Rotator cuff tears affect over 22% of the normal population and this percentage climbs to over 36% in patients in their 80’s according to one study published in the Journal of Orthopedics. The scary fact found in this study that up to 2/3rds of the patients above the age of 60 had no symptoms of the tear! Thus, we can see that rotator cuff problems are very common as we age and most of us will never know if we ever have this problem until our shoulders become painful and dysfunctional at a later date.
The rotator cuff is a group of four major muscles coming together to help “rotate” the shoulder joint. The true cause of rotator cuff tears can be multifactorial meaning that there are many reasons we cannot account for the disease. However, some researchers have found a common thread in biopsies performed at the area of the tear. There seems to be a link between a decrease in stem cells around where the tear happens. Repairing the tear and supplementing the repair with stem cells helps the repair process and prevent retearing according to another study. Although, there are only a few studies on this subject, there appears to be a link between the lack of cells and disease and the replacement of these cells and success.
A new technique combining hyaluronic acid and platelet rich plasma named enhanced PRP may provide this same type of results without a major surgery or the extended cost of stem cell therapy. Hyaluronic acid has been used for numerous medical conditions such as cataracts, skin wrinkles and arthritis for over 20 years. In orthopedics we have used this under the trade names Orthovisc, Monovisc or Supartz with about 50-60% of patients responding positively with knee arthritis. Although the mechanisms of action are many, a simplified explanation is that this cushions and lubricates the joint. However, not only does it cushion and lubricate, it is a natural carrier or substrate for growth factors. Hyaluronic acid provides an optimal environment for cells to live and thrive. However, it lacks the essential growth factors found in our body for the repair of damaged tissue. Luckily, platelet rich plasma contains numerous growth factors including Platelet Derived Growth Factor (PDGH) and Vascular Endothelial Growth Factor (VEGF). These are released fairly quickly when injected into an area of damage and they are lost within the bloodstream. However, when they are injected with a hydrogel such as hyaluronic acid, they can be slowly released in the area of damage over a longer period of time. This slow release, coupled by the fact that hyaluronic acid acts as a scaffold for tissue healing provides an optimal environment for the treatment of small to midsize rotator cuff tears. Not only is this a theoretical treatment, but one which was tested in a double blinded, placebo controlled study.
Patients were split into 4 groups of about 50 patients into each group. All the patients had a partial tear of the rotator cuff. One group received normal saline as a placebo, Group 2 received Hyaluronic Acid ( HA), Group 3 received PRP and Group 4 received the combination of PRP + HA. Patients were followed closely with follow up visits at 1,3,6 and 12 months and a repeat MRI. Patients were asked to complete two surveys ( the Constant Score and the American Shoulder and Elbow Surgeon). The PRP and the PRP+HA groups improved. The PRP + HA group improved the pain and function ASES score by 40.82 points and the PRP group improved by 27.02 while the HA group only improved 11.34 points and the Saline group worsened by 1.21 points. The Constant score confirmed these findings with an improvement of the PRP+HA group by 33.19 pts. The PRP group improved by 23.73 pts and the HA group by 12.93 pts. However, surprisingly the MRI scoring of the size and retraction of the rotator cuff also improved. In the combination therapy group, the score improved 5.85 pts; the PRP group also had an improvement of 2.89 pts and the HA group only improved 0.41 pt. However, the saline group worsened by 2 pts. What this data shows is that not only does the combination of HA and PRP provide far superior clinical results with reduction of pain and increased function of the shoulder, but it also demonstrates healing of the partial rotator cuff tears.
The best part of this treatment is the value for patients. The cost of this combination therapy for shoulders is about $1050 which is much lower than the cost of many PRP injections and certainly lower than stem cell therapies and surgical repair. In addition, the complication rates of these injections is very low. At Cellular Healing, we provide nearly painless injections with the additional use of nitrous oxide (laughing gas) anesthetic. There are no major restrictions after these injections and you can return to work or play the next day. The only drawback is the fact that you may need to have this repeated every 1-2 years. Thus, you could argue that the combination treatment of HA and PRP is one of the best values in orthopedic medicine.
