Regenerative Injections- Let's Be Honest Here

Concerned. Disappointed. Those are the first words that come to mind when I read or hear about another non-physician advertising regenerative injections, such as stem cell or platelet-rich plasma. I’ll be honest here…the greatest number of advertisements come from the practices of chiropractors. Here’s the irony: chiropractors cannot legally give orthopedic-based injections. So, what’s the catch? Most hire mid-level providers, physician assistants (PAs) or nurse practitioners (NPs), to give these injections. Mid-levels serve very valuable roles in our healthcare system. Some are skilled enough to provide injections in a very competent fashion. However, our medical system has been designed such that mid-levels are mentored and directly supervised by medical doctors who have expertise in providing procedures such as injections. In the case of a chiropractor’s office, how can the supervising chiropractor mentor or teach the mid-level to do an injection when he or she has never given a joint, tendon or other similar injection in his or her entire career? It just doesn’t make sense, plain and simple. Then, you are talking about very advanced injections, most of which are not covered by insurance and cost the patient hundreds to thousands of dollars. Finally, many of these injections done by mid-levels are not guided in any fashion, meaning neither ultrasound nor fluoroscopy (live x-ray) is used. Thus, the accuracy of the injection is likely less than optimal.

Here’s the bottom line: even with all the radio, magazine, TV and social media advertising done by some practices claiming to be experts in “regenerative injections,” you need to carefully choose who you want to provide these advanced office procedures. I have a very healthy respect for several of my colleagues who are chiropractors. I freely refer to them. They do an excellent job with care of the spine and rehabilitation of some extremity issues as well. However, orthopedic injections are just not in their wheelhouse.

At Impact Sports Medicine and Orthopedics, we have used ultrasound guidance for 10 years and only after taking a minimum of 6 courses on the subject. We are carefully studying the science and trends pertaining to regenerative injections and have provided these to our patients over the past 8 years. We are not the only ones in the Nashville area doing these advanced injections, but you will be hard-pressed to find any practice more experienced or dedicated to the honesty and integrity of the process.

-F. Clarke Holmes, M.D.

The Top 5 Reasons to Have a Regenerative Injection

Regenerative injections, also known as orthobiologic injections, include platelet-rich plasma (PRP), amniotic membrane and fluid, alpha-2 macroglobulin and mesenchymal stem cell (MSC)

1)      Cortisone has not gotten the job done- corticosteroid injections are potent anti-inflammatories and can be effective in treating inflammatory conditions, but these have either zero or even a detrimental effect on healing. Most chronic tendon problems are not inflammatory, and thus, cortisone will provide minimal long-term benefit. Not all cases of arthritis are inflammatory either.

2)      You are hoping to avoid surgery or you had surgery and are less than satisfied- we know that certain surgeries produce superior outcomes compared to nonsurgical treatment, particularly in younger and active individuals. Examples include ACL reconstruction after a full ACL tear and shoulder stabilizing procedures after multiple dislocations. However, there are numerous conditions that have equal or superior outcomes with nonsurgical treatment. These include small tears of the rotator cuff, hamstring, patellar and Achilles tendons; plantar fasciitis; degenerative meniscal tears; tennis and golfer’s elbow and mild to moderate osteoarthritis of the knee, hip, shoulder and basal thumb joint. These conditions are ideal candidates for regenerative injections, especially when traditional surgical and nonsurgical treatments are not producing major levels of benefit

3)      Cost- no, insurance does not cover regenerative injections. However, these injections are designed to provide long-term or permanent benefit. The expected goals are months to years of reduction in pain, improvement in function, soft tissue healing and slowing or suspending joint degeneration, i.e., preventing osteoarthritis from getting worse. Thus, these injections have a very good chance of saving you money. These benefits translate into fewer physician’s visits, fewer trips to physical therapy (although we still see the value of PT), fewer medications and potentially, the elimination of the need for an expensive surgery.

4)      You want a game-changing treatment, not one that just treats symptoms- regenerative injections are designed to change the environment of the area injected. Through the introduction of nutrients, growth factors and potentially stem cells, the goal of these injections is to not only make a patient feel and function better, but also to produce a healing response. This can mean tendon or ligament re-growth, cartilage regeneration and/or the reduction of unhealthy inflammation in the area of damage.

5)      The medical literature- although insurance companies would like to paint regenerative injections as “experimental” and thus not pay for them, the truth is that there are now hundreds of studies that demonstrate a clinically significant benefit in the treatment of chronic tendon problems and osteoarthritis with regenerative injections. In fact, hot off the press, a prominent sports medicine journal just posted a detailed review of orthobiologic injections. The authors came to this conclusion:  There was a total of 21 PRP (platelet-rich plasma) studies in the study. All PRP studies showed clinical improvement with PRP therapies in outcomes surveys measuring patient satisfaction, pain, and function…. The one PRP study that had a 2nd look arthroscopy reported increased cartilage regeneration with PRP. All 8 MSC (mesenchymal stem cell) studies with follow-up MRI and all 7 MSC studies with 2nd look arthroscopy showed improvement in cartilage regeneration in terms of coverage, fill of the defect, and/or firmness of the new cartilage.

Translation: patients are very satisfied with their outcomes after receiving these injections, and there is evidence that new cartilage is growing in response to these injections.

In conclusion, regenerative injections are rapidly entering and evolving within the world of orthopedic medicine. At this point, both their present and future look very bright. When considering a regenerative injection, seek the consultation of a medical doctor who has vast experience in researching and performing these procedures.

-Clarke Holmes, M.D.