Five caller issues discussed
- Andy asks whether regenerative injections may help sacroiliac-region pain and symptoms attributed to a herniated disc.
- Sylvia asks why PRP and cell-based orthopedic treatments are generally not covered by insurance.
- Russell and Stephen ask about the differences among prolotherapy, PRP, cell-based treatments, and exosome products.
- Siobhan and Melanie ask about recurrent shoulder dislocation and damaged or stretched cervical-spine ligaments.
- Relle asks whether cell-based treatment could improve restricted hip motion, while Dr. Chapo discusses shortening recovery from adhesive capsulitis.
Part 1
ANNOUNCER: Are you living in pain? Is it joint pain or muscle pain? If so, stay tuned. Welcome to Living Pain-Free with Marc Darrow, MD, from the Stem Cell Institute in West Los Angeles.
This program discusses possible solutions for persistent pain. Dr. Darrow uses and teaches about cell-based treatments, platelet-rich plasma, and prolotherapy. To speak with Dr. Darrow, call 866-870-5752. Ask for a copy of his book, Stem Cell and Platelet Therapy: Regenerate, Don’t Operate. Now, here is Marc Darrow, MD.
MARC DARROW, MD: Today we are discussing one of my favorite subjects: how to address orthopedic problems without surgery when appropriate. That can include knee, neck, back, shoulder, or hip pain, as well as muscle, tendon, and ligament injuries.
I began doing this work around 1997, before completing my UCLA residency in 1998. The treatments now commonly discussed include cell-based procedures and PRP, or platelet-rich plasma. These are office procedures in which the treatment material is injected into a selected area. Surgery is sometimes necessary, especially in emergencies, but many orthopedic procedures are elective. Patients should understand their options before rushing into an operation.
Imaging also requires context. An MRI can show tears, herniated discs, and degenerative findings in people who have little or no pain. Treatment should focus on the patient and the pain generator, not simply on making an image appear normal.
For a free telephone consultation and a copy of my book, call the office at 800-300-9300. Procedure videos are available at StemCellInstitute.com.
Andy
MARC DARROW, MD: Andy, do you have a question about PRP, cell-based treatment, or an orthopedic problem?
ANDY: I have a herniated disc and what I was told is a strained sacroiliac region. Have regenerative injections been shown to help either problem, and how would that work?
MARC DARROW, MD: I treat sacroiliac-region pain regularly. The sacrum is the wedge-shaped bone at the back of the pelvis. Some patients are offered steroid injections or fusion, but the first step should be identifying the structure that is actually painful.
No treatment is guaranteed, and regenerative medicine is not a cure-all. Patient selection matters. The physical examination is especially important because a herniated disc on an image may not be the structure causing the pain. I have herniated discs in my neck and lower back without pain.
My grandfather, who was also a physician, taught me to use my hands and examine the patient. Imaging is useful, but it should not replace a physical examination. When patients come to me after an unsuccessful operation, I often ask whether the surgeon physically examined the painful area before recommending surgery.
If two physicians offer the same surgical recommendation and you remain uncertain, it may be reasonable to obtain another opinion from a clinician who uses a different diagnostic and treatment approach.
ANDY: That makes sense. Thank you.
MARC DARROW, MD: God bless you, Andy. I appreciate your call.
Sylvia
MARC DARROW, MD: Sylvia, your question is why these treatments are not covered by insurance. Is that correct?
SYLVIA: Yes. Is it because the treatment is too expensive?
MARC DARROW, MD: In most practices, PRP and many cell-based orthopedic procedures are self-pay. Coverage policies vary, but insurers often classify these treatments as investigational or not medically necessary for particular orthopedic indications.
Surgery can involve hospital, anesthesia, rehabilitation, and lost-work costs. Regenerative procedures may cost less than an operation, but that does not automatically result in insurance coverage. Reimbursement rules, evidence standards, regulatory questions, and established medical practice all affect coverage decisions.
I do not expect broad insurance coverage in the immediate future. Patients should verify benefits directly with their insurer and understand the total cost before deciding on treatment.
Russell
MARC DARROW, MD: Russell, how are you today?
RUSSELL: I understand there are options involving PRP and cells. I have also heard about adding exosomes, but I do not know what they are. When are these used alone or in combination?
MARC DARROW, MD: Prolotherapy has been used for many years and traditionally involves an irritant solution such as concentrated dextrose. The goal is to stimulate a localized healing response.
