While we do offer stem cell therapy for knee osteoarthritis, the focus of this article will be on Platelet-Rich Plasma Therapy. We receive many emails which ask which is the better treatment for me, stem cells or PRP? That answer comes best after a physical examination and when we have the opportunity to sit down together and discuss what are your goals of treatment. Goals of treatment would be different for a mountain climber than a stair climber at home.
In the same regard, we get many emails that ask us if PRP is better than hyaluronic acid injections or cortisone injection. Many of these people already had cortisone and hyaluronic acid injections. They are somewhat skeptical because these treatments did not help them as much as they thought they would.
In our experience, we have found PRP injections to be the superior treatment. In fact we have submitted our findings for peer-review and upcoming medical journal publication. Supporting our view most recently is a 2019 study in the medical journal Orthopade (1) which found that Intra-articular PRP injections into the knee for symptomatic early stages of knee osteoarthritis are a valid treatment option. The clinical efficacy of Intra-articular PRP injections is comparable to that of the Intra-articular-hyaluronic acid injections and Intra-articular cortisone after 3 months, HOWEVER, the long-term effectiveness of PRP injections is superior to hyaluronic acid and cortisone.
What are PRP or Platelet-Rich Plasma Injections and how do they help issues of chronic knee pain?
- PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected into the knee to stimulate healing and regeneration.
- PRP Injection Therapy is a natural (using your own blood platelets) and is a cost-effective alternative to surgery—designed to rebuild cartilage, repair torn meniscus and ligaments, and reduce swelling and pain. In the hands of an experienced clinician, it is not a treatment to delay joint replacement, it is a treatment that can help a patient avoid a surgery. It works by stimulating the natural immune repair mechanisms and supplying the growth factors necessary to build tissue.
- PRP injection delivers a high concentration of endogenous (your own “home-grown”) platelets to the knee where osteoarthritis is present. Blood is composed of plasma, red blood cells, white blood cells, and platelets. It’s these platelets that are the injury’s “first-responders” and help revascularize an injured area, construct new tissue, and stop the bleeding.
- Because platelets play a significant role in the healing of tissue, reintroducing a high concentration of platelets directly into the injured area may enhance the healing process.
In this article we will discuss research on grade 1 to 3 knee osteoarthritis and PRP treatments. When a new patient comes into our office for a consultation for their knee osteoarthritis, we do a careful assessment of the patient and then make recommendations. Sometimes, the lack of range of motion in this patient’s knee and other factors lead us to a recommendation of stem cell injections. This recommendation is based on a realistic expectation of what both treatments may offer. For some, having the PRP only may not offer the healing that they hope to achieve.
Why has the use of Platelet Rich Plasma therapy (PRP) for knee osteoarthritis seen a dramatic increase in the past few years? Research.
Doctors at the world’s leading medical universities and hospitals are showing that PRP can regenerate damaged knee cartilage and meniscus in patients suffering from knee osteoarthritis and PRP can also enhance healing after knee ligament reconstruction.
An October 2018 study in the journal Current reviews in musculoskeletal medicine (2) says this:
“Recent research into the applications of PRP for knee osteoarthritis has further indicated both the efficacy and safety of PRP treatment. Although research has shown a tendency toward better efficacy at earlier stages of osteoarthritis, evidence exists to indicate positive effects at all stages of osteoarthritis. In summary, since knee osteoarthritis is an extremely prevalent condition that can be a challenge to treat, it is imperative that safe and effective nonoperative treatment methods be available to individuals that are suffering from this condition.”
In July 2018, medical university researchers in Ireland lead a multi-national European research team to conclude in their research:
“Platelet-rich plasma therapy is a simple, low-cost and minimally invasive intervention which is feasible to deliver in primary care to treat degenerative lesions of articular cartilage of the knee. This therapy appears to have minimal associated adverse events and may have beneficial effects in terms of pain, health utility, patient satisfaction and goal-orientated outcomes.”(3)
What is interesting about this study is who the PRP helped:
- The 12 participants in the study had an average age of 72.6 years and average Body Mass Index (SD) of 31.8 meaning that the average person in this study was obese and seven (58%) were male.
- The most common goal of this group was was to be pain free,
- followed by walking normally without aid
- Reduction of knee stiffness
- prevention of knee replacement
- and being able to dance and garden again.
Even a single injection of PRP provided benefit.