You can call 810-299-8552 for a personal one-on one consultation or you can click HERE to schedule on-line.
 Minagawa H, Yamamoto N, Abe H, et al. Prevalence of symptomatic and asymptomatic rotator cuff tears in the general population: From mass-screening in one village. J Orthop. 2013;10(1):8–12. Published 2013 Feb 26. doi:10.1016/j.jor.2013.01.008
 Cai YU, Sun Z, Liao B, Song Z, Xiao T, Zhu P. Sodium Hyaluronate and Platelet-Rich Plasma for Partial-Thickness Rotator Cuff Tears. Med Sci Sports Exerc. 2019;51(2):227–233. doi:10.1249/MSS.0000000000001781
Combination of a Joint Lubricant and Natural Growth Factors May Be The Best Since Peanut Butter & Chocolate?
Remember the ads for Reese's Peanut Butter Cups? When peanut butter collided with chocolate and a match made in heaven was born. That image came up again when I started to read the studies on the combination of platelet rich plasma with hyaluronic acid and I thought again “a match made in heaven.”
Hyaluronic Acid Restores Natural Lubrication
Hyaluronic Acid (HA) was FDA approval for the treatment of osteoarthritis of the knee since the 1990’s. The major mechanisms of actions are proposed to restore the normal viscosity (thickness) of the joint fluid and the reduction of inflammatory products produced by an osteoarthritic joint. Interestingly enough, hyaluronic acid can be formed into many different shapes as a scaffold for three dimensional mesenchymal stem cell growth. The problem with hyaluronic acid treatments in the past has been the low response rate. Only 50 to 60% of the patients receiving hyaluronic injections in the knee have a positive response. This has lead some organizations such as the American Academy of Orthopedic Surgeons (AAOS) to rescind its initial recommendation of this treatment for arthritis. ( see references)
Platelet Rich Plasma Restores Natural Balance
Platelet Rich Plasma (PRP) has also been used in orthopedics since the 1990’s but mainly to enhance procedures using large bone grafts. Recently, this has been expanded to treat common tendon and joint problems with some success. The mechanisms of action of PRP are also numerous, but two main proposed actions include reduction of harmful biochemicals as well as the delivery of important growth factors necessary for joint hemostasis (the balance between damage and repair with each of our joints). Since, PRP is made from the host (you), it is not considered a drug and thus, does not need FDA approval. Numerous studies have been conducted comparing PRP to HA and although both provide positive benefits, PRP has been shown to have wider response in a greater number of patients over a longer period of time. Yet, there are still failures of both treatments. This led researchers to ponder the thought of combining HA with PRP to see if there is synergistic effect. (see references)
Combining PRP and HA Complement Each Other
Basic research into the possibility of combining the positive benefits of restoring the natural thickness and function of the joint fluid with the growth factor benefits of platelet rich plasma led to the proposal of a three armed study comparing HA, PRP and the combination therapy of PRP and HA. In addition, a sequence of basic science studies proposed numerous positive mechanisms of action to reduce proinflammatory chemical production; protection of the cartilage and meniscus; as well as reducing the production of osteoarthritis immune cells. Thus, scientists followed these recommendations and designed a few studies on human knee osteoarthritis to see if these proposals are true.
