PRP Treatments: Why the Details Matter in Regenerative Orthopedics

PRP (platelet-rich plasma) has become one of the most recognized treatments in regenerative orthopedics, but “PRP treatments” can mean different things depending on how it is prepared, what is being treated and what other regenerative components may be used with it. At Breakthrough Regenerative Orthopedics, Dr. Timothy Taylor looks beyond simply giving a PRP injection. From platelet concentration and the type of tissue being treated to combining PRP with platelet-poor plasma (PPP), alpha-2 macroglobulin (A2M) or hyaluronic acid (HA), the treatment is tailored to the injury and the individual patient.

What is PRP, and why does the specific preparation of PRP matter?

PRP, or platelet-rich plasma, contains concentrated platelets and white blood cells along with multiple growth factors that play a role in the body's healing process. When we prepare PRP, one of the primary things we're looking for is a high concentration of platelets and the right types of white blood cells. If we can get a good platelet dose from a patient's blood draw, we know we've created a product that can help stimulate the healing response we're looking for.

The preparation matters because if PRP isn't prepared appropriately, you may end up with a lower and less effective platelet dose that doesn't produce the response we want. Studies on platelet dose are clear- superior outcomes are obtained with platelet dose over a specific threshold- generally around 5-10 billion platelets.  PRP initiates an inflammatory response. That is intentional as inflammation is the first step in the healing cascade. We're trying to activate the body's healing response and get it focused on the area we've treated.  Platelets call stem cells to the area where they are injected and this further continues the healing response.

We can also modify the PRP depending on what tissue injury we're treating. Inside a joint, for example, we may not want as much of an inflammatory response or additional swelling. If I'm treating a tendon, ligament or muscle, however, I may want more of that initial inflammatory response to help stimulate tendon healing. So when treating with PRP,, there isn't one formulation that we use for everything.

What types of injuries and areas of the body can be treated with PRP?

We use PRP throughout the body. We can use it inside joints and to treat tendons, ligaments and muscles and fascia injuries. Where the injury is located isn't necessarily the deciding factor. What I'm looking at is what is the type of structure that's injured, the extent of the injury and what we're trying to accomplish with the treatment.

The size of the injury and the number of structures we're treating can determine how much PRP we need. The formulation may also change depending on whether we're treating a joint versus a tendon, ligament or muscle.  In certain cases, the injury is so severe that we may opt for stem cells instead of PRP, as the stem cell treatments can be significantly stronger than PRP especially when considering structural healing.

That's why we don't look at PRP as simply a shot that we give for a particular body part. We're determining exactly what is injured and then deciding which formulation of PRP can best be used for that particular tissue.  We may even want to include Platelet-poor Plasma or PPP or plasma protein concentrate with alpha 2-macroglobulin.

What is platelet-poor plasma, and how does A2M fit into regenerative treatment?

Platelet-poor plasma, or PPP, is what's left after we prepare platelet-rich plasma and remove the red blood cells. For a long time, it was essentially treated as a byproduct and discarded. More recently, research has shown us that there are still a lot of proteins, healing factors and growth factors within PPP that can be extremely useful.

One we're particularly interested in is A2M, or alpha-2-macroglobulin, which is one protein that is concentrated in the plasma protein concentrate we prepare when desired. In osteoarthritis where cartilage inside a joint is injured, there are enzymes (matrix metalloproteases) involved in the process of breaking down damaged cartilage. The problem is that these enzymes can begin chewing up healthy cartilage as well as the scar tissue they were designed to remove.

A2M binds to those enzymes and slows down that degenerative process. That's particularly interesting when we're treating an arthritic joint because we're not only thinking about how to stimulate healing; we're also thinking about what's happening within the joint environment.

PPP can also complement what we're doing with PRP in treating muscle injuries. PRP can help increase the proliferation, or number, of cells in an injured area. PPP contains factors that can support muscle cell differentiation—the process of helping precursor cells develop into muscle. Combining those different components gives us another way to support the overall healing process.

Finally, the plasma protein concentrate we prepare from the PPP contains A2M, IgF-1, Fibrinogen and Fibrinonectin, all of which are helpful with healing of soft tissue injuries such as tendons, ligaments, muscle and fascia.   So now, many times we combine the PRP with the plasma protein concentrate (rich in A2M and other proteins) to strengthen the soft tissue injuries we used to treat with just PRP and PPP.

