Platelet rich plasma injections also known as PRP have garnered significant attention for their remarkable results. It’s derived from your own body and uses its natural healing mechanisms to alleviate joint pain, treat tendon injuries, and accelerate your recovery.
But with so much buzz, you've got to wonder: what's the real story behind this seemingly miraculous therapy? Can it truly deliver on its promises, or is it just another passing fad?
In this deep dive, we'll be covering everything from how PRP works and its potential benefits, to the risks, costs, and clinical evidence behind it all. We’ll discuss what you need to do to prepare for a PRP injection as well as go over a sample recovery protocol for after your treatment.
We’ll compare PRP injections to other common treatments such as cortisone and even discuss how platelet rich plasma compares to stem cells. The goal is to equip with all the knowledge you need to make an informed decision about whether PRP injections are right for you.
What is platelet rich plasma (PRP) therapy?
Let’s first start with, what is platelet rich plasma? PRP is an innovative treatment that involves the use of a patient's own blood to promote healing and induce recovery in various areas of the body.
The process starts with a simple blood draw. Once collected, the blood is placed in a centrifuge, which spins at high speeds to separate the blood components. This separation results in three main layers: red blood cells at the bottom, a thin layer of white blood cells and platelets in the middle called the 'buffy coat,' and the liquid portion, or plasma, at the top.
It's the middle layer, rich in platelets and growth factors, that we are particularly interested in. Platelets are tiny cell fragments in our blood that play a crucial role in clotting and tissue repair. The growth factors they release help to stimulate tissue healing, tissue remodeling, tissue proliferation, and most importantly, in controlling pain and inflammation.
Platelet rich plasma is considered to have a platelet concentration of at LEAST 4 to 6 times that of baseline values. By concentrating these platelets and injecting them into a target area, PRP therapy is believed to kick-start the body's natural healing processes. All of this makes platelet rich plasma a promising alternative to more invasive procedures like surgery.
With that said, it’s worth pointing out what PRP can accomplish and more importantly, what it can’t do. PRP therapy can effectively treat a variety of orthopedic conditions, including tendon injuries, muscle strains, ligament sprains, and joint inflammation. It has been particularly successful in addressing chronic tendinopathies and chronic overuse conditions, such as tennis elbow, golfer’s elbow, gluteal tendinopathy, and plantar fasciitis.
PRP has also been extremely successful at reducing pain and symptoms related to osteoarthritis. Other studies have shown that NFL football athletes treated with platelet rich plasma for muscular injuries have a quicker return to play.
However, it’s important to point out that PRP is not stem cells. We’ll discuss the differences between platelet rich plasma and bone marrow derived mesenchymal stem cells as well as adipose derived mesenchymal stem cells later in the video.
It’s also essential to understand that PRP therapy is not a magic cure-all. It cannot reverse joint damage such as in osteoarthritis, nor can it replace the need for surgery in cases where there is a complete tear of a tendon or ligament. PRP therapy is most effective when used as part of a multimodal treatment plan that includes exercise and physical therapy, activity modification, and other nonsurgical treatments.
How are platelet rich plasma injections performed?
So the first thing we’re going to talk about is how are platelet rich plasma injections performed? Start to finish, the entire process takes less than one hour with the longest part being the blood draw and the processing time.
The first step is the blood draw. The amount of blood that is needed varies based on the target treatment area. Larger structures such as knees and hips typically require a higher dose of platelets and therefore needs a larger blood draw. Multiple treatment areas on the same day also require a larger blood draw.
The blood sample is then put in a special tube and placed in a centrifuge. There are a number of different centrifugation techniques, including single spin and double spin protocols, and most take about 15 to 30 minutes to process. Once the platelets are separated, they are combined with a small amount of plasma to create the platelet rich plasma solution.
The treatment area is then cleaned and sterilized to minimize the risk of infection. A small amount of local anesthetic may be used to numb up the treatment area and reduce discomfort during the procedure. Once the area is prepped, a physician will inject the PRP solution under imaging guidance into the injured area or damaged tissue.
I want to point out here that imaging guidance is essential for platelet rich plasma injections. It doesn’t matter how many years of experience your doctor has. Even the most skilled and seasoned orthopedic providers can miss their injections. And you certainly don’t want to be the one that they miss.
To illustrate my point, here is a comparison of accuracy for common injections using ultrasound guided and landmark based techniques. The data speaks for itself. Landmark based accuracies often range in the low to mid 60’s. Accuracy with ultrasound guidance is almost always guaranteed. The last thing you want to do is undergo a medical procedure only for your health care provider to do a landmark based injection and then miss the target.
Body Area | Ultrasound Guided Accuracy | Landmark Based Accuracy |
Glenohumeral joint | 92% | 72% |
Acromioclavicular joint | 90-100% | 17-72% |
Biceps tendon | 87% | 27% |
Elbow joint | 91% | 64% |
Hands and wrist joints | 94-100% | 59-82% |
Hip joint | 97-100% | 67-78% |
Knee joint | 96-100% | 55-100% |
Foot and ankle joints | 100% | 58-100% |
Are PRP injections painful?
All musculoskeletal injections involve the use of a needle, which can cause some discomfort. To minimize this, I typically employ a combination of techniques. First, I utilize an ethyl chloride cold spray to desensitize the skin. Then, I administer ropivacaine, which is a local anesthetic, to numb up the area. Ropivacaine is preferred over other common anesthetics like lidocaine and bupivacaine because it has fewer cytotoxic effects and is less likely to interfere with the effectiveness of the PRP.
It is important to note that while we administer the numbing medicine underneath the skin and down to the target area, we do not inject it directly into the target area. This precaution is taken to ensure that the local anesthetic does not interfere with the effects of the PRP.
Joint injections are typically well tolerated and result in only mild discomfort. However, tendon injections can be more uncomfortable. This is because most tendon treatments involve a small degree of needle tenotomy, which requires inserting the needle directly into the affected tendon to mechanically disrupt or break up damaged or degenerated tissue. Since only a minimal amount of local anesthetic is used in this procedure, the needle tenotomy can lead to increased discomfort and pain.