Researchers in China have performed controlled studies examining the clinical effects of combining hyaluronic acid and platelet rich plasma for two very common orthopedic conditions, namely arthritis of the knee and partial rotator cuff tears of the shoulder. Both studies had positive results. ( see references)
HA and PRP Combo Provides Superior Results for Knee Arthritis
In the knee arthritis study, researchers conducted a double blinded, placebo controlled study over a 52 week period. This is one of the most powerful methods to determine if a treatment is equal to or superior to another treatment. Both the patients and the researchers are blinded, or unable to know which treatment each patient received. Patients either received a placebo ( a saline injection) , hyaluronic acid, PRP or a combination of PRP and hyaluronic acid injection. At the end of the study, the patients receiving the hyaluronic acid injections alone had an average increase in function and a decrease in pain by 10.9 points through a very standard method of measurement called the Western Ontario & McMaster Universities Arthritis Index abbreviated WOMAC . The PRP patients had an increase of 15.9 points, but the combination of hyaluronic acid and PRP had an amazing increase of 23.7 points! Thus, combining the two may provide superior relief for over a year period. If we compare this to some studies on knee replacement, the average improvement after a year is about 24 points. Although, this is not a direct comparison study and it is hard to compare the two results, it does give us some baseline information for future studies. (see references)
HA and PRP Mixture Helps Repair Rotator Cuff Tears of the Shoulder
In the shoulder study, patients were split into 4 groups of about 50 patients into each group. All the patients had a partial tear of the rotator cuff which is a common condition causing pain and weakness of the shoulder. One group received normal saline as a placebo, Group 2 received Hyaluronic Acid ( HA), Group 3 received PRP and Group 4 received the combination of PRP + HA. Again, patients were followed closely with follow up visits at 1,3,6 and 12 months and a repeat MRI. Patients were asked to complete two surveys ( the Constant Score and the American Shoulder and Elbow Surgeon). As expected, the PRP and the PRP+HA groups improved. The PRP + HA group improved the pain and function ASES score by 40.82 points and the PRP group improved by 27.02 while the HA group only improved 11.34 points and the Saline group worsened by 1.21 points. The Constant score confirmed these findings with an improvement of the PRP+HA group by 33.19 pts. The PRP group improved by 23.73 pts and the HA group by 12.93 pts. However, surprisingly the MRI scoring of the size and retraction of the rotator cuff also improved. In the combination therapy group, the score improved 5.85 pts; the PRP group also had an improvement of 2.89 pts and the HA group only improved 0.41 pt. However, the saline group worsened by 2 pts. What this data shows is that not only does the combination of HA and PRP provide far superior clinical results with reduction of pain and increased function of the shoulder, but it also demonstrates healing of the partial rotator cuff tears. (see reference list)
Thus, we can see a developing pattern of superior results not only in the knee, but also in the shoulder with very similar results at one year. This confirmed by patient surveys and now also by MRI evidence.
The best part of this treatment is the value for patients. A good portion of this treatment is covered by most (but not all) insurance carriers for knee arthritis. Medicare and many major carriers cover the hyaluronic acid injections and a standard PRP injection is only $500 for each joint. Thus, you could have very good pain relief for less than the cost of two new tires or many round trip airfares. There are very limited complications and side effects from these treatments, and the only drawback is the fact that you may need to have this repeated every 1-2 years. Compare this to a joint replacement costing over $35,000 and more than $4,000 out of pocket expenses as wells as a complication rate of anywhere from 3% to 16% and more than 6 weeks away from work or recreation. Most of these injections require no time off work and the complication rates are very low. Many of the current treatments for either knee arthritis or rotator cuff tears have very high costs; long periods of time away from work or physical activity and have higher rates of complications. Thus, you could argue that the combination treatment of HA and PRP is one of the best values in orthopedic medicine.
Could the combination of Hyaluronic Acid and Platelet Rich Plasma be the best idea since peanut butter combined with chocolate? As the announcer would say…”only time will tell.”
If you are interested in consultation and discussing your joint concerns with a board certified orthopedic surgeon, call 810-299-8552 or register online HERE.
About the Author: Dr. Edward G. Loniewski, DO, FACOS, FAOAO is a board certified orthopedic surgeon specializing in adult arthritis. He is fellowship trained and has extensive experience in alternative therapies for treating arthritis including over 4,000 cell based treatments since 2005. He has been featured on the Outdoor Channel as well as WXYZ TV. local news channel and has over 60 informational videos through CellularHealing.net. He is recognized as an expert in cell therapy as a frequent speaker at national and international conferences. Dr. Loniewski has developed instrumentation and cell therapy techniques used by physicians all over the world. He is also founder of a not for profit organization which provides cell therapy to the underprivileged as well as trains the physicians of tomorrow on the proper use of cell therapies. He has offices in Brighton, Michigan and provides one on one consultation to personalize a comprehensive program tailored to your specific goals easily fit within your social and professional commitments. Register for a SEMINAR or for a CONSULTATION. “Remember, these are your cells for your healing.”
