Tendon injuries can be very painful and difficult to heal, even with rest, medications and physical therapy. David Lisle, MD, orthopedic sports medicine physician, describes another option that involves injecting your own blood into the injury as a way to stimulate healing.
You can listen to an interview Dr. Lisle by clicking on the link below, or read the transcript below. Post any questions you have for Dr. Lisle as comments.
To learn more about Platelet Rich Plasma Therapy, visit www.UVMHealth.org/MedCenter/PRP.
UVM Medical Center: If you’re an athlete or just an active individual, there may come a time when you suffer from chronic pain due to tendon injuries. Some commonly known conditions are tennis elbow or jumper’s knee. Standard treatment options include medications, physical therapy and sometimes even surgery, but today we’re going to learn about a newer option called Platelet Rich Plasma Therapy or PRP, which uses an element in your blood, platelets, to rebuild the damaged tendons and thus offering some pain relief and speeding up the healing process.
University of Vermont Medical Center is one of the only centers in the region that offers PRP, and one of our doctors who specializes in this treatment is with us today to fill us in. He’s David Lisle, an orthopedic sports medicine physician at the UVM Medical Center and an Assistant Professor at the Larner College of Medicine. Thanks for being with us.
David Lisle: Thanks for having me.
UVM Medical Center: I think it might make sense to start with telling people what platelets are, because it’s not familiar to a lot of folks.
David Lisle: Platelets are found in our blood, and we know them most commonly as a blood clotter – when we cut ourselves, they clot the blood. They also have a very powerful ability: to signal to other cells and create the beginning of the healing process when we damage our tissues.
UVM Medical Center: I think when people give blood at the Red Cross, sometimes they just take the platelets out, right?
David Lisle: Most of the time when you donate blood, they do leave the platelets in. Those are primarily blood donations to harvest red blood cells. When we do PRP, we’re actually trying to remove those red blood cells from the preparation before treatment.
UVM Medical Center: How do you do that?
David Lisle: It’s as simple as a blood draw and much less blood is taken than what you would have if you’re donating blood. It’s usually anywhere from 30 to 60 cc’s, sometimes a little bit more. It’s just a blood draw that we do in the office. Then we take that blood and we put it in a centrifuge and spin it down and we remove the red blood cells and just take the platelets.
UVM Medical Center: Then it’s a process of reintroducing those to the area where there’s trouble.
David Lisle: Right. Depending on where the patient may have trouble, whether it’s in the elbow or the knee, also sometimes the rotator cuff, less commonly, we will use special imaging modality with ultrasound. Musculoskeletal ultrasound helps us see the damaged tissue, and with a needle we just re-inject the platelets into the area. Oftentimes we’ll create a small injury to that area, it’s a controlled injury to help stimulate healing while we inject the platelets.
UVM Medical Center: That’s interesting. It helps draw healing elements to that area?
David Lisle: Yes. The whole idea of the platelet treatment is that Tendinosis is a stagnant process in the body. The body has decided not to go ahead and heal that tendon for a multiple number of factors. When we do the procedure, we are creating a small injury to that tendon to let the body know that that is what needs to be healed. The platelets are just a more robust method to allow the body to heal and to recognize it. Platelets are very pro-inflammatory and inflammation is the first stage of healing of our body for anything.
UVM Medical Center: How long does it take to start working?
David Lisle: It really works right away. Patients … we certainly use some anesthetic to help numb the area. I liken it to having a tooth pulled. Initially, with the numbing medicine, it feels pretty good and when that wears off, patients do feel … it’s like getting a bee sting, several bee stings, but the platelets activate pretty much immediately and they begin that healing process. That being said, tendons are very slow movers when they heal, and so when I’m following patients through the process, I’m very careful to let them know that this is not a quick fix, this is something that’s … the PRP injection is just the beginning of the process and it can be six weeks to even three months before we are fully healed and the tendon is back close to its normal state.
UVM Medical Center: How well does it work?
David Lisle: The literature shows that most patients respond. I think the percentages out there are somewhere between 66% to 75%. In my experience, that’s about right. I think not everybody does respond to PRP, and we’re not entirely sure why. I think some of the patients who aren’t allowed or aren’t able to take some rest after the procedure, it is more challenging to get those folks to heal. Also if they have more severe symptoms coming in at the outset, then it’s also very hard to get those folks to heal. I’d say about three fourths will respond.
Each tendon has its own challenges. The most common one might be the lateral epicondyle, which is the tennis elbow, the lateral part of the elbow, and the medial epicondyle also called golfer’s elbow. Those seem to respond pretty well. I’d say the Achilles tendon and the rotator cuff tendon respond the least and are on the lower side of the percentages for healing.
UVM Medical Center: You were saying before that you prefer that there’s less activity afterward, which makes sense. How quiet do people need to be? You were also talking about folks who just can’t accomplish that because of their job or whatever.
David Lisle: Sure. After the procedure, we like to immobilize the joint for 48 hours. If we can get a patient to take a week, even two weeks off of any heavy manual labor, that’s very helpful. Sometimes it’s just not possible. Some folks need to go back to work after three or four days. After the procedure, I am careful to give them a note for work. They either get a sling or a knee immobilizer or a walking boot to keep that joint shut down for a few days. They also get a physical therapy referral, which starts at the two week mark, and that’s extremely important for the whole process. The PRP jumpstarts the healing, but the physical therapy at about the two week mark helps with the healing process, as well.