What can I expect after a platelet rich plasma injection?
Ok so what can you expect after a platelet rich plasma injection? For most PRP injections, you are able to drive yourself home afterwards. This is something that you will want to discuss with your treating provider prior to the procedure.
What’s really important to understand is that some soreness or pain at the injection site is normal and expected. Many people will actually get worse before things get better. This is especially true for soft tissue injections such as tendons and ligaments.
This is because activation of platelets and release of growth factors in the soft tissue will result in a local inflammatory reaction. This entire process is self limiting and will resolve on its own within a week.
With that said, this local inflammatory response can be rather uncomfortable. And here’s the key thing. You cannot take any NSAID medications to help reduce the pain. Common medications in the NSAID class of drugs include aspirin, ibuprofen, naproxen, diclofenac, and indomethacin. These medications interfere with platelet function and can blunt the effects of your PRP.
This study found that NSAIDs taken after a PRP injection resulted in significantly worse outcomes when compared to no NSAIDs. You’ll want to avoid all these medications for at least 2 weeks after the injection and, if you can, up to 6 weeks post injection.
So what are you supposed to do if you have some post injection pain but you can’t take NSAIDs? It is perfectly acceptable to take acetaminophen, or Tylenol. Tylenol works by relieving pain through a different mechanism.
However, some studies like this one do suggest that even acetaminophen can potentially affect platelet function, just to a significantly less degree than NSAIDs. Whether this truly affects outcomes is still unknown. As of right now, I do advise my patients that if they have discomfort after their injection, they can take 1 or 2 extra strength Tylenol every 8 hours to ease the pain.
In addition to taking Tylenol, there are a few other methods to reduce post injection pain. Applying heat to the affected area can really help reduce post procedural soreness. I recommend doing this for 10 minutes three times a day for the first three days.
Heat will do two main things. Number one, it will help improve blood flow to the area which can dissipate post injection soreness and prevent muscle and joint stiffness. Number two, heat also helps increase cell to cell signaling. So in theory, applying heat will increase platelet degranulation and growth factor release. Both of these would be very beneficial after a PRP treatment.
What is the recovery time after a PRP injection?
So what kind of recovery time are we looking at after a PRP injection? Recovery and rehabilitation is actually an extremely active area of research. I’m going to present a general guideline which most people can use, but oftentimes the post injection rehabilitation needs to be individualized. This is definitely an area where discussing with your physician or physical therapist can be beneficial.
I like to break down the post PRP injection rehab protocol into three main phases. The first phase is the post injection phase and lasts from day 0 which is the day of the injection through the end of day 3. The goal of the first phase is to protect the site of the injection.
And protecting the site of injection can mean a lot of different things. It could mean just taking it easy or it could mean complete immobilization. PRP treatments for arthritis generally do not require strict immobilization. But PRP treatments for soft tissues can be different. Some tendons may require non weight bearing with crutches or partial weight bearing with a walking boot. This is something that needs to be discussed with your treating provider.
For those of you who do not need immobilization, I tell my patients to just take it easy in phase 1. This means no exercise and nothing above light physical activity. I especially want my patients to avoid any repetitive motions and to avoid heavy loading of the treated area.
The reason for this is we really want to allow the platelets to do their thing. Any type of overuse or excessive loading can negatively affect PRP outcomes. We really want to spend the first 3 days taking it easy.
After phase 1, we move on to phase 2 which runs from days 4 to 14. The goal of phase 2 is to discontinue any immobilization devices and then to slowly increase load. Around days 4 to 7, I recommend working on gentle stretching and range of motion activities. Do this for a few minutes, maybe two to three times a day. This is really just to work on mobility and to prevent stiffness.
On days 7 to 14, I like to add light stretching, strengthening, and cardiovascular exercises. These are not meant to be intense exercises. The goal here is to start putting just a little stress on the area to promote the body’s natural healing mechanisms. You’ll want to start with simple body weight exercises and advance to light weights. Do the strengthening exercises three times a week as tolerated by pain. Gentle stretching can be done daily.
Now in addition to the strengthening exercises, I also encourage all my patients to participate in aerobic exercises such as walking or easy pedaling on a stationary bike. Endurance exercises help reduce inflammatory markers that circulate in the body. Light cardiovascular exercise will kickstart these benefits without adding too much stress on the body. Starting on day 7, you can do aerobic exercises daily and advance as tolerated.
After day 14, we move on into phase 3 which spans from weeks 3 to 6. The goal here is to restore as much range of motion as possible and to improve strength and endurance. This is where we also try to get athletes to work on proprioception, balance training, and sports specific movements. You’ll want to slowly add more weights and resistance every week with the goal of building muscle. Continue to do strengthening exercises about three times a week.
We also want to advance our aerobic exercises as well. This could mean different things for different people and really depends on your previous baseline activity. But the goal is to at least get you doing some type of low resistance cardio such as a brisk walk, cycling, or swimming. As you get more strength, some people can advance back to jogging and then running.
Of course, all of this is with the caveat that your pain is relatively well controlled. If at any point your pain gets worse, back off for a few days and then gradually restart. Typically after the 6 week mark, all restrictions are lifted and we want you to get back to your previous baseline physical activity. Sometimes a repeat PRP treatment is recommended. No big deal, you would then go back to phase 1 after the repeat procedure.
How soon can I expect results after a PRP injection?
How soon can you expect results after a PRP injection? Ok so to understand when you can expect results after a PRP injection, it is important to discuss the body's natural healing cascade. After an injury, a complex series of events occurs to repair damaged tissues and restore normal physiological function. This process can be divided into three overlapping phases.
The first phase is the inflammatory phase, which begins immediately after tissue injury. It involves the activation of the immune system and the initiation of an inflammatory response.
Platelet activation plays a crucial role in this phase, as various chemical mediators such as growth factors, cytokines, and chemokines are released. The inflammatory phase typically lasts a few days and is essential for initiating the healing process.
The second phase is the proliferative phase, which focuses on the regeneration and repair of damaged tissues. This phase overlaps with the inflammatory phase and involves processes like angiogenesis which is the formation of new blood vessels, granulation tissue formation, epithelialization, and fibroblast-mediated wound contraction.