Chiou CS, Wu CM, Dubey NK, et al. Mechanistic insight into hyaluronic acid and platelet-rich plasma-mediated anti-inflammatory and anti-apoptotic activities in osteoarthritic mice. Aging (Albany NY). 2018;10(12):4152-4165.
Altman RD, Intraarticular sodium hyaluronate (Hyalgan) in the treatment of patients with osteoarthritis of the knee: a randomized clinical trial. Hyalgan Study Group. J Rheumatology. 1998 Nov; 25(11):2203-12
Chen CPC1, Cheng CH2, Hsu CC3, Lin HC1, Tsai YR1, Chen JL4. The influence of platelet rich plasma on synovial fluid volumes, protein concentrations, and severity of pain in patients with knee osteoarthritis. Exp Gerontol. 2017 Jul;93:68-72. doi: 10.1016/j.exger.2017.04.004. Epub 2017 Apr 20.
Platelet rich plasma is not just platelets - it is a combination of growth factors and important proteins which not only prep the area for repair, but also deliver important growth factors into areas where they cannot reach.
This healing cascade can be used for:
Arthritis of the knee, hip, ankle and wrist
Tendonitis of hip, knee and shoulder
Bursitis of the hip, knee and shoulder
Carpal Tunnel Syndrome
Platelet Rich Plasma for Arthritis
The growth factors and proteins found in platelet rich plasma may help with the pain and loss of function commonly associated with arthritis.
Earlier studies performed in Italy on the use of platelet rich plasma for arthritis of the knee revealed some promising results for arthritis of the knee. Dr. Elise Kon from the Rizolli Orthopedic Clinic in Bologna, Italy followed over 100 patients for over one year, and found that all parameters of knee function and pain improved but these injections would lose their effect over time.
Researchers from many other respected institutions such as Rush University, Cornell, and the Hospital for Special Surgery also found some benefits of using platelet rich plasma in basic science studies as well as animal studies and suggested that the positive findings were not just due to the platelets, but the other bioactive components. Some further studies were developed to compare PRP to common treatments and determine which treatment was superior; one study compared an injection of a steroid to platelet rich plasma and found that the PRP patients had superior reduction in pain and improvement in function for longer periods of time.
Italian researchers compared PRP to the very commonly administered hyaluronic acid injections sometimes known as rooster comb or chicken fat injections with the trade names Supartz™ or Synvisc™. Over 120 patients were given either the hyaluronic injection or PRP, and followed for six months. The PRP patients had superior outcome scores, and PRP even worked very well in severe forms of arthritis. This finding was repeated over and over in other studies; a review of these studies lead researchers to conclude that “PRP is a viable treatment for knee OA, and has the potential to lead to symptomatic relief for up to 12 months.”
This finding was confirmed with another meta-analysis of over 551 studies, concluding, “This study suggests that PRP injection is more efficacious than HA injection and placebo in reducing symptoms and improving function and quality of life. It has the potential to be the treatment of choice in patients with mild-to-moderate OA of the knee who have not responded to conventional treatment.”
Not only does PRP reduce the pain of arthritic joints, but one study demonstrated that PRP increased the muscle strength of the treated knee, as compared to a placebo treatment in the other knee. Researchers found that the PRP treated knee had significantly more strength than the knee which received an injection of normal saline.
Given all of this evidence, keep the following in mind: no matter what other people tell you, PRP has significant evidence of being proven useful in the treatment of osteoarthritis when compared to commonly accepted treatments! Even when we compare the results to alternative methods of treating arthritis such as prolotherapy, PRP appeared to have a longer lasting positive effect.
