PRP - Platelet-Rich Plasma Therapy
What is PRP?
Maybe the acronym PRP is unfamiliar to you; it’s one of the
newer sports injury treatments. PRP, or “platelet-rich plasma,” is a non-surgical treatment for chronic sports and musculoskeletal injuries that is taking the sports medicine and orthopedic community by storm. Professional and recreational athletes alike credit PRP treatment for enabling them to get back in the game, and patients with joint arthritis are experiencing less pain and greater function.
Dr. Tortland has been performing PRP treatments since December 2007, making him among the first--and most experienced--physicians in the country offering this treatment.
Why Does PRP Work?
Platelets are a specialized type of blood cell. Blood is made up of
93% red cells (RBCs), 6% platelets, 1% white blood cells (WBCs), and plasma. The goal of PRP is to maximize the number or concentration of platelets while minimizing the number of RBCs. Generally speaking, the higher the concentration of platelets, the better.
Most people associate platelets with clot formation. While that
certainly is an important function of platelets, they are also very much
involved in injury healing. Human platelets are naturally extremely rich in connective tissue
growth factors. Injecting these growth factors into damaged ligaments, tendons, and joints stimulates a natural repair process. But in order to
benefit from these natural healing proteins, the platelets must first
be concentrated. In other words, PRP recreates and stimulates the
body’s natural healing process.
How is PRP Done?
In the office, blood is drawn from the patient (just like getting a blood test) and placed in a
special centrifuge. The centrifuge separates the RBCs, and the remaining platelets and plasma are then highly concentrated. The red blood
cells are discarded, and the resulting platelet concentrate is used for
Unlike many other practices, at Valley Sports Physicians all of our PRP injections are given under direct ultrasound guidance to insure accurate placement of the platelet concentrate in the damaged area. In fact, Dr. Tortland is a nationally-recognized expert in musculoskeletal ultrasound.
The entire treatment, from
blood draw, to solution preparation, to injection, takes 30-40 minutes. Before injections are given the skin and underlying tissue is first anesthetized to minimize the discomfort.
BEWARE - Not All PRP Is The Same!
Currently there are over half a dozen companies making & selling
commercial PRP preparation systems, of course with each company claiming
that their PRP is the best! PRP products can vary widely in terms of platelet concentrations, the presence or absence of red blood cells (RBCs), the presence/absence of white blood cells (WBCs), and the volume of PRP created.
Some PRP is not much better than whole blood or platelet poor plasma, with very low platelet concentrations. Much of the commercial PRP is rich in RBCs, which have been shown to kill as many as 15% of synovial cells inside a joint. Many PRP products contain high amounts of inflammatory WBCs, contributing to increased post-injection pain.
At Valley Sports Physicians we spent a year researching and pioneering a new method of creating a high quality PRP, containing an average of 1.5 million platelets per microliter (well above the commercial PRP average), essentially free of RBCs, and containing helpful pro-growth WBCs while eliminating the inflammatory WBCs. Our method was validated via independent clinical laboratory testing. So you can be assured that the PRP product you receive from us is the absolute highest quality, purity, and effectiveness currently available. When you're spending hundreds of dollars on a treatment, you want to be sure that you're getting the best possible product!
How Often are Injections Given?
In most cases, after the initial treatment, a follow up visit is scheduled 6-8
weeks later to check on healing progress. Some patients respond very well to just one treatment.
However, typically 2-3 treatments are necessary. Injections are given every 8-12 weeks on average. In rare cases, such as more severe hip arthritis, PRP injections may be given once every 4 weeks for 2-3 treatments.
What Conditions Benefit From PRP?
PRP treatment works best for chronic ligament and tendon
sprains/strains that have failed other conservative treatment,
- Rotator cuff injuries, including partial-thickness and full-thickness tears
- Shoulder pain and instability
- Tennis & golfer’s elbow
- Hamstring and hip strains
- Knee sprains and instability
- Patellofemoral syndrome and patellar tendinosis
- Ankle sprains
- Achilles tendinosis & plantar fasciitis
- Knee, hip, and other joint osteoarthritis
- Sports hernias & athletic pubalgia
- Other chronic tendon and ligament problems
- Nerve entrapment syndromes, such as Carpal Tunnel Syndrome
In addition, PRP can be very helpful for many cases of osteoarthritis
(the "wear & tear" kind). PRP can help stimulate a "smoothing over" of the roughened and arthritic cartilage, reducing the pain and disability of arthritis. This includes:
- Knee arthritis
- Hip joint arthritis
- Shoulder arthritis
- And other joint arthritis
Is PRP Covered by Insurance?