These events contribute to the formation of new tissue. The duration of the proliferative phase varies, lasting several days to weeks depending on the type of injury.
The final phase is the remodeling phase where newly formed tissue undergoes restructuring and maturation. This phase can last for months or even years. Initially, the collagen fibers synthesized during the proliferative phase are disorganized and weak.
However, over time, collagen is remodeled and realigned along the lines of mechanical stress, increasing tissue strength and integrity. This phase allows tissues to regain their strength and functionality.
When PRP is introduced into soft tissues, it can be viewed as simulating a new injury. This triggers the inflammatory phase, which explains why some patients may experience a temporary worsening of symptoms before they start to improve.
Additionally, the healing process following PRP injections into tendons may take approximately 8-10 weeks before noticeable improvements begin. Typically, patients will start to observe a clear and definite improvement in symptoms around the 3-month mark. This aligns with the remodeling phase of the body's healing cascade.
In contrast, PRP injections into joints, particularly for arthritis-related conditions, yield faster results. Most individuals will notice a significant improvement in symptoms within the first few weeks following the treatment.
Unlike in soft tissue injuries where tendons require time for remodeling, the main goal of PRP injections into joints is to regulate the inflammatory environment within the joint. Platelet activation takes place within a few days after the injection, triggering the release of significant quantities of growth factors. This process ultimately leads to symptom improvement. Most people notice a definite improvement by 4 weeks.
Of course, while the information I just presented offers a general understanding of the healing process and the expected timeline for PRP treatment, it’s important to understand that there are many other factors that can influence the success and response of PRP injections.
Different tendons have varying healing capacities and some tendons require longer to heal than others. The achilles tendon for example is notoriously difficult to treat with long healing times. The extent and severity of tendon injuries also play a role in the outcomes of PRP treatment. Severe or chronic injuries may require more extensive treatment and longer recovery periods.
In addition, the overall metabolic health of the patient can influence healing and treatment outcomes. Conditions such as diabetes, high blood pressure, and obesity can impair the body's natural healing processes and negatively affect the response to PRP.
How many PRP injections are required for optimal results?
How many PRP injections are required for optimal results? This really depends on each individual patient and the severity of the condition being treated. In some cases, a single PRP injection may be sufficient to promote healing and alleviate pain. However, for more severe or chronic conditions, multiple injections may be necessary to achieve the desired outcome.
Let’s take tennis elbow for example. This is a chronic repetitive stress injury that leads to degeneration of the common extensor tendons in the elbow. Overloading the tendon causes microtears to accumulate within the tendon and causes the tendon fibers to become thinned out, disorganized, and weak.
Multiple systematic reviews and meta-analyses of randomized controlled trials have shown that tennis elbow responds incredibly well to platelet rich plasma injections. A single PRP injection can lead to significantly better patient reported outcomes and longer more sustainable pain relief when compared to other injections such as cortisone or placebo. In fact, a single high dose PRP injection has been shown to have equal, if not better results when compared to surgery.
We think tendons can potentially get by with just one high dose injection because the PRP is actually working to improve the biochemistry of the tendon. Remember that tennis elbow is caused by repetitive stress and the accumulation of all this stress and pressure result in a chronically degenerated tendon. PRP seems to help remodel the tendon to treat the source of the problem. This is likely why we see better long term outcomes with PRP injections when compared to other treatments.
Of course, not everyone will be successful with just one injection. Sometimes repeat treatment is necessary to treat persistent or lingering symptoms. I usually recommend waiting at least 3 months after the first injection before reassessing and deciding if a repeat injection is needed.
Joints on the other hand are very different. Let’s use knee osteoarthritis as an example. Osteoarthritis is a disease that occurs due to the loss of articular cartilage. Loss of cartilage results in joint space narrowing and this leads to irritation, stiffness, and pain. Damage to cartilage also results in the release of toxic enzymes and proteins into the joint space. This altered biochemistry leads to chronic inflammation that weakens healthy cartilage and damages the joint.
Unfortunately, there is currently no way to reverse the damage to cartilage. Once it’s lost, it cannot be regrown. Neither PRP nor stem cells have been shown to be able to regrow cartilage. Rather, the goal of these treatments is to help decrease pain and improve function related to knee osteoarthritis.
PRP introduces a tremendous amount of growth factors and signaling molecules that can flush out inflammatory markers inside the knee. This leads to a dramatic shift in the biochemistry of the joint which results in improved symptoms.
Multiple studies such as this one have shown that a single HIGH dose PRP injection can reduce pain and improve function in those with mild to moderate osteoarthritis for up to 1 year. Other studies have shown that you would need three LOW dose PRP injections to achieve the same outcome.
But unlike some tendon problems where PRP can potentially solve the root cause, the effects of PRP in joints will eventually wear off and when that happens, symptoms will return. This is because osteoarthritis is a chronic progressive disease and tends to get worse over time. Age, genetics, obesity, metabolic health, prior injury. All of these are risk factors for predicting worsening progression of arthritis.
This study performed synovial fluid analyses and found that PRP injections resulted in significant decreases in inflammatory markers inside an arthritic knee for up to one year. But at the one year time period, these inflammatory markers were back to baseline. This is consistent with other studies that suggest the effects of PRP injections in joints seem to last around one year.
Now think about this. If we were to let those inflammatory markers reaccumulate in the joint, the arthritis will get worse and the pain, stiffness, and loss of function will return. Therefore, the goal of PRP treatment is to not only treat pain and symptoms, but also to try to slow down the progression of arthritis.
This study found that one treatment series of three high dose PRP injections slowed the progression of arthritis by up to 50% at 5 years post treatment when compared to placebo. This data is consistent with other studies such as this one that have found that PRP injections can delay the need for knee replacement surgery.
With all of that said, there is still a lot of debate with regards to the ideal number of PRP injections for joints and arthritis. What’s clear is that high dose PRP is better than low dose PRP. My current treatment algorithm for arthritis is to administer one high dose PRP injection and then re-evaluating patients in 4 weeks.
