Stem Cell Injection Therapy
One of the most exciting recent developments in the treatment of chronic musculoskeletal conditions is the use of adult mesenchymal stem cells (MSCs).
Drs. Tortland & Kozar were the first in New England to offer this treatment and they remain the region's leaders in office-based stem cell treatment for musculoskeletal conditions.
What are Adult Mesenchymal Stem Cells?
Stem Cells are undifferentiated cells that have the potential to become other, more specialized types of cells. Stem cells are broadly categorized as either "embryonic" or "adult." As the name implies, embryonic stem cells are derived from human fetuses, whereas adult stem cells are obtained from, well, adults!
Currently there are over 70 proven therapies using adult stem cells, while there are none using embryonic stem cells. This is in part because scientists have had tremendous difficulty controlling how embryonic stem cells differentiate; they have a nasty habit of causing tumor formation, including teratomas. Adult stem cells, on the other hand, do not suffer from this pitfall.
Mesenchymal stem cells, or MSCs, are multipotent stem cells that can differentiate into a variety of cell types, including: osteoblasts (bone cells), chondrocytes (cartilage cells) and adipocytes (fat cells). This has been demonstrated in ex vivo cultures and in vitro or in vivo. MSCs are obtained from the bone marrow, most commonly the back of the iliac crest (the "hip bone"), and less commonly from the tibia (the shin bone).
MSCs can differentiate into many different cell types, as indicated in the diagram below.
How Are MSCs Obtained?
Harvesting MSCs for injection therapy is done right in the office. The skin is numbed first with a little Novocain. Next, the hip bone is numbed with more Novocain. A special needle is then passed through the cortex of the bone into the marrow cavity. This is a painless procedure in most cases. The liquid marrow is then very slowly drawn into a syringe. Once an adequate amount of liquid marrow is obtained, the needle is removed and a bandage applied.
The syringe containing the liquid marrow next is placed in a special centrifuge. The marrow is spun and the stem cells are highly concentrated and passed into a new syringe from which the injection(s) are given.
The entire procedure takes about an hour and is minimally uncomfortable.
How Are Stem Cell Injections Given?
All of our stem cell, PRP, and prolotherapy injections are given under direct ultrasound guidance
. We first numb the skin with a little Novocain. Then, using ultrasound, we guide the needle to the precise location and inject the stem cells. The ultrasound guidance insures both accurate and safe injections. (Drs. Tortland & Kozar are nationally-recognized experts in musculoskeletal ultrasound.)
Following injection, for weight bearing joints (ankles/feet, knees, hip) patients need to avoid bearing weight for 24-48 hours. But it is critical that the joint NOT be immobilized. Gentle protected movement is critical to stimulate healing. For non-weight bearing joints, gentle protected movement is generally encouraged, but forceful or aggressive activity, such as sports, is prohibited. Your doctor will give you more specific post-injection activity guidelines.
In our office, in cases where the stem cells will be injected into a joint, we prefer to perform a dextrose Prolotherapy
treatment first, 3-4 days before the stem cell procedure. The prolotherapy helps prepare the joint biologically for the healing process generated by the stem cells.
About 2 weeks after the stem cell procedure, a PRP injection
is commonly given. This helps keeps the stem cells active. Another PRP treatment may then be given about 2 months later.
How Often are Injections Given?
In most cases, patients respond very well to just one round of treatment.
However, 2-3 treatments may be needed in very severe cases. Treatments are never given more frequently than every 3-6 months.
What Conditions Might Benefit From Stem Cell Injections?
Stem cell injections are most commonly used for the treatment of conditions that have failed or responded incompletely to other more conservative treatments. Conditions include, but are not limited to:
- Osteoarthritis of the joints
- Chronic partial Rotator Cuff tears
- Persistent partial tendon tears, such as tennis elbow, plantar fasciitis, quadriceps and patellar tendon tears.
- Partial muscle tears
- Meniscal (cartilage) tears in the knee
- Chondromalacia patella (patellofemoral syndrome)
Are There Risks Associated With Stem Cell Treatment?
Any injection is potentially at-risk for causing infection, bleeding, nerve damage. Risks will also vary depending on the structure(s) being injected. However, because we are using your own cells
, you cannot be allergic to the treatment! Also, because the injections are done under ultrasound guidance, the risks of damaging surrounding structures, or of injecting the wrong location, are almost completely eliminated. Your doctor will review the complete risks of treatment with you. Nonetheless, the risks of treatment are extremely
Are Stem Cell Treatments Covered by Insurance?
Currently stem cell injections are still considered experimental. Most insurance plans, including Medicare, do NOT pay for stem cell injections.
When Can I Expect to See Improvement?
On average, most patients start to see signs of improvement anywhere
from 4-8 weeks after the completion of the complete treatment protol. This can be less overall pain, an
ability to do more activity before pain sets in, and/or faster recovery
What is the Success Rate?
Studies suggest an improvement rate as high as 80-85%, though some arthritic
joints, namely the hip, do not respond as well (60% at best). 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 Stem Cells Regrow New Cartilage In My Joint?
The goal of 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
Will Stem Cell Treatment Help Me Avoid A Joint Replacement?
This is a frequently asked question. In the case of mild arthritis,stem cell 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 stem cell treatment is not a viable option. In severe or advanced
osteoarthritis stem cell treatment 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 stem cell treatment 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 Stem Cell Treatment Cost?
At Valley Sports Physicians the cost of stem cell treatment is based on the
level of complexity involved in treating a given area(s). In addition, the cost of the stem cell treatment reflects the cost of the complete treatment protocol, as outlined below:
- Pre-stem cell prolotherapy treatment (for arthritic joints only): $200-$400
- Stem cell treatment: $2000-$2400 (A
cash discount of $50 is given if payment is made at the time of
- Post-stem cell PRP treatment (for arthritic joints only): $700-$900 (A
cash discount of $50 is given if payment is made at the time of
- Tendon or ligament: $2000-$2400
- Arthritic joint: $2900-$3700
In the case of moderate-to-large tendon and muscle tears, such as
rotator cuff, tennis elbow, and Achilles, stem cell treatment alone may be less
effective because the liquid stem cell solution has less tendency to stay in the tear;
it leaks out. In order to combat this we often will combine stem cells with
fat concentrate to create a gel that fills the defect and promotes more effective
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 stem cell solution with the fat due
to the fact that it seems to work that much better than stem cells alone 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 stem cells 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 $700 to the cost of treatment.