Are you a weekend warrior with a painful sports injury that won’t heal? Whatever your sport, you now have access to medical procedures used by professional athletes. At California Pacific Orthopaedics and Sports Medicine (CPOSM), you will be treated like a pro. byteclay.com recently spoke with CPOSM’s Dr. Rowan Paul about non-invasive treatments for sports injuries. Dr. Paul is currently a team physician for the Oakland Athletics and San Francisco Ballet. In addition, Dr. Paul was a division one varsity swimmer at Brown University and is a triathlete, marathoner, martial artist, skier, snowboarder, and yoga practitioner.
Dr. Paul specializes in minimally invasive regenerative medicine that includes treatment options such as Platelet Rich Plasma (PRP) and amniotic allograft. Dr. Paul also uses TENEX for tendon repair.
Mark Davis: Let’s talk about the PRP procedure where you draw blood from the patient, centrifuge it to create PRP and then inject the PRP into the treatment area. How does the PRP heal the damaged tissue?
Rowan Paul: Platelets by their very nature are the ambulance of our body; they’re the first responders. Say we cut ourselves and we bleed. The platelets that are normally inactive in the blood stream get activated because of a couple of chemicals, thrombin, but also turbulent blood flow. They activate and bind to the walls of that torn tissue and they dump their powerful growth factors. Those growth factors trigger a response that attracts the body’s construction crew to the area to remove necrotic dead, damaged tissue and then later the blood and bone marrow stem cells are attracted into that torn tissue to promote healing and the development of new healthy blood supply to help heal the tissue. We leverage that process.
MD: It’s all done on an outpatient basis?
RP: That’s right.
MD: Typically how long would the recovery be?
RP: It depends on the application. The collagen healing cycle in tendons for example is anywhere from three to four months. Some people may see a very early response. Typically, four to six weeks and they start to feel better. I would say the peak effect is at least three months out, two to three months actually in my experience. Sometimes you need one injection, sometimes you need two, and sometimes you need three. It depends on the severity of the injury you’re treating, the individual’s biologic healing response to PRP, the inherent circulation of that injured tissue, and the load on that tissue. There are a lot of variables that play into how quickly it heals.
MD: What injuries are commonly treated with PRP?
RP: PRP has been used for numerous things such as tendon healing from tendinosis, which is chronic non-inflammatory degeneration of tendon, partial tendon tears, osteoarthritis, plantar fasciitis, tennis and golfer’s elbows, patellar tendinosis, Achilles tendinosis, and chronic refractory bursitis. It’s also been used for non-healing or delayed fracture and wound healing.
MD: It looks promising that the insurance companies will start covering it.
RP: Exactly. It begs the question when is there enough data to recommend and cover PRP? Cortisone has been used since the 50s, and surprisingly there are actually not a lot of prospective randomized control trials that show that it provides long-term healing. It only clearly helps with short-term symptoms with inflammatory conditions. Yet it has been in widespread use for decades for chronic degenerative bone and joint disease. I would argue that there’s stronger randomized control evidence for actual healing of joints and tendons with PRP. It’s going to get harder and harder to ignore it.
MCD: Cortisone is not good for long-term use.
RP: That’s true. In joints, cortisone actually triggers what’s called apoptosis, it triggers cell death essentially. Every time you’re injecting cortisone you may be actually degenerating cartilage to a small degree. It temporarily suppresses the body’s immune system so you’re blocking the body’s pain mechanism- the body’s stimulus to say, hey stop doing what you’re doing you’re hurting me. It works very well and very quickly at reducing inflammation and therefore pain and swelling within joints and tendons. The argument goes and the evidence would suggest therefore that long-term repetitive use is not good for you. I will use it as a first line therapy but I try to move very quickly to the more efficacious strengthening and potentially regenerative treatments like PRP.
MD: My understanding is that a PRP injection can leave you quite sore for a few days.
RP: Yeah, that’s right. PRP triggers a healing inflammatory response that can last from three to five days and that can hurt. In my experience, especially with the low white cell PRP injections, they don’t get a lot of that huge painful response. I have learned to tweak my formulation over 7 years of experience with PRP and I’ve been very targeted with the use of ultrasound guidance that in my opinion is a critical variable to the success of PRP. I’ve been able to reduce the pain that people feel significantly.
MD: Can you name some pro athletes that have had PRP?
RP: It is common knowledge that Kobe Bryant got it for his Achilles, Tiger Woods for his knee. It used to be no one had ever heard of it, now it’s more valued than cortisone. Troy Polamalu, Ray Lewis, Hines Ward, these are football guys. In terms of baseball, Alex Rodriguez, Alex Avila, Nelson Cruz, Brett Anderson.
Next up: Dr. Paul describes the amniotic allograft procedure. Stay tuned…