For most people, they are very happy with their progress and decide to continue to work on exercise therapy. Some people need a second injection at the 4 week mark to get them to a place they are happy with. I’ve very rarely needed to administer three high dose PRP injections.
I then recommend administering booster injections at one year intervals to prevent the build up of inflammatory markers. The goal with these maintenance injections is to try to keep the joint as healthy as possible and to try to slow down the progression of arthritis.
I want to point out that all of this is still very dynamic and continues to be an active area of research. Protocols continue to change often so this is something you want to discuss with your health care provider to individualize treatment.
What are the risks and side effects of PRP therapy?
What are the risks and side effects of PRP? The beauty behind platelet rich plasma is that because it is derived from your own body’s cellular mechanisms, there are no side effects from the injection. The caveat to that is anytime we stick anything through the skin there is a risk of bleeding and a risk of infection.
But these risks are minimal especially since the procedure is done with sterile technique and under ultrasound guidance. In addition, there is pretty much zero risk for allergic reaction that can be seen with other injectable medications. Again, the only things being injected are your own cells.
By far the biggest side effect of PRP is the post-inflammatory reaction that some people will get a few days after the injection. This is especially true for soft tissue treatment such as tendons. Without fail, this always seems to surprise my patients with how uncomfortable it can get. But the bright side is, it will get better on its own after a few days.
Can PRP therapy be combined with other treatments?
PRP therapy can and should be combined with other treatments as part of a comprehensive treatment plan for various orthopedic conditions. In many cases, PRP therapy is used in conjunction with physical therapy, activity modification, and other conservative measures to maximize the healing potential and improve patient outcomes.
Let’s first discuss combining different injections with platelet rich plasma. The first and most common question that I get is combining platelet rich plasma with cortisone. The theory is cortisone works fast, PRP works over time, can we combine the two so we can get something that works fast AND something that works slower but more effective over time.
Unfortunately, this does not work in practice. When used together, cortisone can interfere with the effectiveness of PRP injections by inhibiting the production of growth factors and cytokines. This reduces the effectiveness of PRP in promoting tissue healing and regeneration.
In fact, I recommend waiting at least 4 weeks after a cortisone injection before getting a PRP injection to make sure that the effects of the steroids do not affect the outcomes of platelet rich plasma.
The converse is also true. I recommend waiting at least 4 weeks after a PRP injection before administering cortisone injections in other parts of the body to ensure that the effects of the PRP are not inhibited.
Ok, so cortisone is a no-go. What hyaluronic acid injections? Can we combine that with platelet rich plasma? Both HA injections and PRP injections are great treatment options for knee arthritis. Multiple head to head trials comparing PRP injections to hyaluronic acid injections suggest that people who get PRP injections have more favorable outcomes.
More recently, there is a trend towards combining the two injections together with the hopes of achieving a synergistic effect. The thought process behind this is that PRP has mainly a biologic effect in treating the microenvironment of an arthritic knee. Hyaluronic acid has more of a mechanical effect in lubricating the knee. PRP and hyaluronic acid both have anti-inflammatory properties that occur through different pathways. So, theoretically, combining these two treatment options will result in better outcomes.
But in reality, systematic reviews and meta-analyses suggest that combination of PRP with hyaluronic acid is NOT superior to PRP monotherapy. This is true for both knee osteoarthritis as well as hip osteoarthritis.
There are all sorts of other cocktails that some physicians advertise. For example, PRP plus bone marrow aspirate concentrate or PRP plus adipose derived mesenchymal stem cells. PRP plus dextrose prolotherapy. PRP plus amniotic tissue allograft. PRP plus exosomes.
Unfortunately there just isn’t a lot of evidence out there to look at all these combination therapies. In fact, there just isn’t a lot of data out there for some of these therapies to begin with. Given that PRP works really well as a solo treatment, in my opinion, it doesn’t seem worthwhile to spend the extra money to experiment with other treatments.
Now, I also get asked a lot if you can combine platelet rich plasma with surgical procedures. Can PRP be used to help augment surgical repair of damaged tissue? The answer is yes. There is a growing body of evidence to support the use of augmenting orthopedic surgeries with PRP.
For example, more and more studies such as this systematic review and meta-analysis suggest that platelet rich plasma can help augment a meniscus tear repair. PRP augmentation led to lower failure rates as well as better postoperative pain.
The same is true for rotator cuff repairs. Both of these two studies found that platelet rich plasma combined with a rotator cuff repair can reduce retear rates, improve functional outcome scores, and reduce overall pain.
How can I optimize my PRP for best results and how do I prepare for a PRP injection?
How can you optimize your PRP for the best results and what do you need to do to prepare for a platelet rich plasma injection?
There are many variables that can significantly affect outcomes of PRP treatments and many of these variables are things that you can control. I’m going to break it down into two major categories. The first is a person’s overall health and physiology and how we can try to optimize that. The second is consumables such as medications or drugs and how they affect platelet function.
The first category is a person’s overall health and physiology and we’ll start with blood pressure. We all know high blood pressure is bad. It results in cardiac remodeling eventually leading to heart failure and cardiovascular disease.
But high blood pressure also affects platelets. High blood pressure induces platelets to release their factors into the blood plasma and can DECREASE overall platelet numbers. Therefore, trying to achieve optimal blood pressure control PRIOR to a PRP injection may be beneficial and improve outcomes.
And what about nutrition? How does diet affect platelet properties? Well it turns out that diets high in saturated fats can negatively affect platelet function. In some extreme cases, we can physically see the differences.
Most PRP preparations end up with a clear golden yellow plasma. However, when someone’s cholesterol and triglycerides are extremely high, their PRP ends up being a cloudy yellow or even milky white. All of these excess fats can negatively affect PRP outcomes.
The same is true for blood sugar. High blood glucose concentrations have been shown to activate platelets. You may think this is a good thing because we WANT the platelets to be activated. But the key thing here is we want the platelets to be activated AFTER they are injected into their target tissue. NOT before.
So if you have high blood glucose going into your PRP injection, then there is a chance that many of your platelets have already been activated and quote and quote used up. And if they’ve already been used up, then you have less overall platelets that can work in the target tissue.
