“Stem cell injections” is a term patients are seeing more frequently, but it can mean very different things depending on where the cells come from and what is being treated. In regenerative orthopedics, Dr. Timothy Taylor uses a patient’s own bone marrow or adipose tissue (fat) as part of a targeted treatment plan for orthopedic injuries and joint conditions. Understanding the differences between bone marrow aspirate concentrate (BMAC), microfragmented adipose tissue (MFAT) and platelet-rich plasma (PRP) can help patients better understand why one approach may be recommended over another.

What do you mean when you talk about stem cell injections in regenerative orthopedics?

When we're talking about stem cells in regenerative orthopedics, we're primarily looking at mesenchymal stem cells (MSC’s). These are progenitor cells that have the ability to differentiate into different types of musculoskeletal tissue, including bone, cartilage, muscle, tendon and ligament.  More recent research suggests that perhaps we should be calling these medicinal signalling cells (MSC’s) as that differentiation mentioned above happens mainly in the lab.  In the human body after injection, these cells work more like orchestra conductors encouraging all the other cellular healing processes to move forward.  Only a minority of these stem cells are actually incorporated into the new tissues created.

We use a couple of different sources for these cells. Two of the primary FDA-approved options we use at Breakthrough are bone marrow aspirate concentrate, or BMAC, and microfragmented adipose tissue, or MFAT. Both give us regenerative components that we can use as part of a treatment, but they have different characteristics that can make one more appropriate than another depending on the structure we're treating.

While umbilical stem cells and exosomes hold a lot of promise, the FDA has not approved them for use in the USA even though many other regenerative orthopedic clinics use them.  To date, the FDA has required clinics to harvest and treat with stem cells on the same day and use those cells or tissues in a manner that is consistent with their normal function in the body- this is called “homologous use.”  

We at Breakthrough Regenerative Orthopedics, comply with these FDA regulations for stem cell use and are proud to do so.

What is BMAC, or bone marrow aspirate concentrate?

With BMAC, we take bone marrow, often from the posterior iliac crest at the back of the hip. We then concentrate that bone marrow in a process somewhat similar to the way we prepare PRP from a patient's blood.

The resulting bone marrow aspirate concentrate contains platelets, mesenchymal stem cells, hematopoietic stem cells and a variety of growth factors.

I particularly like BMAC for treating joints. We can place it into the joint itself, but there are also situations where we may use it to treat problems within the bone underneath that joint.  

Dr. Mazzola spent thousands of dollars and months of self-funded research to ensure that our BMAC is of the highest quality and concentrates stem cells better than most published protocols.

Why would you inject BMAC into the bone itself?

When a joint has significant arthritis, some patients also develop bone marrow lesions or bone marrow edema deep to the cartilage. We can see these areas on an MRI. Essentially, we're seeing impaired bone function and bony degeneration occurring within the bone itself, and these lesions can be very painful and can take a long time to heal on their own.  Interestingly, this bone below the cartilage (called subchondral bone) communicates and supports the health of the cartilage overlying it.

When we're treating osteoarthritis, we may put BMAC or another regenerative treatment inside the joint to help calm the joint environment. But if there is also a bone marrow lesion, we may need to inject directly into the bone as well.  Research studies by Dr. Hernigou of France have detailed the significant superiority of treating this subchondral bone versus simply treating inside the joint with remarkable improvements over 15 years of outcome data!

That allows us to treat what's happening on both sides of the cartilage—from within the joint and within the bone the cartilage. We're looking at the relationship between the cartilage and the bone it connects to rather than focusing on only one piece of the problem.

That can make a significant difference in patient outcomes as Dr. Hernigou’s studies have clearly shown.

Does getting bone marrow for a stem cell injection hurt?

It can be uncomfortable, but we do a lot to make the procedure as comfortable as possible.

When we're obtaining bone marrow or treating an area inside the bone, we carefully anesthetize the skin and the tissue all the way down to the bone. We also numb the periosteum, which is the sensitive outer layer of the bone.  In addition, if we are harvesting bone marrow from the hip bone we provide a caudal block which takes the pain of harvesting typically down to a 2-3/10 level of pain.  Without the caudal block, pain was typically around a 7-8/10 so this is a big improvement.

We also can provide nerve blocks to the areas being treated which lowers pain in the treated area significantly.  Finally we can use some gentle sedation medications which even further lowers pain.  At Breakthrough, our goal is to keep patients as comfortable as possible during these advance stem cell procedures.

Once everything is numb, what patients are most likely to notice is a change in pressure. When we're aspirating bone marrow, there's negative pressure as we draw it out. Patients may describe that as a deep, achy sensation.

Similarly, if we're injecting into the bone to treat a bone marrow lesion, there can be a temporary increase in pressure. A patient may suddenly notice, “Okay, I can tell something is happening there.”

That sensation is generally brief. We're talking about moments rather than several minutes of significant discomfort. The area may feel achy afterward, but patients are able to get up and walk out of the office. More common than not, patients tell us that their procedures hurt alot less than they were imagining!

How do you decide between PRP and a stem cell procedure?

A lot depends on the severity of the injury and what we're treating. For many soft-tissue injuries, I really like PRP. It's less expensive for the patient, it can do an excellent job, and because we're obtaining it through a blood draw, I can usually prepare enough PRP to treat multiple areas if necessary.

So, for injuries that aren't as severe, PRP may be all we need.