If you would prefer to have a face to face consultation with Dr. Loniewski, please feel free to contact us at 810-299-8552 for an appointment today or you can register on-line at : https://www.cellularhealing.net/next-steps/book-an-appointment
One of the important distinctions of receiving treatment at Cellular Healing is the way your diagnosis and treatment plan are designed by a board certified and fellowship-trained orthopedic surgeon. We able to recognize specific signs and symptoms of your joint which may require one or more minimally invasive procedures to optimize your results. Procedures are only recommended when a patient has a condition that will benefit by placement of cells within the bone next to the damaged cartilage.
If you have symptoms of continual pain near the bone next to the joint and this pain even occurs at night, you may have inflammation in the bone next to the joint. This inflammation is now a serious condition which will persist and worsen unless the underlying abnormal bone is treated. Think of this as a growing rust spot spreading deeper into your bone. If you had an MRI (Magnetic Resonance Imaging), this may be reported as a bone marrow lesion (BML) or subchondral edema or even as a stress fracture. This inflammation is the most important predictor of progression of your arthritis. Researchers have found a clear link between the development of bone marrow inflammation and progression of the disease as well as eventual need for joint replacement unless the inflammation is treated. Normally, a MRI of your knee is ordered to determine this condition, but it is not always required especially if you have classic symptoms and positive physical tests.
Some common symptoms of inflammation of the bone near the joint include:
Night pain which is dull constant and aching
Constantly rubbing the joint to reduce symptoms
Little or short term relief with injections
Progressive pain with weight bearing or exercise
Inflamed Bone Marrow Procedure:
This procedure is used to treat acute or chronic bone marrow inflammation. This is a condition where the area underneath the cartilage becomes very inflamed causing the bone supporting the cartilage to swell and sometimes begin to collapse. At times, this is reported as a fracture or break in the bone. Your bone reacts similar to a break in the bone, but normally, this does not require fixation with pins, screws or plates. It only requires a transplant of healthy bone marrow graft from your pelvis to help correct the underlying deficiency. In rare cases, a special synthetic bone graft is injected to help provide immediate structural support to the area. The cause of this intense response of your bone is still not fully understood; however, entering into this area with a special needle and stimulating new blood flow can help to correct the problem. Adding in natural growth factors, platelet rich plasma and even mesenchymal stem cells within this bone marrow graft can aide in the healing process. The other choice to treat this condition is to perform a joint replacement. With joint replacement, the problem is solved by cutting out the diseased portion of bone and replacing this with a metal and plastic joint.
Bone marrow is taken from the pelvis during the surgery while you are under an anesthetic to produce a bone marrow graft. The bone marrow is then processed into two distinct products. One product is the Bone Marrow Concentrate (BMC), which contains the mesenchymal stem cells along with some Platelet Rich Plasma (PRP) and other important Plasma Proteins (PP) used in the healing process. The other product is Platelet Poor Plasma or General Fluid Concentrate (GFC), which also contains even more important plasma proteins. Additional bone marrow is harvested from the pelvic area in small batches under high suction to reduce the number of blood cells and increase the number of stem cells and other important growth factors. This is called a bone marrow aspirate (BMA). This BMA is used to supplement the grafting of the bone marrow lesion.
A specially designed bone graft delivery device is directed into the inflamed bone. Once the graft delivery device is within the inflamed area, high pressure suction is used to cause a change in the marrow pressure and the stimulation of blood flow into the area. In addition, this removes the damaged cells and prepares the area for delivery of new cells. Once the area is properly prepared, the bone marrow concentrate (BMC) and bone marrow aspirate (BMA) are mixed into a graft and very slowly placed to fill in all the damaged area. The general fluid concentrate is mixed with either the bone marrow aspirate or concentrate and made into a slurry to bind the stem cell mixture and prevent the cells from migrating out of the joint. This slurry mixture is placed into the joint to help heal the damaged areas from the other side of the joint. Patients are usually asked to maintain protected weight bearing with the use of a walker or crutches for a minimum of one week. Most patients are also provided with with a local anesthetic around, but not within the joint as well as some oral pain medications to help control the pain which is normally minimal to moderate. You will be asked to use a blood thinner for 5 days and than continue a simple baby aspirin for a total of 2 weeks to prevent a potential blood clot. You will normally return to our office in approximately 1-2 weeks for a check up, and most patients will receive an additional platelet rich plasma (PRP) injection which acts to fertilize the process and hasten the recovery process. The PRP is just a simple blood draw and joint injection given after a local anesthetic. Most patients can return to their normal activities of daily living in about 7-10 days. However, you are asked to reduce any excessive stress to the joint such as running or squatting for 3 months when we can re-evaluate your progress and allow you to return to all your normal activities. You will be encouraged to continue with our ten step program to help with the recovery of your joint such as goal setting, weight control, nutrition, bracing and simple exercises.