In general, you want to be eating a heart healthy anti-inflammatory diet focused on vegetables, fruits, nuts, seeds, and fatty fish. A great example of this would be the Mediterranean diet.
Now let’s move on to the second category which is drugs and consumables and we’ll start with alcohol and tobacco. Increasing levels of alcohol consumption are associated with DECREASED platelet activation and aggregation as well as reduced platelet response. The same is true for smoking cigarettes. So trying to reduce or eliminate alcohol or tobacco consumption a few days before and after a PRP procedure may improve outcomes.
I also get asked a lot about cannabinoids and marijuana products. Whether marijuana or using topical or oral CBD affects platelet function is still debated. There are some studies to suggest that marijuana as well as CBD can interfere with platelet activation and platelet aggregation. So, just like tobacco and alcohol, if you can avoid using cannabinoids a few days before and after your PRP injection, you may get better outcomes.
When it comes to medications, we know if you take common over the counter pain or anti-inflammatory medications such as aspirin, ibuprofen, or naproxen before or after a PRP injection, you will have significantly WORSE outcomes.
The reason for this is because all of these medications are in the NSAID class of drugs. And NSAIDs can interfere with platelet function. The same is true for other antiplatelet agents such as Plavix, Brillinta, and Effient. So if you are taking these medications, then the effects of the PRP will be affected.
Other types of blood thinners are not absolute contraindications to getting a PRP injection. However, blood thinners like warfarin, xarelto, and eliquis can increase your risk for bleeding. This is something you’ll definitely want to discuss with your healthcare provider.
With all of that said, other than the mentioned types of medications, pretty much every other over the counter or prescription medication is compatible with PRP injections. Common supplements including glucosamine chondroitin, turmeric and curcumin, boswellia serrata, fish oil, and collagen are likely safe to continue with PRP injections.
In terms of preparing for the injection itself, it’s very important that you get a good night's sleep. This will help promote overall well being and make the blood draw and injection experience more comfortable. Remember to drink plenty of water and stay hydrated. This will make the blood draw process significantly easier.
Regarding fasting, unless specifically instructed by your healthcare team, it is generally advisable not to skip meals prior to the procedure. Fasting can lead to feelings of weakness and dizziness afterward. Make sure your body has adequate energy before the injection by eating a nutritious meal.
Are there certain people who shouldn't get PRP therapy?
Are there certain people who shouldn't get PRP therapy? So because platelet rich plasma is from your own body, pretty much everyone can get PRP treatments. However, there are a few clinical scenarios where one may want to avoid them and I'd like to briefly discuss them.
One such instance is when a patient has underlying cardiovascular disease, such as coronary artery disease, or has experienced a stroke. This is because these patients are typically prescribed antiplatelet agents like aspirin or clopidogrel. We already discussed how antiplatelet agents can completely negate the effects of PRP because these medications interfere with platelet function.
So administering PRP injections to these patients may not be advisable, as they would need to discontinue their antiplatelet medications for a few weeks. This could significantly increase their risk for a major cardiovascular event. In these cases, the risks of stopping the antiplatelet agents far outweigh the benefits of PRP, especially if there are alternative treatments.
Another clinical scenario is if a patient has systemic inflammatory conditions, such as rheumatoid arthritis or ankylosing spondylitis. Patients with these conditions often experience pain in multiple body parts and may require taking daily NSAIDs or even low-dose steroids to manage their symptoms.
The same is true for people who are planning to undergo other medical procedures or surgeries. These patients may need to take NSAIDs for other reasons and unfortunately, that would interfere with the effects of platelet-rich plasma.
I also get asked a lot if age affects PRP and whether our senior athletes and weekend warriors can also get platelet rich plasma treatments. The short answer is that patients of all ages can get PRP. When we look at the studies using PRP to treat knee osteoarthritis, the mean age is in the 60s with some studies including patients who are much older. All of these studies using high dose PRP conclude that platelet rich plasma injections have excellent outcomes.
In my own experience, I’ve found PRP to work well for people of all ages. In general, younger patients need fewer injections to achieve a desirable outcome. Older patients with more severe arthritis or tendon degeneration are more likely to need more than one injection or possibly more frequent injections to achieve an equally desirable outcome.
Is PRP therapy covered by insurance? Why not? What is the cost?
Are PRP injections covered by insurance? Unfortunately, no. It is a cash pay procedure in almost all settings. According to this paper published in early 2020, the mean cost of a PRP injection in the United States was $707 with a large standard deviation of $388.
There were a lot of variables that affected price. Injections were more expensive in areas that had a higher median household income. Injections were also more expensive in cities that had larger population sizes. Geography also played a role with the West being the most expensive region.
In the United States, the only health care insurance that covers PRP injections is Tricare. And for those of you who don’t know what Tricare is, it is the health care insurance for the United States military active duty service members and their families. And this makes total sense. Tricare has a large incentive to get their active duty military members back to being healthy and physically active.
But what about all the other insurance companies? Cigna. Blue Cross. Blue Shield. Aetna. United Health Care. Medicare. How come these major insurances are not covering platelet rich plasma injections? Every single one of them still considers PRP to be experimental and without sufficient evidence.
But in reality, there is plenty of evidence that PRP injections result in better patient outcomes. Even major medical societies have written about the benefits of platelet rich plasma. For example, the European Alliance of Associations for Rheumatology put out a consensus statement with a few of the following highlights. Here’s what they wrote:
Number 1. Intra-articular injections of PRP are an effective symptomatic treatment for early to moderate knee osteoarthritis. Number 2. Intra-articular injections of PRP may be useful in severe knee osteoarthritis. And Number 3. PRP treatment should be offered as a second line treatment after failure of oral or non pharmacological treatment for knee osteoarthritis.
This means that if oral anti-inflammatory medications like ibuprofen or naproxen or exercise and physical therapy do not help sufficiently decrease pain and symptoms, the European Alliance of Associations for Rheumatology recommends offering platelet rich plasma injections for the treatment of symptomatic knee osteoarthritis.