Why would you combine PRP with hyaluronic acid?

We use PRP with hyaluronic acid for a number of regenerative treatments, including both joints and soft tissues.

With soft-tissue injuries, hyaluronic acid can help moderate some of the initial flare associated with PRP and support a smoother healing process. It can increase hydration within the tissue and help reduce things like scar tissue and adhesions as the area heals.

Inside a joint, hyaluronic acid also provides lubrication and cushioning, which can help the joint move more smoothly. It can have a calming effect on inflammation and swelling as well.  The combination has been shown to be superior to PRP alone in the treatment of knee osteoarthritis for example so we recommend that combination for most cases of joint osteoarthritis.
There are situations where hyaluronic acid can even be helpful on its own. For a patient with osteoarthritis, depending on the severity, improving lubrication and reducing friction within the joint may help calm things down and allow that person to return to more of their normal activity.

The important thing is that we're not automatically adding something because it's part of a standard recipe. We're looking at what we're treating and determining which combination makes sense for that patient.
How much downtime should a patient expect after PRP treatment?
Downtime depends heavily on what we're treating.

Soft tissues generally take longer to heal, and patients are usually more sore after treatment of soft tissues than simple joint arthritis. If I'm treating a tendon or one of the major ligaments around the knee, for example, I'm going to want that patient taking it easier while the tissue heals. Recovery in that situation may be in the six-to-eight-week range before you're progressing back toward more demanding activities.

A PRP injection into a joint can be different. Once we've placed PRP inside the joint, it stays within that environment and begins doing its job. I still wouldn't recommend that someone go skiing the following week, but depending on the patient and the severity of the problem, being back on the slopes around four weeks later may be reasonable.

This is why timing matters. If there's something you want to get back to—ski season, a trip, a race or another activity—tell us. We can talk about the expected healing timeline and plan treatment around your goals rather than treating the injury without considering what you want to do afterward.  Shockwave or prolotherapy may be a better choice if you are in the middle of a new class or your training season.

How long does it take to know whether PRP treatments are working?

One of the things I tell patients is that the body naturally takes time to heal. Think about something as common as rolling your ankle. Even with a relatively straightforward sprain, it can take three to four months before you're really feeling back to your normal 100%.

Regenerative medicine follows a similar timeline- these are just the rules of biology.

When I see a patient at their first follow-up, usually around six to eight weeks after a procedure, I expect to see improvement in things like strength and function. That doesn't necessarily mean I expect their pain to be gone at that point.

Around the three-to-four-month mark, we have a much better idea of what we've gotten out of the treatment. That's when we're looking at how the patient is feeling, how their function has changed and whether they're getting back to the things they want to do.

It's important for patients to understand that regenerative treatment is a process. We're stimulating the body to heal; we're not simply masking symptoms and expecting an immediate result.  In addition, follow-on treatments such as nerve hydrodissections or shockwave may be needed to finish the healing process and diminish your pain.

How much does PRP treatment cost?

The cost depends on what we're treating and how many treatment targets are involved. Treating one or two targets is very different from treating multiple structures, and the components we use can also affect the overall cost.
That's why I don't like to give patients a generic PRP price without first evaluating them.

During the initial assessment, we're going to determine what is actually causing the problem and develop the treatment plan together. Once we know the number of treatment targets and whether we're recommending PRP alone or combining it with something such as A2M or hyaluronic acid, we can give the patient a much better idea of the expected cost.

I'll review my examination notes and determine if there's another area we should consider treating—or potentially remove or combine treatment targets that I initially thought might need treatment. That can also impact the final cost.

The goal is for the patient to understand what we're recommending, why we're recommending it and approximately what it will cost before they make the decision to move forward.

Is PRP the Right Treatment for Your Injury?

PRP treatments aren't a one-size-fits-all injection. The tissue being treated, severity of the injury, preparation of the PRP and combination of regenerative treatments can all affect the treatment plan. At Breakthrough Regenerative Orthopedics, Dr. Timothy Taylor starts with a comprehensive 90-minute evaluation to determine what's actually causing your pain and which approach makes sense for your body, your injury and your goals. Schedule an evaluation to learn whether PRP or another regenerative orthopedic treatment may be an appropriate next step.