The healing process is not immediate, and most patients start to notice improvement around 3 months from the time of the procedure. We can help accelerate this healing time with the addition of low level laser, homeopathic joint injections and even nutritional supplementation. The key is to have patience with this process because it does take time for the cells to change the chronically inflamed area. Overall, we have had good success with this procedure, and most patients are satisfied with their outcomes for prolonged periods of time. A small minority of patients require an occasional platelet rich plasma injections to help with the continued healing process.
If you have more questions regarding this treatment of your joint with bone marrow, please feel free to ask any of our staff. We are here to make sure you make the right choice for your joint pain.
If you would like a free consultation, please either click on FREE CONSULTATION or call Kim at 810-299-8552
Bone Marrow has long been a delicacy reserved for the wealthy of ancient times. Decadent dishes served to royalty with special spoons to scoop up the precious gem of the innermost hidden treasure of animals was the subject of artists and even poets as they “sucked the marrow out of life.” Was this just an exercise in poetic justice, or was there some true benefit of enjoying this carnivorous treat? We went to the Wooden Spoon Restaurant in Brighton, Michigan (675 West Grand River, Brighton, MI) to find out.
Here they serve a roasted, smoked canoe sliced appetizer of bone beef bone marrow. They have been serving this appetizer as part of their rotating appetizer menu for a few years with many of their long term patrons praising the benefits of this tasty, tantalizing treat.
We met first with the head chef and partner, Steve Pilon who came up with the concept and he had his right hand Sous Chef Mason prepare this for us as we filmed the entire event. Here is the simple recipe:
Ask your local butcher to give you a “canoe cut” version of the femur of any cow cut in 1/3rds or 1/4th.
Place this bone side down to keep the precious bone marrow cargo protected from leaking out in the smoker for 20 minutes at a temp of about 250 degrees fahrenheit.
You can remove from the smoker and wrap and freeze if you wish or proceed to cook this in a 400 degree convection oven for 8 minutes on a cooking sheet. Make sure that the marrow is facing upward and cradled nicely by the bone edges. You do not want the marrow to run out onto the sheet. The marrow is done when it is bubbly, but not runny. You want it to be firm like a foam, but not a liquid .
Transfer carefully with the bone marrow side up onto a plate and garnish with a nice contrasting salad of arugula, grapefruit and blue cheese as well as some pickled onion on the side.
From a scientific standpoint, bone marrow is one of the most perfect fats to eat. This is the only part of the cow which is an unsaturated fat making it special in taste and dietary value. There are 0% trans-fats in bone marrow and it is also a source of a complete dietary protein. Some other great benefits of bone marrow is the fact that it contains Adioponectin which is something that not only gives marrow its unique flavor, but it can also help protect chronic diseases such as diabetes and cardiovascular disease. Apiopenectin also helps to break down other fats in our body and places a role in preserving our body’s vital nutrition during starvation or fasting. The collagen content of bone marrow also helps your digestive tract as well as helps make your skin look healthy. Overall, eating bone marrow is a way to obtain the perfect fat and there is no bones about that!
If you would like to schedule a visit to the Wooden Spoon Restaurant at 675 West Grand River, Brighton, MI , please call 810-588-4386. Open for lunch and dinner Mondays thru Saturday (always closed on Sundays!) If you would like to schedule a face to face appointment with Dr. Loniewski, please call 810-299-8552.