Episode 21 - Platelets for Regeneration: PRP in musculoskeletal injuries.

Why steroids are bad for tendons and cartilage long-term

Dr. Goodman explains why he steered away from steroid injections for Mike's rotator cuff tear, citing a 2017 JAMA study showing decreased cartilage volume in patients receiving steroid injections. This is where regenerative medicine like PRP comes in as an alternative.

"there's been a couple studies that have come out recently. The most recent one was back in 2017 in JAMA, where they actually looked at patients with knee arthritis and followed them out for two years and showed that patients that were getting triamcinolone injections, which is a steroid we commonly use in knee injections, had some significantly decreased cartilage volume compared to those who just got inarticular saline."

Chronic tendon pain is disordered healing, not inflammation

Dr. Goodman explains the key insight behind PRP: chronic tendon issues are tendinopathy (disordered healing) not tendinitis (inflammation). Anti-inflammatories miss the point. PRP restarts the healing cascade by delivering concentrated platelets with growth factors via alpha granules.

"Is it different than injecting something like a steroid or something like that into a joint? Sure. So, you know, we've used steroids for a long time in orthopedics and sports medicine, and there's certainly a role for those. But the more we learn about the pathophysiology behind, especially tendon pain and chronic tendon injury, we're learning more and more that there's probably a period initially where you have some kind of injury, whether that's small or whether you have a serious injury. But then, as time goes on, the inflammation that's associated with that acute injury starts to actually settle down, and what you're left with is this process of disordered healing. So, that tendon has tried to heal itself, but those collagen fibers have laid down in kind of an abnormal pattern. And because of that, you get into the cycle of repetitive kind of micro-trauma and tearing that leads to chronic pain over time. And so, we used to refer to all these as tendonitis, and people have probably heard that. And more and more, we're starting to classify these long-standing tendon issues as being more of a tendinopathy. And the itis usually refers to something that's inflammatory. And we're learning more and more that over time, there's really less of an inflammatory component that goes along with these. So when you take a kind of a biopsy of someone's tendon with some of these chronic tendon pain and issues, you really don't see a lot of inflammatory cells in there. and that makes us rethink how we've been going about treating these patients. So, you know, typically we've done things like steroid injections or non-steroidals that limit inflammation, and that's what we're focusing on is inflammation. But more and more, we think that the inflammatory aspect of this is actually fairly minimal this far out. And instead of focusing on inflammation and reducing inflammation, we need to focus on this disordered healing. And I think that's where PRP and some of treatments like that come into play because we can hopefully restart that healing process and get someone's body to heal itself with a little bit of help. And that's where platelet-rich plasma comes in, right? Like you're actually taking the patient's own plasma, focusing it on the platelets and injecting that into the space to try to improve healing, correct? Yeah, exactly. So when you get a cut or an injury, body responds by having the platelets aggregate in that area. So, let's say you cut your hand or your finger and you get a scab on that area. Well, the platelets are what forms that fiber and clot. And those platelets carry with them a lot of cytokines and growth factors in these alpha granules. And when they form, they release all of those, which sends signals to other cells in the area, but also up and down regulates gene expression to get your body to heal. So, that's why you can heal that kind of cut on your finger that you got over a period of time. So we're trying to recreate that process, but in a very localized area using a precision approach, typically with ultrasound, to put that medicine or the platelets, in this case, exactly where it needs to be."

Leukocyte-rich vs leukocyte-poor PRP for different conditions

The PRP preparation matters. Leukocyte-rich PRP with neutrophils may help break down disordered tendon tissue, while leukocyte-poor PRP is preferred for osteoarthritis where you want to limit inflammation. Dr. Goodman customizes the spin protocol based on the condition being treated.

"we have a system where we can select a neutrophil-rich or leukocyte-rich or leukocyte-poor PRP, and we can spin the platelets down accordingly based on a protocol to hopefully maximize what we're trying to do."

PRP procedure details and success stories with plantar fasciitis

The procedure takes about an hour: 60cc blood draw, two spins targeting 5 billion platelets, then ultrasound-guided injection. Dr. Goodman shares a success story of a woman in her 60s with years of plantar fasciitis who was pain-free two months after PRP plus tenotomy.

"two months out, she came back in almost in tears because her symptoms were gone and she was able to go to Europe and walk around and she was just super excited."