Most insurance plans, including Medicare, do NOT pay for PRP injections.
Do PRP Injections Hurt?
The level of discomfort of the treatment depends in part on the area being treated. For example, injections given into a joint often are minimally uncomfortable and in some cases painless. Injections given into tendons tend to be more uncomfortable. There is usually moderate pain for the next
For the first week after the injections it is critical to
avoid anti-inflammatory medications, including Advil, Motrin,
ibuprofen, Aleve, Celebrex, and Mobic. These will interfere with the healing
response. Tylenol is OK. Your doctor may prescribe pain medication also for post-injection discomfort.
When Can I Expect to See Improvement?
On average, most patients start to see signs of improvement anywhere from 4-8 weeks after treatment. This can be less overall pain, an ability to do more activity before pain sets in, and/or faster recovery from pain.
Are There Risks With PRP?
Anytime a needle is placed anywhere in the body, even getting blood
drawn, there is a risk of infection, bleeding, and nerve damage.
However, these are very rare. Other complications, though rare, can
occur depending on the area being treated, and will be discussed by
your doctor before starting treatment. Because PRP uses your own blood, you cannot be allergic to it.
What is the Success Rate?
Studies suggest an improvement of 80-85%, though some arthritic joints, namely the hip, do not respond as well. Some patients experience
complete relief of their pain. In the case of tendon and ligament injuries the results are generally permanent. In the case of joint arthritis, how long the treatment lasts depends partly on the severity of the condition. Mild arthritis may not need another round of treatments. More advanced arthritis, on the other hand, typically requires a repeat course of treatment, usually in 1-3 years.
Will PRP Regrow New Cartilage In My Joint?
The goal of PRP treatment is to reduce pain and to improve function. While there is some weak evidence that treatment occasionally does result in increased cartilage thickness, the important point to keep in mind is that the cartilage lining the joint surfaces has no pain fibers! For example, often we see patients with knee or hip arthritis where the joint that does NOT hurt has WORSE arthritis on x-ray! Pain from arthritis is very complex and involves far more than just how thick the cartilage is.
Will PRP Help Me Avoid A Joint Replacement?
This is a frequently asked question. In the case of mild arthritis, PRP treatment may halt the development of further arthritic decay. However, in advanced arthritis, as noted above the goal of treatment is to reduce pain and improve function. In some cases the arthritis is so severe that PRP is not a viable option. In severe or advanced osteoarthritis PRP treatments may help delay the eventual need for a joint replacement, but it is rarely a treatment that eliminates the need for it. Some patients are not surgical candidates because of other medical conditions. Other patients simply do not want joint replacement surgery under any circumstance. In these cases PRP may be a viable treatment option, but it is not a permanent solution in these specific situations--treatments will need to be repeated periodically.
What Does PRP Treatment Cost?
At Valley Sports Physicians the cost of PRP treatment is based on the level of complexity involved in treating a given area(s). Prices range from $700 to $1100 per treatment. If two joints or areas are treated at the same time, the cost is NOT double-- there is a slight increase.
What Does the Research Say?
The last 10 years has seen an explosion in research dedicated to investigating the potential benefits of PRP. One problem with PRP research, however, is that often investigators do not specify what the quality & character of the PRP used. See the discussion above, "Not All PRP is the Same!"
Below are some summaries from a few representative research studies:
Peerbooms et al in 2010 compared a single PRP injection to a cortisone injection for the treatment of chronic tennis elbow. 51 patients received the PRP injection while 49 received a cortisone injection. At one year follow up 73% of the PRP subjects were significantly better, compared to only 51% of the cortisone injection subjects. Of note was the observation that those receiving the cortisone injection felt better initially than the PRP group, whereas the PRP group progressively improved. Their conclusion: "Treatment of patients with chronic lateral epicondylitis with PRP reduces pain and significantly increases function,
exceeding the effect of corticosteroid injection." (Peerbooms et al. Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial. Am J Sports Med. 2010;38(2):255-262).