And what about medical societies in the United States? The American Academy of Orthopedic Surgeons put out a technology overview summary on platelet rich plasma. The authors conclude that “the literature supports the hypothesis that PRP CAN offer statistically significantly greater benefit compared to placebo and active treatment alternatives such as hyaluronic acid, corticosteroid, and NSAIDs for patient reported outcomes related to pain and symptoms for time points up to 12 months.”
And here’s what a consensus statement from the American Medical Society for Sports Medicine says about platelet rich plasma. They write that “the research suggests that PRP injections are MORE effective in reducing pain and improving function than steroid or hyaluronic acid injections for knee osteoarthritis, particularly in those who are younger and have mild to moderate disease.”
When it comes to tendons, they write that “multiple randomized controlled trials have demonstrated that lateral epicondylopathy [which is tennis elbow] responds POSITIVELY to PRP injections. There have also been positive results seen in randomized controlled trials for the treatment of gluteus medius tendinopathy and plantar fasciopathy with PRP.”
So with all of this data and with major medical societies confirming the efficacy and even superiority of platelet rich plasma injections, why won’t insurances cover this procedure?
The first thing insurance companies may say is that it’s too new and has an unknown safety profile. But honestly, this is a non issue. The beauty of platelet rich plasma is that it comes from your own body. It is literally your own cells and you can argue this is one of the safest procedures that you can do.
Multiple randomized controlled trials and systematic reviews have shown that PRP is effective AND safe in the long run. The same cannot be said of cortisone injections. Cortisone injections into tendons can damage the tendons and can lead to weakened tendons and even tendon rupture. Cortisone injections into joints have been shown to damage healthy cartilage and increase the risk for rapidly destructive joint disease.
The second thing insurance companies will say is that there continue to be clinical trials showing that PRP is no better than placebo. And because of the conflicting results they refuse to cover the procedure. The rebuttal to this is rather nuanced so I will again use knee osteoarthritis as an example.
In my opinion, there is now robust data to support the use of platelet rich plasma injections for the treatment of symptomatic knee osteoarthritis. This includes randomized controlled trials, systematic reviews, and meta-analyses.
But every once in a while, we will get a clinical trial like the RESTORE trial or the PEAK trial. The authors from the RESTORE trial conclude “Among patients with symptomatic mild to moderate radiographic knee osteoarthritis, intra-articular injection of PRP, compared with injection of saline placebo, did not result in a significant difference in symptoms or joint structure at 12 months. These findings do not support use of PRP for the management of knee osteoarthritis.”
And here’s what the authors from the PEAK trial concluded. They write “There is no evidence that single or multiple PRP had any additional beneficial effect compared to saline injection up to 12 months follow-up after treatment of early stage symptomatic osteoarthritis of the knee.”
So when insurance companies glance at the conclusion of one of these studies, they immediately say “see, it doesn’t work. We are not going to cover PRP.” Unfortunately, many PHYSICIANS also read these studies and conclude the same thing, PRP doesn’t work.
This article was from the American academy of family physicians. The title is: “Another Study Fails to Find Platelet-Rich Plasma Injections Effective for Adults With Degenerative Joint Disease of the Knee”. Here they are looking at the results from the PEAK trial and the title is intentionally provocative.
What most people don’t understand is that not all PRP is the same. Dosing really matters, just like for any other drug that we prescribe to patients. The same thing is true for platelet rich plasma. Both the RESTORE trial and the PEAK trial used low dose PRP.
The RESTORE trial used a kit that produced about 1 to 2 billion platelets. The PEAK trial used a kit that produced around 2 to 3 billion platelets. It turns out, newer clinical studies have shown that there is a dose response curve for PRP, just like any other medication. And you want to aim for 10 billion platelets to get a clinical effect for knee osteoarthritis.
So what we actually gained from the RESTORE and the PEAK trial is clarity on the low end of the dose response curve for PRP. This is also why many new studies are starting to examine the high end of the dose response curve by starting with volumes of at least 60 cc’s of blood.
PRP dosing is now recognized to be critical and some orthopedic journals no longer accept research papers unless the study specifically measures and publishes their PRP preparation and platelet counts.
Ok the last thing I want to touch on is what I think will finally get insurance to cover PRP injections. And of course, it all comes down to money. We need more studies looking at the cost benefit analysis of platelet rich plasma injections.
Take a look at this study. They performed a cost benefit analysis of platelet rich plasma injections for the treatment of knee osteoarthritis for their specific country. They write that “intra-articular injection of PRP, compared to other injections, is a cost-effective treatment option for patients with mild and moderate knee osteoarthritis. In addition, intra-articular injection of PRP was identified as the best injection, with the highest level of net monetary benefit, for knee osteoarthritis management.”
I firmly believe that if this analysis was done in other countries including the United States, we would see similar results. PRP leads to better symptom improvement and better function. This allows people to be more effective at work which will generate more productivity and more revenue for their companies.
More importantly, people are more functional and able to exercise more. This means they are less likely to gain weight, less likely to have high blood pressure, less likely to have diabetes, high cholesterol, or all sorts of other medical comorbidities.
Elderly with osteoarthritis are also more likely to exercise and this will prevent muscle atrophy. This leads to reduced fracture risk and decreased costs related to hospitalizations and elderly care. This is where PRP can have a dramatic improvement on the quality of life and health care of our population. But until these cost benefit analyses are done, I find it unlikely that insurances will cover PRP injections.
How does PRP compare to other common treatments, especially cortisone injections?
Platelet rich plasma injections have been compared to corticosteroid injections for a number of orthopedic conditions. Rather than going through each indication one by one, let’s take one joint condition and one tendon condition as examples.
Let’s first start with knee osteoarthritis. There are now numerous randomized controlled trials as well as multiple systematic reviews and meta-analyses that all conclude the same thing. Platelet rich plasma injections are incredibly effective at reducing pain and symptoms as well as at improving function when it comes to knee osteoarthritis. All of the following studies were published in the last two years.
I think the evidence is clear that platelet rich plasma injections work incredibly well for the treatment of symptomatic knee osteoarthritis. But understanding why PRP works is even more important, especially when compared to cortisone injections.