UVM Medical Center: I think we probably should make sure people understand what tendons are and their function, and why do they get into this condition where it gets painful?
David Lisle: Yeah. Tendons are what connects our muscles to bones. They typically have relatively poor blood supply and they are subjected to different stresses, depending on the tendons. For instance, the rotator cuff sees some tensile or stretching type stress.
UVM Medical Center: That’s in the shoulder?
David Lisle: In the shoulder, right, in the shoulder. Also some compressive forces. The Achilles mostly sees some tensile stress, as well. Each tendon has its own load that sometimes creates injury over time. Tendinosis implies small microscopic injuries to the substance, the tendon. When we think about tendons, we think about many, many threads, thousands of threads, or think of uncooked spaghetti, if you will. Very organized, linear pattern for that tendon.
With Tendinosis, over time, small injuries create … I don’t like to use the word scar tissue, but they create small tears, microscopic tears in that tendon, and the body tries to heal those, but over time, with back and forth tearing and healing, the body shuts down the attempt to heal and often that tendon becomes stagnant in a painful state and that’s what Tendinosis is.
The whole idea of platelets, re-injecting them in the area, is to create that healing response, jumpstart the healing to get the body to recognize an injury and start the inflammation that begins the healing.
UVM Medical Center: The stagnance comes from poor blood supply? You were saying before they just don’t normally have a good blood supply.
David Lisle: Yeah, most tendons don’t have great blood supplies. If you look under a microscope, you see very few vessels. Over time, if a tendon sees too much load, sees overuse, really, then it can be stuck in a state called Tendinosis, which is quite painful and debilitating.
UVM Medical Center: Dr. Lisle, who are the best candidates for this?
David Lisle: I think anybody with Tendinosis is a potential candidate. We do, obviously, have a visit to discuss the procedure and also get a sense of how severe the Tendinosis is. I believe those who are very motivated are excellent candidates. One thing to consider also is that most insurances do not cover PRP except for Workers Compensation. One of the barriers, of course, is cost, unfortunately. We have worked hard to keep the cost of PRP down to help provide it for as many patients as possible, but I would say any patient with Tendinosis is potentially a candidate.
UVM Medical Center: Is there a sense about insurance companies coming around on that and covering it at some point?
David Lisle: At the moment, it’s still listed as an experimental procedure and as more and more literature shows a positive result, I think it will get shifted over into a covered procedure.
UVM Medical Center: How long has it been around?
David Lisle: It started in ’06 in Stanford, so it’s been around for a little over 10 years. The initial studies were only on the elbow and the studies were so positive that other scientists started looking at platelets a little more carefully. A lot of the studies on tendon repair are done in Scandinavia and a lot of those articles and experiments are extremely positive. It’s been around for over 10 years now and I think it’s taken hold. I would say that almost everywhere in the country, there are folks using platelets to heal tendons.
I think one thing that needs to be said is that there are areas in the body that we do not use PRP for. I get asked or requested to do PRP injections for injuries, or in places that have no studies or no literature to base that procedure on. For instance, most recently somebody asked to have PRP in the AC joint, the acromioclavicular joint in the shoulder, a smaller joint on the top of the shoulder. There really is no evidence for that to be placed in that region, so I wasn’t really comfortable taking that leap.
UVM Medical Center: Are there any side effects?
David Lisle: I would say the most common side effect is pain. It’s like a bee sting or a multiple bee stings. When the numbing medicine wears off, no question, the number one side effect is pain. But since it’s using your own tissue, your own blood, the body responds very nicely to that. There is very few negative side effects. Of course, the worst case scenario is it just doesn’t work, but we aren’t introducing anything foreign into the body. The primary thing that I tell patients is that after the numbing medicine wears off, it’s going to be somewhat uncomfortable and, like I said before, it’s like having a wisdom tooth removed, when the numbing medicine wears off, it’s a little bit uncomfortable. I usually do give somebody a very small number of tablets of medicine to help with that first evening, for the next day.
UVM Medical Center: For the percentage of folks for whom it doesn’t work, what happens then?
David Lisle: It depends. Sometimes we will try a second PRP injection or a treatment. It depends on how much it didn’t work. If there’s a partial response and we’re just not quite where we want to be, sometimes we’ll try a second PRP. If we had absolutely no response to the platelets, then in certain instances, we do look into a surgical correction, but we do know that the surgery is for Tendinopathies or for Tendinosis is not 100% successful either. That’s why we like to do the non-invasive or minimally invasive procedures first. If someone fails the treatments, then sometimes we do have to look into a surgical correction.
UVM Medical Center: Is that a really extensive process? Long recovery time and all that?
David Lisle: There is a long recovery time, but it’s extremely different for every tendon. If we’re talking about the rotator cuff tendons or the tennis elbow tendons, every recovery is going to be very different based on the different tendons.
UVM Medical Center: I’m afraid to say we’re out of time, but I want to thank Dr. David Lisle. He’s an orthopedic sports medicine physician at the University of Vermont Medical Center and Assistant Professor at the Larner College of Medicine. If you want to learn more about our sports medicine program at the UVM Medical Center, you can go to our website, which is uvmhealth.org and there’s a search box at the top right of the homepage and you put in sports medicine and that’ll bring you to a page with a lot of information. Thanks very much for being with us.
David Lisle: Thank you.