amount of wear and tear damage to tendons due to movement. Because of their function, bursa sacs are common sites of inflammation and pain. Bursitis can cause symptoms similar to tendonitis; most people that develop tendonitis also have some bursitis. Like tendonitis, there are many possible treatments for bursitis, including anti-inflammatory medications, physical therapy, exercise, etc. Bursitis can be treated with a variety of injections that can provide benefit for inflammation and pain.

How are Steroids different than PRP?

Steroids are powerful anti-inflammatory medications used to treat many conditions associated with inflammation such as arthritis, bursitis, tendinitis, etc. Steroids injections are commonly referred to as “Cortisone Injections.” These anti-inflammatory steroids are not the same type of steroids used by bodybuilders to gain lots of muscle. These steroid medications are purely used for their anti-inflammatory benefits.

Steroid injections are often used to treat the same conditions as PRP, however, steroid injections can only treat the inflammation associated with these conditions. There are times, when steroids can actually prevent the healing of tissues, and possibly even make the injury worse. Regenerative medicine attempts to not only treat the inflammation from the injury, but also attempts to heal that tissue to correct the underlying issue. By healing the tissue, there is a higher likelihood that the inflammation and pain will not return in the future.

Am I a candidate for a regenerative medicine injection?

Since platelet rich plasma is natural and taken from your own body, PRP is deemed safe, without significant risk or side effect. Any risks of the procedures are due more to the needle itself, as opposed to the substance being injected. Since PRP is your own body’s product and a more natural method of healing your body, almost everyone that is experiencing some form of dysfunction, is an “appropriate candidate” for regenerative medicine. 


There are a few recommended criteria needed to be considered a good candidate for a regenerative medicine injection. Usually, patients should have failed to improve with appropriate conservative measures. Conservative measures depend on the patient and the condition being treated. It may consist of treatments such as anti-inflammatory medications, steroid injections, physical therapy, chiropractic care, massage, etc. Prior to being considered a candidate, most candidates will need some form of imaging study (x-ray, MRI, ultrasound) to confirm history and exam findings.


If the condition being treated is predominantly inflammatory, then steroids injections can provide great benefit. However, if imaging shows significant tearing of the structures in the region of pain, then steroid injections are not an ideal choice. Steroid medications do not help heal tissue and they may actually cause more harm to tears. Steroids medication can weaken tissue, so having an injection at the site of significant tearing may make a tear worse. If imaging studies show tear of tendon, ligaments or cartilage, then it is wise to consider regenerative medicine injections over steroid injections to help treat the condition. 

In many cases, prior to proceeding with a regenerative medicine injection, a steroid injection is often attempted. When performed correctly, steroid injections can provide significant benefit in many cases in which inflammation is the primary reason for pain. Also, unlike regenerative medicine, steroid injections are often covered by insurance. The hope is that once the pain and inflammation is treated with the steroid injection, the body will be able to heal the affected area (our bodies have difficulty healing tissue with significant inflammation). Unfortunately, as stated previously, it is difficult for the body to heal many tissues naturally, as blood flow to the damaged regions (joints, tendons, ligaments) is often limited. Regenerative medicine provides a hopefully more effective way of delivering the natural healing supplies of the blood to the area of pain, by injection as opposed to normal blood flow.

Are PRP Injections painful?

Steroid injections are different than platelet rich plasma injections in terms of pain levels. Steroid medications do not cause much pain when injected. Platelet Rich Plasma, on the other hand, typically causes some mild to moderate discomfort during the injection. Blood products (we are basically injecting concentrated blood products) are very irritating to body tissues, including joints and tendons. PRP may cause a flare of pain after the procedure due to an increased inflammatory response. This increased inflammation in the region of the injection can help promote further healing, as increased inflammation usually means increased blood flow. Increased blood flow to regions of pain will bring in more healing components naturally to that area. Any pain after these injections can be helped by using ice, Tylenol or stronger pain medication. Your doctor may provide you with a prescription medication for pain to help after the injection.

Will the PRP Injection make all of my pain go away?