First and foremost, cortisone injections really do work. They last on average two to three months with some people longer, and others not as long. They have powerful anti-inflammatory and pain relieving effects. The bigger concern is that recent studies suggest cortisone injections can damage and weaken healthy cartilage. When compared to placebo saline injections, cortisone injections result in significantly more joint space narrowing in the knees. This by definition means worse arthritis.
Other studies have shown that multiple cortisone injections are associated with rapidly destructive joint disease. This is characterized by rapidly progressive joint space narrowing, osteolysis, and loss of the integrity of the joint. All of this can result in severe bone on bone arthritis.
We don’t see these side effects with platelet rich plasma, in fact, quite the opposite. PRP has been shown to decrease levels of inflammatory markers inside an arthritic knee. It can also reduce subchondral bone marrow edema. This leads to a healthier joint environment that can protect healthy cartilage.
This is what long term data shows. Platelet rich plasma injections have been shown to help protect healthy cartilage and slow down the progression of arthritis. Because PRP actually helps change the biochemistry of an arthritic joint, it has also been shown to delay the need for knee replacement surgery.
Ok, now what about soft tissue? Let’s look at tennis elbow and golfer’s elbow. These conditions are caused by repetitive stress and overloading of the tendons in the elbow. The increased pressure on the tendons over time leads to microtears and a condition known as tendinopathy. The weakened tendons lead to pain and problems with function.
Again, cortisone injections for tendons have been shown to reliably reduce pain and symptoms. The bigger concern is that cortisone injections have side effects. They restrict the delivery of nutrients to a wounded area. They slow the formation of new tissue. They damage existing collagen. And they increase tissue degradation.
Dermatologists and plastic surgeons actually use these catabolic effects of cortisone to break down keloids. Keloids are an overgrowth of collagen that lead to large scar tissue. The big problem here is that tendons are also composed of collagen and injection of cortisone into these tendons will lead to tendon degradation.
And this is exactly what we see in clinical trials. This study is a systematic review looking at the efficacy and safety of corticosteroid injections for the treatment of tendinopathies.
They write that there are “consistent findings between many high quality randomized controlled trials that corticosteroid injections reduce pain in the short term. But this effect was REVERSED at intermediate and long terms. This is a landmark meta-analysis in that it presents high level evidence that cortisone injections are HARMFUL in the long term for tennis elbow.”
Now let’s contrast all of that with platelet rich plasma. There are multiple systematic reviews and meta-analyses that directly analyze and compare corticosteroid injections to platelet rich plasma injections. All of the following studies conclude that platelet rich plasma injections are effective at reducing pain and symptoms in both the short term and continue to have LONG term benefits.
In fact, the authors from this review write that PRP injections may offer similar levels of improvement to pain and function when compared to tennis elbow surgery.
So I think it’s abundantly clear that platelet rich plasma injections are superior to corticosteroid injections in terms of improving pain and function for both joint issues as well as tendon and soft tissue problems. PRP has a significantly better side effect profile and may even prevent arthritis from getting worse.
Head to head studies comparing platelet rich plasma injections to hyaluronic acid injections show similar results. This study was a systematic review and meta-analysis that included 14 randomized controlled trials. Comparisons showed that PRP outperforms hyaluronic acid for pain, function, stiffness, and sports related symptoms at most follow up time periods all the way out to 1 year.
The takeaway from all of this is that PRP has been shown to have superior outcomes compared to other common injection therapies.
What’s the difference between PRP and “stem cells”? BMAC vs PRP? MFAT vs PRP?
So we’ve talked about PRP versus cortisone, but one of the most common questions I get is “what about stem cells?” What’s the difference between PRP and stem cells and why can’t we just regenerate our tissue?
When most people talk about stem cells, they are thinking of pluripotent stem cells. These are cells that can divide and grow into pretty much anything. Think of embryos that are just starting to grow and create new organs. They are incredibly versatile and can potentially regenerate or repair diseased tissues and organs.
But when we talk about stem cell procedures or stem cell injections, we are actually using and referring to another type of stem cell NOT the pluripotent stem cells. Instead we are using a special type of adult stem cell called the mesenchymal stem cell. These cells have a limited capacity when compared to pluripotent stem cells, but they still have tremendous ability to reduce pain and symptoms.
So the two most common places to get mesenchymal stem cells are either from adipose or fat tissue usually harvested from the abdominal cavity. This is called microfragmented adipose tissue or MFAT for short. The second way to harvest mesenchymal stem cells is from the posterior iliac crest through a procedure called a bone marrow aspiration. These cells are called bone marrow aspirate concentrate or BMAC for short.
It’s important to point out that once we isolate the mesenchymal stem cells and then inject them, there is no current evidence to suggest that we are regrowing or regenerating anything. Remember, these cells are NOT pluripotent. You don’t get a new knee after mesenchymal stem cell injections.
Just like with platelet rich plasma, the goal of these stem cell treatments is to use the enormous amount of growth factors and cascades that they initiate to help reduce pain and improve function. Let’s first ask the question, do MFAT and BMAC injections really work?
This study looked at people with knee arthritis who were treated with MFAT, again that’s adipose derived mesenchymal stem cells, and published results at 2 years follow up. They found that pain improved at 6 months and was slightly better at 12 months but then was back to baseline at 24 months. Similarly, function gradually improved at 6 months and 12 months but was back to baseline at 24 months.
And what about BMAC? This next study was a systematic review and meta-analysis that compared those who got mesenchymal stem cell injections from BMAC, which is bone marrow, to those who got injections with MFAT.
They found that both groups had significant improvements in pain and function. More interestingly, they found that the patients who got BMAC had significantly better outcomes when compared to people who got MFAT.
So it seems like both types of mesenchymal stem cell injections are effective at treating symptoms related to knee arthritis. And it seems that bone marrow may be a better option than adipose tissue.
Now we want to answer the question, how do they compare with PRP? This study was a 2 year outcomes study comparing BMAC to PRP. Patients with knee arthritis were randomized to get either one BMAC injection or one high dose PRP injection.
