Let’s be clear: We treat the patient, not the disorder. PRP is just one tool to improve function. I will often combine forms of treatment with a PRP injection(s). Exercise is the most common, and really is the fountain of youth.
So, what are platelets?
Platelets consist of dense granules, alpha granules and thousands of proteins. The dense granules contain serotonin, ADP, histamine, and calcium in very small amounts.
The Alpha granules contain multiple growth factors – Insulin-like growth factor (IGF), platelet derived growth factor (PDGF), transforming growth factor (TGF), Vascular endothelial growth factor (VEGF), fibroblast growth factor (FGF) and connective tissue growth factor (CGF).
Platelets deliver the cellular signalling proteins needed to start multiple metabolic pathways – clotting cascade, chemotaxis – and stimulation of cellular machinery towards proliferation and differentiation of cell lines.
How (we think) PRP works in a joint:
There is a delicate balance between degradation (catabolism) and synthesis (anabolism) within the joint. Excessive mechanical load can lead to a catabolic cascade. Some people have a genetic predisposition towards catabolism (like in primary generalized osteoarthritis) and can lead to early degeneration.
The growth factors within PRP are anabolic. They stimulate the synthesis of extracellular matrix, and the production of proteins by chondrocytes and synoviocytes. There are factors regarding PRP which are not yet understood as well. For instance, some individuals claim that pain relief from the injection can happen within hours. This is quite contrary to the physiology described above which can take days to weeks. The mechanism of pain relief is still not clearly understood. What we can say is that it is effective in some individuals with osteoarthritis and it is more effective in early osteoarthritis and early joint pain.
The PRP Patient Process:
Step 1: The Initial Consultation
The first visit is meant to confirm the pathology in question and discuss options for treatment. We have a few questionnaires for you to fill out. This gives us an idea of your current levels of pain and function. You will meet with my staff and we will sit down and talk about what’s going on, examine the region of interest, review your prior bloodwork, imaging (XR, CT, MR, etc) and if necessary, use diagnostic ultrasound to look for additional pathology. We will then talk about your treatment options and answer questions you may have.
Step 2: Preparing for the PRP injection
There really isn’t much for you to prepare for. If you’re sick, then let us know and we will reschedule for a different day. Make sure you have breakfast, take your meds, and try to be as hydrated as possible before coming to the clinic. Wear something with short sleeves. If you have a significant needle phobia then using a topical anesthetic, like an Emla cream, can help to decrease the pain of taking your blood. Just place the cream over your elbow where you would usually get blood drawn and we will do the rest. Don’t worry about having to be poked over and over again – we have a one ‘poke’ rule. The first attempt is like at the hospital lab and everything is under ultrasound guidance.
Don’t take these drugs:
There are certain drugs that inhibit the function of normal platelets. There are lots of these medications on the market and we would suggest not taking them for at least one week prior to the blood draw and 2 weeks after the injection. The following is a list of medications:
Basically no NSAIDs: ASA (Asprin), Ibuprofen (advil), Naproxen / Aleve / naprosyn, Vimovo, celebrex (celecoxib), diclofenac / Arthrotec / Voltaren
Do take these drugs:
Tylenol, gabapentin, tramadol, tramacet, tapentadol, Emtec, and T3’s do not alter platelet function.
Step 3: The PRP injection
During this visit, you will come in to the clinic and have blood drawn either at a morning appointment or in the afternoon. It takes approximately one hour to process your blood. You may leave the clinic until the time of your injection, just make sure you double check with the front office staff when it is.
For most injections we use ultrasound guidance. This has been shown to be very accurate and much better than doing a ‘blind’ injection. We use small needles which eliminates the need for aesthetic in many cases. In fact, the blood draw is often more annoying than the PRP injection itself.
After a knee injection, you may experience odd sensations in the knee, a sensation of fullness and a reduction of pain within a few hours. Reductions in joint swelling generally take 1-2 weeks. The full effect can take 3-4 weeks and some people have worse pain for a few weeks afterward. It often requires a 2nd injection at 6-8 weeks to gain maximal effectiveness. However, we do not require patients to have multiple injections of PRP as there is little research to prove this is required.
After a shoulder injection, it is not uncommon to lose some range of motion in the shoulder. Worst case scenario: some individuals may get a frozen shoulder for up to 6 weeks.
Step 4: Follow- up and Rehab
For patients being treated for joint pain, we recommend taking it easy for several days afterwards. You don’t have to lie in bed and rest. Walking and minimal weight-bearing activities such as cycling and swimming are perfectly acceptable. Wait at least 5 to 7 days before going for a run, if you’re into that.
We will see you in approximately 6 weeks after the injection to check in. If you’re doing well then you can call us for a repeat injection whenever you want. Just like medications for blood pressure or diabetes, we can titrate the PRP dose to your symptoms and function.
Frequently Asked Questions:
What are the side effects?
Most common side effect is pain for a few days after the injection. Fortunately, the risk of pain after a joint injection is quite low. If there is going to be pain, you will know it within a few minutes to hours. For other soft tissue injections such as ligament and tendons having pain for a few days afterwards is to be expected. For example, if you have plantar fasciitis and have a foot injection then you can expect to have pain for a several days afterwards. There has never been a documented case of infection after a PRP injection. In fact, some physicians use it to treat chronic wounds and infections.
Will I need a driver?
We suggest a driver for all procedures except for unilateral knee joint PRP injections.
Cost and Coverage?
PRP is not paid for by the provincial or federal government, MSP, pharmacare, or other insurance companies in Canada. American visitors may have a portion of the fees paid for by their insurance company. The responsibility to interact with the insurance company is left to the patient. In BC and Alberta you can expect to pay $450 (and up to $1800) per injection depending on the provider. It is important to ask any physician if they can adjust the dose of PRP for the procedure you are having. Also make sure that your provider can inject a variety of types of PRP (hint: we can).
PRP: The Most Cost-effective First-line Treatment
Injuries and illnesses are expensive. Here is an example of where PRP is the most cost effective treatment when used as a first-line therapy.
Example 1- Plantar Fasciitis
This is a painful condition that affects the ligament along the bottom of the foot. If you just leave this condition untreated it will go away by itself, but generally takes about two years to resolve. The usual treatment recommendations are foot orthosis (shoe insoles), gait analysis, physical therapy, topical and oral medications etc. Injections usually come next after several months, and then surgery at 18-24 months if you can convince the surgeon to do it in the first place. Then recovery and rehab from surgery takes months.
Phyical therapy consult: $70
Shockwave therapy (multiple sessions): $45 x4-8 sessions
A new pair of shoes or sandals: $100
Wages lost from time off of work: $$$
As you can see, the cost of care can increase quite quickly and depending on how many practitioners you have started seeing, the costs will reach a thousand dollars within a few months. I’ve seen patients who have had acupuncture, manipulation, laser therapy and many other forms of pocket manipulation before seeing myself, only to have one injection and have their symptoms improve over the next month.
Example 2- Patellofemoral pain syndrome
This painful knee condition is very common, so everybody has opinions about it; unfortunately, that doesn’t mean everybody knows how to successfully treat it. Many people try the usual strengthening, insoles, k-taping, activity modification and so forth.
Physical therapy consult: $70
Physical therapy follow-up sessions: $45-$55
Knee brace: $30 –$1500
Activity modification: Cancelling the membership to that athletic program, yoga program or Fitness Center.
Wages lost from time off of work: $$$
This is a pretty conservative estimate. If you start seeing a chiropractor, massage therapist, acupuncturist, kinesiologist the costs increase again, totaling to over $1000 per year.