Research and clinical experience suggest that PRP can successfully treat chronic degeneration and tears of tissue tendons, and pain from joint articular cartilage degeneration. It is important to understand that PRP isn't a miracle cure. The Hospital for Special Surgery in NYC estimates that their success rate for the platelet-rich plasma treatment is between 60-75%. The Mayo clinic claims an 80% success rate. For a minimally invasive procedure for chronic painful conditions that are notoriously hard to heal, having a success rate over 50% is pretty impressive.


Please note that this success rate does not reflect a complete 100% improvement in pain. It is very difficult to improve chronic pain conditions completely. However, PRP does offer a natural way to significantly improve function in pain patients that have no other options to help pain. In an ideal world, everyone would get total pain relief from PRP injections. In reality, a significant decrease in pain and improvement in function is the major goal we are looking to achieve.

How long will it take to get pain relief after PRP?

This is another way that PRP and steroids are different from one another. Steroid medication usually starts to provide benefit for most people within 1-3 days after the injection, with a maximum benefit occurring between 7-14 days after the injection.


PRP offers no quick pain relief and has no pain-relieving properties. Minimal lidocaine medication is used for this injection, since anesthetic medications may affect the effectiveness of the PRP. It can take several weeks or months to notice the benefit of the PRP injection (it takes time for the damaged tissue to heal itself). Maximum effects can take up to 6 months to achieve. Since it takes longer for PRP to work than classic steroid injections, a second PRP injection, if needed, is usually given about 8-12 weeks after the first injection.

How long will the pain relief last after a PRP Injection?

Everyone responds differently to injections. Platelet Rich Plasma injections are designed to help regenerate injured tissue. If the PRP is able to heal tissue, there is a much higher likelihood that PRP will provide longer lasting relief than steroid injections. Steroid injections will provide pain relief as long as inflammation remains low. PRP injections, if they regenerate/heal tissue as hoped, can provide a possible more permanent solution to pain.

Can I have any type of sedation for this procedure?

Most of these injections are performed in the office/clinic setting, so having IV sedation is not an option. You may take pain medication prior to the injections (Not NSAIDs), if you have a responsible driver to take you home after the procedure. If there is a good reason why sedation is required for you (such as an extreme fear of needles), then it may be possible to set this procedure up in a surgical center that is able to provide you with some IV sedation. Feel free to discuss this with your doctor at your visit.

How many PRP Injections will I need?

This will vary from person to person depending on numerous factors. After the injection, you will follow up with your physician about 4-6 weeks after the injection. This amount of time allows the injection to heal damaged tissue. The determination if you will need a second injection is based on your response to the first injection. If you got significant improvement in pain and function after the first injection, no further action is required. If you did not get as much improvement as expected, doing a second injection may provide an additional benefit. Treatment options will be discussed at your follow up visit. Some patients require more than one injection in the same location to get adequate tissue healing.

What if the PRP Injection does not help my pain?

If the injection does not help your pain, then your doctor will re-evaluate you at your follow up appointment and discuss other treatment options. There are several possible reasons why the PRP injection was not successful. Examples include:

  • Some people require more than one injection to get adequate pain relief.

  • There may be another source of pain causing your symptoms.
  • Injections do not help everyone. It is possible that some patients just do not respond well to injections.
  • If you have severe condition, injections may not be beneficial. PRP is much more effective in healing mild to moderate damaged tissue. Severely damaged tissue may not heal without surgical intervention.

Will I eventually need surgery for my condition?

Possibly. The goal of our clinic is to prevent surgical intervention, if possible. Surgery is usually only considered an option if the pain is so severe that it limits function/mobility despite going through all conservative treatments. The only other time surgery is recommended would be if not doing surgery could result in severe damage to the area of pain. Your provider will help determine when surgery is right for your condition. 

What should I do before the Procedure?

Do not take NSAID medications (advil, ibuprofen, aleve, naproxen, Mobic, meloxicam, etc.) for 10-14 days prior to the procedure. NSAID mediations affect your platelet function. To ensure that platelets are functioning optimally for the injections, holding NSAIDs prior to the injection is prudent. If desired, you may take a different type of pain medication that does not affect your blood platelets. Ask your physician which medications would be acceptable to take prior to the procedure.


Drink at least 4 eight oz glasses of water the night before the procedure. This will make drawing your blood easier on the day of your procedure.

What can I expect on the day of the procedure?