In the video below (there is no sound), I demonstrate how why administer PRP. In this case the patient has problems of meniscus degeneration. We apply multiply injections to support regeneration of the whole knee. Below the video is research that showed positive results of even a single PRP injection against a single placebo injection.
In November 2017, researchers reported on the benefits of PRP compared to placebo injection in patients who had osteoarthritis in both knees. Published in the American journal of physical medicine & rehabilitation, the study showed PRP treatment significantly improves pain, stiffness, and disability in patients with knee osteoarthritis compared to normal saline (placebo) treatment.(4)
Also in November 2017, in the International journal of rheumatic diseases, researchers reported a summary of the most recent findings on the benefits of PRP for knee osteoarthritis.
- This study performed an overview of the research to provide recommendations for PRP use in knee osteoarthritis patients through the best evidence. “They concluded that PRP is an effective intervention in treating knee osteoarthritis without increased risk of adverse events.”(5)
In the medical journal Arthroscopy, a journal devoted to obviously arthroscopy, surgeons are told that Platelet Rich Plasma injections (PRP), offers better symptomatic relief to patients with early knee degenerative changes (than hyaluronic acid or placebo), and its use should be considered in patients with knee osteoarthritis.(6)
This is a verification of early research from the Mayo Clinic which came to the same conclusion – PRP showed better improvement than hyaluronic acid injection and placebo in reducing symptoms and improving function and quality of life. Especially in in younger, active patients with low-grade osteoarthritis.(7)
This is from the Mayo Clinic research:
“Intraarticular platelet-rich plasma (PRP) injection has emerged as a promising treatment for knee osteoarthritis. Studies to date, including multiple randomized controlled trials, have shown that PRP is a safe and effective treatment option for knee osteoarthritis. Intraarticular PRP is similar in efficacy to hyaluronic acid, and seems to be more effective than hyaluronic acid in younger, active patients with low-grade osteoarthritis. Treatment benefits seem to wane after 6-9 mos. There are numerous PRP treatment variables that may be of importance, and the optimal PRP protocol remains unclear.”
At the end of that paragraph the Mayo team points out that benefits may only last 6 – 9 months and that there is much variation in the way PRP is delivered so it is difficult to understand why PRP may not work.
Is PRP a “one and done” treatment? For some yes, for many NO
When we see a new patient with degenerative knee disease who had “failed” PRP treatments at other clinics, we ask them how many treatments did they have? More often than not they say “one injection.” For some with minor osteoarthritis, as pointed out by the medical studies highlighted in this article, one injection provides benefit.
But one injection may not be sufficient for someone who has a more active lifestyle than others.
Research on two PRP injections
Here is a recent study where the patients received two PRP injections as the complete PRP treatment program. This treatment group was considered to be “active.” This research was published in the journal Sports Health.(8)
- Fifty patients with knee osteoarthritis were followed for a minimum of 12 months.
- All were treated with 2 intra-articular injections of autologous PRP.
- Twenty-five patients had undergone a previous operative intervention for cartilage lesions, whereas 25 had not.
- Note – 25 of the 50 patients had some type of surgical procedure on their knee before their first PRP treatment. Operated patients had undergone either cartilage shaving or microfracture.
- All patients (even the ones with past knee arthroscopic procedure) showed significant improvement in all testing and measurement scores for pain and function at 6 and 12 months and returned to previous activities.
Research on three PRP injections
A paper published in the Journal of physical therapy science.(9) It comes from doctors working in medical university hospitals in Turkey.
- One of the major results of this study was the effectiveness of PRP treatment for pain and physical function in grade 3 knee osteoarthritis.
- The effectiveness of a single injection was found to be significantly lower than that of two or three injections.
- 3 PRP injections separated by 2-week intervals were found to be more effective for the improvement of pain and mobility than 2 injections in Grade 3 osteoarthritis patients
- A significant effect was observed in the early period after a single injection of PRP, but the effect decreased in a short time. Based on the present results, we recommend 2 or 3 injections of PRP for patients with moderate knee osteoarthritis, and physicians’ decisions should be based on various factors such as the level of pain, level of activity, cost-effectiveness, and Body Mass Index
- We further speculate that repeating the application after 6 months may further relieve symptoms for a longer period and delay osteoarthritis progression.
