The following article appeared in the Summit Daily & Vail Daily on July 23, 2021.
In the last decade, interventions involving orthobiologics, like platelet rich plasma (PRP), have been providing relief and new hope for tissue and joint damage. Many patients with conditions like
osteoarthritis, degenerative disc disease and tendinosis are finding significant, long-term improvement from orthobiologics — the use of natural substances like platelets and stem cells to help musculoskeletal injuries heal.
Dr. Matthew Gnirke, a physiatrist at Vail-Summit Orthopaedics & Neurosurgery, specializes in orthobiologics. He employs PRP and bone marrow aspirate concentrate (BMAC) to get people back to the sports and activities they love.
What is it?
PRP and BMAC both use platelets from the patient’s own body. PRP interventions involve a simple blood draw — about 60cc, which is anticoagulated (to prevent blood clotting) and spun to separate different cell types. Physicians then collect the platelets, which are the least dense cells, and inject them into a joint or other damaged site.
BMAC interventions also use platelets, along with a small amount of stem cells; these mesenchymal stem cells have the ability to differentiate (or turn into) cells that produce cartilage, tendons, ligaments and muscles. They are sourced from bone marrow through a needle. The procedure can be done in office, or, if a patient prefers sedation, in a surgical setting.
“BMAC is not a surgical procedure, but it can cause pain,” he said. “The response is highly variable. Many patients describe it as a deep Charlie horse in the buttock. Some feel it less, some more, but the vast majority of patients do tolerate it in the office and sedation is not necessary.”
BMAC is often used for more advanced osteoarthritis and disc diseases, whereas PRP is used for early stage osteoarthritis, joint issues and tendon disorders like tendinosis (the latter of which is caused by degeneration of a tendon’s collagen from chronic overuse, such as “tennis elbow”).
Platelets act like microscopic, natural “surgeons,” Gnirke said. They attach to damaged collagen fibers, which are the fundamental building blocks of tendons, ligaments and muscles. One platelet contains over 1,200 growth factors within it, he said. PRP treatment typically releases at least 1 million platelets into an injured area, releasing growth factors involved in collagen repair and synthesis.
“They are truly wound-healing cells,” Gnirke said.
What can it help?
Orthobiologics are referred to as regenerative medicine because they actually help heal rather than simply masking symptoms like steroid shots do. They are used to treat damaged tendons, ligaments, muscles, joints and discs.
Gnirke has seen patients with early stage osteoarthritis of the knee and other joints, as well as conditions like tennis elbow, improve significantly. These conditions result from slow degradation over time, as collagen fibers lose strength and density and tend to get microtears.
Dr. Matthew Gnirke (photo courtesy of Vail Summit Orthopaedics & Neurosurgery)
“The earlier you catch it, the more likely you’re able to see long term trajectory changing improvement,” he said.
He recommends people come in for an evaluation as soon as symptoms affect them regularly or impact function. Even if you can still ski, bike, hike and do what you love, if you’re modifying movements or aware of discomfort, it often indicates mild to moderate disease, he said. Grinning and bearing pain or stiffness could lead to further breakdown of tissues and joints, which can progress to more severe osteoarthritis (like bone on bone knee damage) or severe disc degeneration and associated pain.
Gnirke finds orthobiologics “quite effective for lower back pain related to degenerative disc disease,” he said. “Studies show an improvement in back pain in two out of three patients over the long term.”
In the past, physical therapy and/or anti-inflammatories, then surgery was used to treat degenerative disc disease — there weren’t many options in-between. Orthobiologics bridge that gap.
Originally used in sports medicine for professional athletes, PRP and BMAC are now available to the general public. Though most insurances still view them as experimental treatments, workman’s compensation insurance and Kaiser Permanente are paving the way for other companies to cover the procedures. No one knows when (or if) that will happen, but it’s still probably years away. Until then, patients can pay out of pocket (usually under $1,000 for PRP).
Studies show that 65% to 75% of patients respond positively to PRP and BMAC.
“Over 2/3 of patients see significant, long-term improvement for greater than one to two years,” Gnirke said.
How the procedure works
Once platelets (and stem cells, in the case of BMAC) are collected, Gnirke delivers injections into the site of injury, using ultrasound or x-ray to ensure the exact site of injection.
Patients often temporarily feel worse before they get better: Pain flare ups range from mild to severe and can last anywhere from one day to up to two weeks. The longer, more severe reactions usually occur with spinal injections, he said. Within a month, patients usually feel they’re at baseline: not better, not worse.
Typically, it takes about six to eight weeks to start feeling improvement; it can take four to six months, and even up for a year if it’s a spinal injection, for improvements to fully take effect. Of course, regenerative medicine is just one of the procedures Gnirke employs. His practice focuses on proper diagnosis, prevention, treatment and rehabilitation of musculoskeletal injuries and disorders. He avoids overtreating and doesn’t believe in preemptive orthobiologics where they’re not needed. His main interest: getting people back to doing what they love.