In a 2011 study by Hechtman & colleagues, 30 patients (31 elbows) with epicondylitis unresponsive to nonsurgical treatment (including steroid injection) for >6 months received a single PRP injection. Results: Patient satisfaction scores improved from 5.1±2.5 at 1 month to 9.1±1.9 (on a scale of 1-10)
at 1-year follow-up. Only 1 patient reported no improvement
after 6 months. Results suggest that a single platelet-rich plasma injection can improve pain and function scores, thus avoiding surgery. (Hechtman et al. Platelet-rich plasma injection reduces pain in patients with recalcitrant epicondylitis. Orthopedics. 2011 Jan 1;34(2):92.
In 2012 Rha & associates compared PRP treatment to dry needling for the treatment of chronic rotator cuff tendinitis. 39 patients were randomized to receive either 2 PRP injections 4 weeks apart, or 2 dry needling treatments, also 4 weeks apart. All treatments were done under ultrasound guidance. Conclusions: "Autologous platelet-rich plasma injections lead to a progressive reduction in the pain and disability when compared to dry needling. This benefit is certainly still present at six months after treatment. These findings suggest that treatment with platelet-rich plasma injections is safe and useful for rotator cuff disease." (Rha et al. Comparison of the therapeutic effects of ultrasound guided platelet-rich plasma injection and dry needling in rotator cuff disease: A randomized controlled trial. Clin Rehab. 2012;27(2):113-122.)
Chronic Plantar Fasciitis:
Monto in 2014 looked at the effectiveness of PRP for recalcitrant plantar fasciitis. Forty patients (23 females and 17 males) with unilateral chronic plantar fasciitis that did not respond to a
minimum of 4 months of standardized traditional nonoperative treatment modalities were prospectively randomized and
treated with either a single ultrasound guided injection of 3 cc PRP or 40 mg DepoMedrol cortisone. Patients were evaluated at 3, 6, 12, and 24 month after treatment. Those receiving the cortisone injection felt better initially than the PRP group, but their improved waned and their pain returned completely to baseline by 12 months. Those in the PRP group, on the other hand, continued to experience gradual improvement and were markedly better at 12 and 24 months. Conclusion: "PRP was more effective and durable than cortisone injection for the treatment of chronic recalcitrant cases of plantar fasciitis. (Monto RR. Platelet-rich plasma efficacy versus corticosteroid injection treatment for chronic severe plantar fasciitis. Foot & Ankle International. 2014;35(40):313-318.)
A 2014 study by Hamid et al looked at effectiveness of PRP injections for Grade 2 hamstring injuries. 28 patients with acute hamstring injuries were randomly assigned to receive either a PRP injection in combination with a rehab program, or a rehab program only. The primary outcome measure was time to return to play, while secondary measurements included pain severity and interference with activity from pain. Results: Patients in the PRP group had an average return to play time of 27 days, while the rehab-only group took 42 days. The PRP group also had significantly lower pain scores throughout the study. (Hamid et al. Platelet-rich plasma injections for the treatment of hamstring injuries: a randomized controlled trial. Am J Sports Med. 2014;42(10):2410-2418.)
Volpi et al treated the affected knees of 8 athletes (10 knees) with chronic patellar tendinosis that had failed to respond to conservative treatment and who were considering surgical intervention. Patients received a single ultrasound-guided PRP injection into the damage patellar tendon. At follow up in 120 days all subjects reported an average 91% improvement, and MRI showed interval healing. (Volpi et al. Treatment of chronic patellar tendinosis with buffered platelet-rich plasma: a preliminary study. Medsport. 2007;60:595-603.)
Cerza & associates compared PRP injections to hyaluronic acid (HA) injections for the treatment of knee osteoarthritis in 2012. 120 patients were randomly divided into 2 groups. One group received 4 weekly injections of PRP, while the other group received 4 weekly injections of HA. Patients were evaluated at 4, 12 and 24 weeks after the 1st injection. Results: Treatment with PRP showed a statistically significant better clinical outcome than did treatment with HA. Of note was that patients with more severe arthritis (Grade III-IV) did not see improvement with HA, whereas severity of disease did not matter with respect to improvement with the PRP. (Cerza et al. Comparison between hyaluronic acid and platelet-rich plasma, intra-articular infiltration in the treatment of gonarthrosis. Am J Sports Med. 2012;40(12):2822-2827.)