Research for athletes
Below is what doctors are saying to each other about athletes who want to stay active. It was published in the medical journal Cartilage: “As a result of the complexity of the arthritic knee, athletes, particularly those with a history of knee injury, have an earlier onset and higher prevalence of osteoarthritis. This can present a clinical dilemma to the physician managing the patient who, despite the presence of radiologically confirmed disease, has few symptoms and wishes to maintain an active lifestyle.”(10)
The difficulty or “challenge” is in the prevention of advancing of knee osteoarthritis. Here the typical recommendations of anti-inflammatory medications, knee braces, and ice, those that the athlete can impose upon themselves, will lead to further knee deterioration. It is a challenge to convince an athlete of this when it may get them on the course, track of field this weekend.
In a recent study, researchers at Hospital for Special Surgery gave patients with early osteoarthritis an injection of PRP (6-mL), and then monitored them for one year. At baseline and then one year after the PRP injection, physicians evaluated the knee cartilage with magnetic resonance imaging (MRI). While previous studies have shown that patients with osteoarthritis can lose roughly five percent of knee cartilage per year, the Hospital for Special Surgery investigators found that a large majority of patients in their study had no further cartilage loss. At minimum PRP prevented further knee deterioration.
Ask Dr. Darrow about your knee pain and how PRP may help you
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1 Huang Y, Liu X, Xu X, Liu J. Intra-articular injections of platelet-rich plasma, hyaluronic acid or corticosteroids for knee osteoarthritis. Der Orthopäde. 2019 Jan 8:1-8.
2 Cook CS, Smith PA. Clinical Update: Why PRP Should Be Your First Choice for Injection Therapy in Treating Osteoarthritis of the Knee. Curr Rev Musculoskelet Med. 2018 Oct 22. doi: 10.1007/s12178-018-9524-x.
3 Glynn LG, Mustafa A, Casey M, et al. Platelet-rich plasma (PRP) therapy for knee arthritis: a feasibility study in primary care. Pilot Feasibility Stud. 2018;4:93. Published 2018 Jul 4. doi:10.1186/s40814-018-0288-2
4 Wu YT, Hsu KC, Li TY, Chang CK, Chen LC. Effects of platelet-rich plasma on pain and muscle strength in patients with knee osteoarthritis. American journal of physical medicine & rehabilitation. 2017 Nov.
5 Xing D, Wang B, Zhang W, Yang Z, Hou Y, Chen Y, Lin J. Intra‐articular platelet‐rich plasma injections for knee osteoarthritis: An overview of systematic reviews and risk of bias considerations. International journal of rheumatic diseases. 2017 Dec 5.
6 Campbell KA, Saltzman BM, Mascarenhas R, Khair MM, Verma NN, Bach BR Jr, Cole BJ. A Systematic Review of Overlapping Meta-analyses. Arthroscopy. 2015 Nov;31(11):2213-21. doi: 10.1016/j.arthro.2015.03.041. Epub 2015 May 29.
7 Pourcho AM, Smith J, Wisniewski SJ, Sellon JL.Intraarticular platelet-rich plasma injection in the treatment of knee osteoarthritis: review and recommendations. Am J Phys Med Rehabil. 2014 Nov;93(11 Suppl 3):S108-21. doi: 10.1097/PHM.0000000000000115.
8 Gobbi A, Karnatzikos G, Mahajan V, Malchira S. Platelet-rich plasma treatment in symptomatic patients with knee osteoarthritis: preliminary results in a group of active patients. Sports Health. 2012;4(2):162-72.
9 Kavadar G, Demircioglu DT, Celik MY, Emre TY. Effectiveness of platelet-rich plasma in the treatment of moderate knee osteoarthritis: a randomized prospective study. J Phys Ther Sci. 2015 Dec;27(12):3863-7. doi: 10.1589/jpts.27.3863. Epub 2015 Dec 28.
10 Kirkendall DT. Management of the Retired Athlete with Osteoarthritis of the Knee. Cartilage January 2012 vol. 3 no. 1 suppl 69S-76S
11 Wang-Saegusa A, Cugat R, Ares O, et al. Infiltration of plasma rich in growth factors for osteoarthritis of the knee short-term effects on function and quality of life. Arch Orthop Trauma Surg. 2011 Mar;131(3):311-7. Epub 2010 Aug 17.
12 Injection of platelet-rich plasma in patients with primary and secondary knee osteoarthritis: a pilot study. Sampson S, Reed M, Silvers H, ey al. Injection of platelet-rich plasma in patients with primary and secondary knee osteoarthritis: a pilot study.Am J Phys Med Rehabil. 2010 Dec;89(12):961-9.1537-2290