They found that both groups had significant improvements in both pain and function at 3 months, 6 months, 9 months, 12 months, 18 months, and 24 months. But what they found was there was no difference between PRP and BMAC treatment at any time point. The authors conclude that PRP and BMAC are BOTH effective at treating symptoms related to knee arthritis and that BMAC was NOT superior to PRP.
So from these studies, we can conclude the following. Both stem cell injections and PRP injections work similarly well for the treatment of knee arthritis. The hypothesis that stem cells would be MORE effective than PRP is NOT currently supported by clinical trial evidence. Both PRP and stem cells are equally effective.
But here’s the thing. Let’s look at cost. Both of these treatments are not covered by insurance and are cash pay only. From our discussion earlier, the average cost of PRP in the United States was found to be about $700. That same study reported that the average cost of stem cells was $2700, which is almost 4 times greater than the cost of PRP.
Harvesting mesenchymal stem cells is also much more invasive with higher rates of adverse effects. And outcomes are exactly the same. Until clinical trials start to show otherwise, cost benefit analyses heavily favor PRP.
How do I choose a doctor that performs PRP?
Ok so if you are interested in pursuing PRP treatments, how do you go about choosing a doctor? The first thing I want to emphasize is the importance of selecting the right provider. Just as not all lawyers possess the same skill set and not all accountants and business managers are identical, the same applies to PRP providers.
It is crucial to be aware that not all healthcare professionals offering PRP are equal, especially when the person promoting PRP isn't a board certified physician. While individuals such as physician assistants, nurse practitioners, physical therapists, and even chiropractors may have good intentions, they do not possess the same level of expertise when it comes to platelet rich plasma.
I have encountered numerous patients who have visited their local chiropractor's office and were persuaded to try umbilical or amniotic stem cells. Or they were told that they needed a combination of exosomes and PRP because the two together are superior to PRP alone.
Unfortunately, many individuals are merely attempting to sell these treatments for financial gain. Additionally, some of these providers are not even authorized to administer injections as it falls outside the scope of their practice. Consequently, they often hire a mid-level provider like a physician assistant, who may lack training in administering injections with imaging guidance, resulting in a high likelihood of missing the intended target.
Even if you manage to find an MD or DO physician, it is essential to note that not all physicians are equal either. Many have misleading information on their websites. A study investigating online direct-to-consumer advertising of stem cell therapy for musculoskeletal conditions revealed that 96% of websites contained at least one statement of misinformation, with an average of nearly five misleading statements per site. These inaccuracies ranged from errors in the basic science of stem cells to outright false and deceptive claims.
So, what steps can you take? Begin by seeking out an MD or DO physician. Ask potential providers whether they utilize imaging guidance in their procedures. Inquire about platelet dosing and ask them to explain and justify the dose they plan to administer. If they are unable to do so, it should raise a red flag. Additionally, ask about outcomes. Are they actively tracking patient outcomes or merely relying on anecdotal stories to persuade you?
Moreover, it is becoming increasingly evident that not all PRP treatments are equal. There are numerous variations of platelet-rich plasma, and our understanding of this field is still in its infancy. Many unanswered questions remain.
Should we use leukocyte-rich or leukocyte-poor PRP? How does platelet-rich fibrin compare to platelet-rich plasma? Should platelets be activated, and if so, what is the best activation method? Choosing a reputable provider who possesses extensive experience in platelet-rich plasma treatments is crucial in maximizing the potential benefits of your therapy.
What conditions has PRP been shown to benefit?
What conditions has PRP been shown to benefit? PRP injections have been extensively studied for a wide range of conditions, with knee osteoarthritis, elbow tendinopathies (including tennis and golfer's elbow), gluteal tendinopathy, and plantar fasciitis being the most well-researched. The robust body of evidence consists of numerous randomized controlled trials, systematic reviews, and meta-analyses, all of which provide strong support for the use of PRP injections in treating these conditions.
Furthermore, clinical trials have shown promising results for PRP treatment in other joints, including hip osteoarthritis, shoulder osteoarthritis, and thumb osteoarthritis. It is logical to infer that if PRP is effective for arthritis in one joint, it should also yield benefits for arthritis in other joints.
However, the evidence regarding tendons is more nuanced. While PRP injections have demonstrated excellent outcomes for elbow tendinopathies and gluteal tendinopathies, the results for conditions affecting the Achilles tendon and patellar tendons have been conflicting. The variability in outcomes can be attributed to factors we previously discussed, such as the use of imaging guidance during injections and the dosage of PRP employed in clinical trials.
In contrast to the achilles and patellar tendons, PRP has shown efficacy in treating rotator cuff tendon pathologies, including tendinopathy, partial tears, and impingement syndrome. Even adhesive capsulitis, commonly known as frozen shoulder, has exhibited improvement with PRP treatment.
Hand and wrist pathologies like de Quervain's tenosynovitis and carpal tunnel syndrome have also responded positively to PRP therapy. Even complex and challenging spine issues have found PRP to be a promising alternative to epidural steroid injections.
While platelet rich plasma treatments hold a lot of promise in the treatment of orthopedic problems, I want to reiterate that it is not a magical cure-all. It will not reverse arthritis. It will not sew together a tendon with a full thickness tear. It will not regrow a fully torn ACL. As we gather more clinical trial data, hopefully we can better understand what conditions can and cannot be treated with platelet rich plasma.
So in order to facilitate access to this information, I have compiled a medical literature database that includes randomized controlled trials, systematic reviews, and meta-analyses on platelet-rich plasma, as well as other treatments such as mesenchymal stem cells, dextrose prolotherapy, hyaluronic acid, corticosteroids, and more.
Each entry includes a brief summary of the findings and a link to the respective online journal. My hope is that this database will serve as an excellent resource for those interested in delving deeper into the latest clinical trials involving platelet-rich plasma and related therapies. I’ll put a link to this database in the video descriptions so check that out if you are interested.
Conclusion
In summary, there is still much to be discovered about platelet-rich plasma treatments. However, it is evident that the effects are real, and a growing body of evidence supports its efficacy. PRP has been found to surpass other conventional treatment options while avoiding any associated side effects. Hopefully with further research, the evidence will become irrefutable leading to insurance coverage and availability for all patients.