With a more significant soft tissue or joint problem, the treatment plan can be different. The knee is a good example because it's one of the most common joints we treat. Depending on what's happening within the knee, I may recommend a multi-step process that includes either BMAC or MFAT, rather than simply choosing PRP or stem cells as an either/or treatment.

Likewise if there are significant soft tissue injuries, we’ve learned that MFAT is stronger than PRP alone as MFAT provides a bioscaffold as well as the most stem cells per volume that the FDA allows.  So for bad SI instability, muscle or tendon tears, we really lean on MFAT alot at Breakthrough Regenerative Orthopedics.

Why would you use PRP and stem cell injections as part of the same treatment plan?

For some joint conditions, I may start with PRP to help change and calm the environment inside the joint. Then, approximately a month later, we can go in with the stem cell treatment.

The idea is that we're creating a better environment before introducing the stem cells. Rather than putting them into a highly inflammatory joint, we're trying to get that joint into a better place first.  This leads to better stem cell survival upon injection so they can do their job better.

Then, depending on the treatment plan, I may follow the stem cell procedure with another PRP treatment about a month later to boost the stem cells already provided. PRP can be used again as part of the process of helping the joint move through that healing cycle.

That's why regenerative orthopedics isn't necessarily about picking one product and giving one injection. We're looking at what is happening biologically and structurally and developing a treatment plan around that individual joint and patient.

What is MFAT, or microfragmented adipose tissue?

MFAT stands for microfragmented adipose tissue. This is adipose, or fatty tissue, taken from the patient's own body and processed so we can use it as part of a regenerative orthopedic treatment.

One of the things we like about adipose tissue is that it contains a high concentration of mesenchymal stem cells- even higher counts than BMAC per volume. It also contains pericytes and perivascular cells that can play a role in cell signaling and helping those regenerative cells function within the area we're treating.

MFAT also has another characteristic that's very different from PRP or BMAC: its physical structure.

PRP and BMAC are a liquid. Adipose tissue has more structural substance to it. It creates a type of biological scaffold, and that can be particularly useful when we're treating damaged soft tissues or for cushioning inside a joint.

Why do you like MFAT for tendon, ligament and muscle injuries?

This is one of the really interesting things about using MFAT for soft-tissue injuries.

When I'm treating an injury with ultrasound guidance, I can actually see a tear in a tendon, ligament or muscle as I’m numbing up the area. As I inject anesthetic into that area, I can see that tear open up on the ultrasound image.

I then know precisely where to treat with MFAT, and I can see the MFAT fill that defect or tear in the soft tissues. Instead of simply injecting a liquid we now have structural tissue acting as a biological scaffold that is also full of regenerative cells sitting directly within the exact area we're trying to treat.

That's one reason I really like MFAT for soft tissue injuries. It can provide some immediate structural support within the injury while also giving us the regenerative components needed to support the healing process.

We can use MFAT in joints as well, but this is more for its joint cushioning effects.  It has also been shown to have longer lasting effects in joints than PRP.

How does the Breakthrough team work with patients throughout a regenerative treatment plan?

Regenerative treatment often involves multiple touchpoints. We want to see how the patient is progressing rather than simply performing a procedure and sending them on their way.

Patients may see our medical assistant, me or our physician assistant at different points in the process. We generally want to follow up around six to eight weeks after a procedure and again around the three-to-four-month mark. 

We're looking at how the patient is healing, whether function has improved and whether there's anything that needs additional attention. Sometimes, once we stabilize one structure, another issue becomes more apparent.

We also work closely with other providers in the community, including physical therapists, physicians, acupuncturists, bodyworkers and other healthcare professionals. A physical therapist may see a patient every week when I don't, so communication between providers helps us understand how that patient is progressing between appointments.

The goal is to have everyone working toward the same outcome for the patient.

Why do you look beyond the specific joint or injury that's hurting?

One thing I really like about Breakthrough is that we do a lot of root-cause analysis.

If someone comes in with knee pain or knee arthritis, I'm not necessarily going to look only at the knee. I'm going to look from their lumbar core all the way down to their feet and ask what may be driving the problem that is leading to pain in that knee.

Was there a specific injury years ago? Is there something happening within the core that's causing the patient to compensate? Is there SI instability or gluteal weakness?  Is the foot out of alignment?  Is that compensation creating additional stress or overuse within the knee?

We want to understand what's happening upstream and downstream from the patient's primary complaint.

If someone invests the time, money and work into treating and rehabilitating an injury, I don't want them to go back to their normal activities only to have the symptoms return because we never addressed the underlying factors that led to the problem in the first place.

That's a big part of how we approach patients at Breakthrough. We're trying to understand the patient in a more complete way rather than simply saying, “You came in with knee pain, so we're only going to look at your knee.”  We’re looking for root cause analysis and trying to correct the dysfunctions and substitution patterns that led to the sore knee or elbow.

Could a Stem Cell Treatment Be an Option for Your Injury?

Choosing between PRP, BMAC, MFAT or another regenerative treatment starts with understanding the injury—not choosing an injection from a menu. Dr. Timothy Taylor and the Breakthrough Regenerative Orthopedics team use a comprehensive physical examination, imaging and musculoskeletal ultrasound when appropriate to identify the structures involved and build a treatment plan around the individual patient. If joint pain or a tendon, ligament or muscle injury is keeping you from the activities you want to do, schedule an evaluation to learn which regenerative orthopedic options may be appropriate for you.