PRP is prepared from the patient’s blood. The blood is processed in a centrifuge to concentrate platelets, which contain signaling proteins involved in healing. Cell-based treatments may be considered for selected injuries and are often combined with PRP.
Exosomes are small extracellular vesicles involved in cell-to-cell signaling. Commercial exosome products are promoted as another biologic option, but their orthopedic use remains an evolving area with important regulatory, product-quality, and evidence limitations.
My personal experience influenced the progression of treatments I adopted. After a dog struck the side of my knee, I injured the ACL, MCL, and meniscus. Prolotherapy helped but did not completely resolve the problem. PRP improved it further, and I later used PRP with a cell-based treatment.
RUSSELL: It sounds as though you view a combination as the strongest approach currently available.
MARC DARROW, MD: That has been my clinical preference in selected cases, but the appropriate treatment depends on the diagnosis, patient, and available evidence. Medicine continues to change, so treatment approaches should change when better evidence and safer options emerge.
John
MARC DARROW, MD: John, what is your sports-injury question?
JOHN: When a professional athlete suffers a major knee injury, the news usually focuses on orthopedic surgery. You rarely hear whether the athlete consulted someone about PRP or a cell-based treatment. Could these treatments help an athlete return sooner?
MARC DARROW, MD: It is impossible to answer for a specific athlete without examining that person and reviewing the injury. A multiligament knee injury can involve the ACL, PCL, MCL, meniscus, and other structures. Some injuries require surgery, while others may be managed nonsurgically.
I evaluate ligament injuries with examination and ultrasound. When a significant tear produces blood or fluid in the knee, ultrasound can guide aspiration. PRP or a cell-based treatment may be considered in selected cases, but the decision depends on the extent of injury, joint stability, sport, timing, and the athlete’s goals.
JOHN: My mother has had back problems for years. She underwent a two-level fusion that helped temporarily, but the pain is returning. Could regenerative treatment be considered?
MARC DARROW, MD: Spinal discs and motion segments help distribute movement. When vertebrae are fused, the levels above and below may experience greater stress. This is commonly called adjacent-segment degeneration or adjacent-segment disease.
Your mother would need a careful examination to determine whether the pain arises from an adjacent level, facet joint, sacroiliac region, muscle, ligament, or another structure. A previous fusion does not automatically identify the present pain generator.
We need to take a short break. To contact the office, call 800-300-9300 or visit StemCellInstitute.com.
Part 2
MARC DARROW, MD: This is Marc Darrow, MD, with Living Pain-Free. We are discussing PRP, cell-based treatments, and how patients can evaluate nonsurgical options before elective orthopedic surgery.
Stephen
MARC DARROW, MD: Stephen, what would you like to know?
STEPHEN: What is the difference between PRP and cell-based treatment, particularly for knee problems? I am a runner, and several older friends also have knee issues.
MARC DARROW, MD: Prolotherapy, PRP, and cell-based procedures represent different approaches to stimulating tissue repair. Traditional prolotherapy uses an irritant solution intended to provoke a controlled healing response. Fibroblasts participate in producing collagen during tissue repair.
PRP uses concentrated platelets obtained from the patient’s blood. A cell-based treatment generally involves a different biologic preparation, such as bone-marrow concentrate, and may be combined with PRP. Which option is appropriate depends on the diagnosis and severity of the problem.
An ankle sprain illustrates the basic idea: the body produces inflammation and initiates healing. A similar ligament injury in the back or neck can be viewed very differently because imaging may also show disc or degenerative changes. The image does not necessarily identify the painful structure.
STEPHEN: I was mainly asking which treatment tends to be the easiest and most effective. Thank you; that was helpful.
Siobhan
MARC DARROW, MD: Siobhan, what specific information about cell-based treatment would be helpful?
SIOBHAN: My younger sister has a shoulder that repeatedly dislocates. A surgeon has recommended an operation because the injury is large and the shoulder keeps popping out. Could regenerative treatment help?
MARC DARROW, MD: Recurrent shoulder instability may involve stretched or torn capsular tissue, labral injury, bone loss, generalized laxity, or other structural problems. Surgery is appropriate for some patients, particularly when there is substantial bone loss, a major traumatic defect, progressive neurologic problems, or persistent instability despite rehabilitation.