Gobbi et al also looked at the effectiveness of PRP for knee osteoarthritis. 50 patients were treated with 2 PRP injections, 1 month apart. 25 patients had previously undergone surgery for cartilage lesions. Results: All patients showed significant improvement in all measured scores at 6 & 12 months and returned to previous activities. No difference in improvement was found among various subgroups (prior surgery vs. no surgery, severity of disease, age). (Gobbi et al. Platelet-rich plasma treatment in symptomatic patients with knee osteoarthritis: Preliminary results in a group of active patients. Sports Health
Sanchez & co. looked at PRP for hip osteoarthritis in 2012. 40 patients with severe hip were included. Each subject received an injection of PRP into the affected hip once a week x 3 weeks. Patients were evaluated at 7 weeks and 6 months. 60% of subjects reported a positive response (characterized by at least a 30% improvement in symptoms). 40% of those who had a favorable response were classified as "excellent responders." Conclusions: "This preliminary non-controlled randomized prospective study supported the safety, tolerability and efficacy of PRP injections for pain relief and improved function in a limited number of patients with OA of the hip." (Sanchez et al.
Ultrasound-guided platelet-rich plasma injections for the treatment of osteoarthritis of the hip. Rheumatology. 2012;51:141-150.)
The medical benefits of ozone are well documented, and ozone use is very popular in other parts of the world, including Europe, South America, and Russia, where the need for inexpensive, yet highly effective, treatments is paramount.
Dr. Tortland has recently begun to incorporate ozone into his PRP and stem cell treatments. For more information about our use of ozone therapy, see our Prolozone and Ozone Therapy page.
In the case of moderate-to-large tendon and muscle tears, such as rotator cuff, tennis elbow, and Achilles, simple PRP may be less effective because the liquid PRP has less tendency to stay in the tear; it leaks out. In order to combat this we often will combine PRP with fat to create a gel that fills the defect and promotes more effective healing.
Likewise with more advanced joint arthritis, the fat acts a matrix to help hold the platelets in place and also helps activate them to release their growth factors more effectively. Think of a garden trellis that helps hold a growing vine in place. In fact, for moderate-to-advanced arthritis, our standard treatment is to combine the PRP with the fat due to the fact that it seems to work that much better than PRP alone.
The fat is harvested from the patient's belly, buttocks, "love handles," or hips using a gentle liposuction technique. (The amount harvested generally is NOT enough to have a cosmetic effect.) The fat is concentrated via centrifuge, and the resulting fat concentrate is subsequently mixed with the PRP to create a gel. The gel fills the tear in the case of tendons/muscles, and helps maintain more constant contact with the joint surfaces in the case of arthritis.
Fat grafting adds an additional $1000 to the cost of treatment.
Nutrition & Rehabilitation
Healing is a caloric-demanding task. The body expends energy trying to repair itself. It is important, therefore, to optimize your nutritional status, preferably before you undergo treatment. Ensuring adequate protein, eliminating (or at least significantly reducing) consumption of sugar and sugar-containing products, and adding healthy fats are essential components of a healing diet. Specifically, minimum protein intake consists of at least 0.5g protein per pound of body weight per day. For a 150 lb person that's 75 grams of protein daily, evenly divided among breakfast, lunch, dinner, and an evening snack. If you exercise your protein needs go up, to as much as 1.0g per pound of body weight daily.
As a general rule of thumb, 1 oz of chicken, beef, or pork contains 7 grams of protein, wheres fish has 5 grams per ounce. For a more complete discussion of protein requirements, see AuthorityNutrition.com.
Healthy fats include avocado, organic coconut oil, olive oil, organic peanut butter, organic butter, and organic raw (not pasteurized) milk. Contrary to popular belief, eating fat does NOT make you fat.
To get maximum benefit from the treatment, and to help prevent
re-injury, a specially-designed rehabilitation and exercise
program may incorporated into your treatment. This helps the newly
developing connective tissue mature into healthy and strong tendon or
ligament fibers. In addition, nutritional support, such as glucosamine, MSM, and increased protein intake can help the healing process.
PRP can be a very effective and relatively cost-efficient treatment alternative for persons suffering from painful musculoskeletal conditions. However, because it is still a relatively new treatment, there are many practitioners who are newcomers to the party. Therefore, it is important that patients choose a practitioner who:
- Has demonstrated experience and a successful track record in performing PRP injections
- Uses a high quality PRP product
- Does all PRP injections under ultrasound guidance (and who is similarly highly skilled in using ultrasound!) to insure that PRP is actually going where it's supposed to!
We work with patients throughout New England and the Northeast and beyond by using PRP as one of our treatments. Please call us at 860.675.0357 to learn more and schedule an appointment.