Before your procedure, your doctor will explain all the risks and benefits of the procedure with you and you will have an opportunity to ask as many questions as you would like to ask. Once you agree to proceed with the injection, you will sign a consent form authorizing the injection, stating that you understand the risks and benefits of the injection. There are no restrictions in terms of eating or taking medication prior to the procedure.  You may take pain medication prior to this procedure.

Take it easy on the day of the injection.  You can do normal every day activity, but we recommend that you do not do any strenuous activity. You can ice the area of the injection for 20 minutes on and 20 minutes off after the injection. You may take pain medications to help with pain after the injection. Wait about 2 weeks before returning to a light exercise and stretching program (as to not damage new tissue being formed). Typically, you will be seen in the office about 4-6 weeks after the procedure to assess the response of the PRP injection.


Just before the injection, an IV will be placed in your arm and blood will be collected in a tube. The exact amount of drawn blood needed is determined by the type and number of injections being performed. Your blood will then be placed in a centrifuge machine to concentrate the platelets in the plasma. The injection site will be cleaned and marked. The PRP will be injected at the site of pain or injury, usually under ultrasound guidance to ensure proper needle tip placement. At the conclusion of the procedure, you will wait around for 5-10 minutes to ensure that you do not feel poorly after the injection. It is often recommended that you bring a driver with you to take you home as you may have some increased pain after the procedure.


What should I expect after the Procedure
The site of the injection may be moderately painful after the injection. This pain is due to the increased inflammation in the tissue as a result of the injection (expected). Inflammation brings more blood flow to the region, also aiding in repair of the damaged tissues. This increased pain and soreness can last up to 2 weeks after the injection. It is usually recommended to take the rest of the day off work. Depending on the type of injection, more than one day off may be needed.


NSAID medications should be avoided for 2 weeks after the injection due to their affected on the injected platelets. We want to make sure the injection is as effective as possible. Even though you cannot use NSAIDs, it is ok to take other approved pain medications.  Your doctor may prescribe these medications to take prior and after your procedure.


For the first two days after the injection, it is advised that you perform only minimal activity (couch potato).  You can return to normal activities of daily living after those first 2 days. Other more strenuous activities (running, cycling, hiking, etc) can usually resume after 2 weeks.  If you are an athlete, your doctor will help map out a return to sport program based on the site of your injection and the particular sport that you play.

What are the risks of this procedure?

With any procedure, there are possible risks, side effects, and complications. Below is a brief list of possible risk and complications after a PRP injection. When performed by a well-trained physician, the following risks are minimal.

Pain: Most Common Risk. It’s not uncommon to have some increased pain from this procedure. If you do have some increased pain after the injection, talk to your doctor about ways to reduce this discomfort. Usually, any increased pain will last less than 24 hours after the injection. 

Bruising: Any injection can cause some superficial bruising on the skin. Resolves spontaneously.

Infection: Minimal Risk. Our staff take great care and time to ensure that the skin surface is cleaned thoroughly prior to the injection to minimize this risk. All needles are opened prior to your injection and discarded after the injection. There is no reusing of any injection supplies from previous patients.

Bleeding: Usually any bleeding stops spontaneously on its own.

Nerve Damage: Very rare. Injections are done under ultrasound guidance if nerve could possibly be injured.

Does insurance cover this procedure?

Insurance does not typically cover PRP injections. Even though there has been a lot of research to support the benefits of PRP, insurance companies still consider this procedure “experimental”. Hopefully this will change in the future, but at this time, it is a cash service.

How much does a PRP injection cost?

The cash price of a PRP injection for a single location is $600 for this office. Most of the cost of this injection buys the supplies needed to draw the blood and separate the blood components. The remaining portion of this cost goes towards the doctor’s professional fee and cost of the injection equipment used to perform the injection. If there is more than one site being injected, then the cost is usually about $100 extra per site (as long as we don’t have to use a second PRP kit).

Are exclusion criteria where PRP is not recommended?

There are couple patients that should not have PRP injections. Chronic use of blood thinners, need for chronic use of anti-inflammatory medications, inability to tolerate blood draws, severe anemia, low platelet count, abnormal platelet function, active systemic infection or active cancer are all contra-indications to PRP injection.