In selected cases without those surgical indications, PRP or a cell-based treatment may be directed toward injured supporting tissues. The aim would be to improve pain and tissue support, but the evidence is not equivalent for every type of instability, and there are no guarantees.
I would need to examine your sister and assess the degree and direction of instability. I have treated patients whose shoulders subluxed frequently, including a gymnast who improved after a series of treatments, but one patient’s response cannot predict another’s outcome.
SIOBHAN: She lives in Orange County and would prefer to avoid surgery if there is another reasonable option.
MARC DARROW, MD: She can obtain a comprehensive evaluation and compare the risks, limitations, and evidence for both surgical and nonsurgical approaches.
Melanie
MARC DARROW, MD: Melanie, what is your question?
MELANIE: Can cell-based treatment help regenerate damaged ligaments in the cervical spine? I have significant pain and compression and was referred to a neurosurgeon, but I would like to avoid surgery if possible.
MARC DARROW, MD: The word “damage” can describe different problems. A ligament may be stretched at its attachment to bone, partially torn, or associated with true mechanical instability. Pain alone does not establish which problem is present.
A neurosurgical referral does not necessarily mean that surgery is required, but symptoms of spinal-cord compression or progressive neurologic loss must be taken seriously. Weakness, worsening balance, bowel or bladder dysfunction, or other signs of myelopathy require prompt medical evaluation.
When no emergency or major surgical indication is present, a clinician may evaluate whether cervical ligaments or other musculoskeletal structures contribute to the pain. PRP or a cell-based treatment may be considered in selected patients, but it should not be presented as a replacement for necessary decompression or stabilization.
MELANIE: That is the type of evaluation I am looking for. Thank you.
Relle
MARC DARROW, MD: Relle, what is your question?
RELLE: An X-ray showed arthritis in my left hip. I do not have pain or a limp, and I can walk normally, but my range of motion is reduced by about 35 percent. I noticed the limitation while taking tango lessons. Could cell-based treatment improve my motion?
MARC DARROW, MD: Arthritis on an X-ray does not automatically explain symptoms. Some patients have extensive arthritis on imaging without pain, while others have pain with relatively modest changes.
Your main goal is increased range of motion rather than pain relief. That is harder to measure because hip motion can vary from day to day, and stiffness may result from cartilage loss, capsular restriction, muscle tightness, impingement, bone shape, or other factors.
It would not be responsible to promise full motion or predict the number of treatments. The examination should establish what is restricting the hip and define an objective baseline. If treatment is pursued, progress could be measured with standardized range-of-motion testing and functional goals.
RELLE: I understand. My primary concern is preserving function, not simply returning to tango.
Dr. Chapo
MARC DARROW, MD: Dr. Chapo, you have a question about adhesive capsulitis, or frozen shoulder.
DR. CHAPO: I treat many shoulder patients. How might regenerative treatment help reduce the recovery time for adhesive capsulitis? I use joint mobilization, which can work well but is often a slow process.
MARC DARROW, MD: Adhesive capsulitis involves pain and progressive restriction of the shoulder capsule. Physical therapy and mobilization are central to restoring motion. An injection may sometimes be used to reduce pain or expand the joint capsule, depending on the technique and diagnosis.
My clinical approach has included PRP or cell-based treatment when I believe injured shoulder tissues are contributing to the pain that caused the patient to stop moving. The goal is to make progressive mobilization more tolerable, but treatment should be coordinated with rehabilitation.
Patients with early shoulder pain should avoid prolonged immobilization unless specifically instructed otherwise. Gentle assisted motion using a pole, broom, or golf club may help maintain movement, although exercises should be individualized.
DR. CHAPO: I use gradual mobilization and have seen good results.
MARC DARROW, MD: Combining an appropriate medical evaluation with carefully progressed rehabilitation can be valuable.
Closing
MARC DARROW, MD: We are out of time. I apologize to the callers we could not reach. Questions can be submitted through StemCellInstitute.com. For a free telephone consultation and a copy of Stem Cell and Platelet Therapy: Regenerate, Don’t Operate, call 800-300-9300.
God bless you all, and thank you for listening.
ANNOUNCER: You have been listening to Living Pain-Free with Marc Darrow, MD. The program is heard Saturdays on AM 870 The Answer. To schedule an appointment, call 800-300-9300 or visit StemCellInstitute.com.