To PRP or Not to PRP?

Q&A with sports medicine physicians Dr. Charles Preston and Dr. Matthew Pecci regarding Stephen Curry’s injury and using platelet-rich plasma injections

I recently caught up with Dr. Charles Preston and Dr. Matthew Pecci in our Sports Medicine Department to expand on the treatment option of PRP injection (platelet-rich plasma injection) that has recently become a hot topic with the recent injury to Golden State Warriors’ All-Star guard, Stephen Curry. I spoke with Dr. Preston first.

Q: Steph Curry has been diagnosed with Grade 1 MCL (medial collateral ligament) sprain of his right knee. Please explain what the MCL is and what that diagnosis means?

Dr. Preston: The MCL is the ligament on the inside of the knee that attaches the femur to the tibia, and a Grade 1 MCL sprain means that ligament was strained but not torn.

Q: Does that mean that ligament was stretched or irritated?

Dr. Preston: The ligament was stretched, causing irritation, and that point would be noted on the MRI exam.

Q: What would be a typical rehabilitation and recovery for such a sprain?

Dr. Preston: Usually an MCL sprain of that grade would take anywhere from 2-4 weeks to fully recover.

Q: Would recovery time be different for a person with heightened athletic activity (Curry) versus a person who may not be as mobile or active?

Dr. Preston: There are two issues here. A person who is more sedentary will be more comfortable with his basic movement and thus feel better in that movement sooner. An athlete exuding pressure on the knee with side to side movement, quick back and forth movement, and pivoting will take longer to feel better in that heightened movement. Another aspect is the age of the athlete. Typically younger individuals will heal quicker because healing takes more time as you age.

Q: A PRP injection was performed in Curry’s case, could you briefly explain what a PRP injection is?

Dr. Preston: In a PRP injection, a blood sample is taken from a patient, then spun down in a centrifuge, where growth factors are isolated, then injected directly in to the affected site. The hope is to stimulate faster healing at the irritated site.

Q: Do you think the option of having PRP done would assist in any way to accelerate recovery in Curry’s case?

Dr. Preston: The PRP gained popularity when Hines Ward, primary wide receiver for the Steelers, was injured before Super Bowl 43 and had a PRP injection, reporting it assisted in his recovery and ability to play in the Super Bowl that year (2009). Curry and the Warriors opting to do PRP may improve his recovery time. An important factor in doing PRP injection in Curry’s case is that it’s not going to burn any bridges or do more harm, since it’s his own blood, his own healing factors being used.

Q: This question is for Dr. Pecci. Can you briefly explain what the diagnosis Grade 1 MCL Sprain means and what role MCL plays in the function and stability of the knee?

Dr. Pecci: The MCL stabilizes the inside of your knee, so typically with an injury like his where he slipped on a wet floor, the force that was directed from outside to inside stretched that ligament. The grade that is given indicates what damage has occurred in that ligament:

  • Grade 1 is some tenderness along that ligament and there’s not much looseness in a movement test. It may have minimally stretched it, but no significant tears or damage to ligament fibers, and there will be definite inflammation from ligament being stretched.
  • Grades 2 and 3 would present more looseness and maybe a partial tear.
  • Grade 4 sprain would be very loose, possibly with a complete tear.

Q: When an athlete is diagnosed with a knee sprain, would that mean that ligaments, cartilage, and meniscus are intact, but there’s been some irritation or inflammation that has occurred within the knee?

Dr. Pecci: In sports medicine, we would never use a generic term or diagnosis of knee sprain. I mean, if there is a sprain or irritation, what is sprained? What is damaged? Is it a ligament, or cartilage, or tendon injury? We may see referrals come in from a primary specialists that give an initial diagnosis of a knee sprain, but with further diagnostic imaging, such as in the case of Steph Curry being an elite athlete, the initial step would be getting an MRI. That way we can further see exactly what is going on within the knee, such as the irritation of the MCL, as well as get a clear view of the cartilage and see if there is any damage. An MRI typically is the test of choice.

An ultrasound is another diagnostic you can perform, and I do a fair amount of these in the sports medicine clinic. This helps me see what is going on when a patient is displaying symptoms such as MCL strain. I am able to see that ligament clearly by ultrasound and know if it’s inflamed or torn. And I get a better sense of the time table of treatment and recovery.

Q: Would an MCL sprain recovery and treatment be different for an anterior cruciate ligament (ACL) or a posterior cruciate ligament (PCL) injury?

Dr. Pecci: Yes. MCL is a good healing ligament, because it’s not inside the knee joint. The blood supply to the knee comes from the outside in, and since the ACL and PCL are inside the knee joint they do not get the same resource of blood supply. Those are not going to repair on their own, or heal very well. So surgery would be warranted to repair ACL and PCL tears. An MCL can be a Grade 4 and completely torn, and can often times heal without surgery. But you just need to protect that knee while it heals, so you need a period of time maybe on crutches, certainly a hinged knee brace to protect any forces that would go across that ligament, and usually a period off activity.

Q: What would be a typical rehabilitation and recovery of such a sprain, as diagnosed in Curry’s case or in any active sports participant, say in high school or college? Would there be any different recovery expectation for an older active athlete?

Dr. Pecci: Recovery time for Grade 1 MCL tear is 2 to 4 weeks. That’s usually a stable time even with a little older but active athletic individual. Of course if there is a tear, or higher grade, it’s going to take a little bit longer. A partial tear may be around 8 weeks, a complete tear may be around 12 weeks or longer. Once the ligament is healed, age may play a factor in transitioning back to activities. A younger athlete who has great balance and muscle mass typically will rebound back to activity quicker than, say, a senior active individual who may not have the same balance and muscle present (less muscle mass surrounding the ligament would put more stress upon the joint in active movements).

Q: Do you think having the PRP done would help accelerate recovery in Curry’s case?

Dr. Pecci: You definitely see PRPs and stem cell treatments not being used how they were initially designed or how they should be used in professional athletes. The reason I say this is that when you have an acute injury like Steph Curry experienced, you already have an instant inflammatory reaction; you already have platelets that have been naturally brought to that area. Thus, the extra platelets that are put in there are likely not to cause any additional healing.

In fact, when I first started using platelets 10 years ago, I would do the same thing, use them for an acute injury. I would see an MCL sprain and put some platelets in that area (PRP injection). From my own experience, an MCL sprain is going to heal in 2 to 4 weeks whether you put platelets in there or not. I understand the demands of a professional athlete and the demands to do everything possible, especially in critical times in a season such as the playoffs. So is putting platelets in going to hurt? No. Is it going to help? Probably not.

The way platelets should be used is to create this inflammatory healing response. When you have an acute injury, you already have the reaction internally. Now six months after an acute injury and a tendon or ligament hasn’t fully healed, a platelet injection may be prime in that situation, to restart the inflammatory process. I use PRP a lot for someone who’s had a partial tear of, say, their Achilles tendon, or quadriceps, or the hamstring. They’re six months or a year out from original onset of acute injury, they’ve given it time to heal, they’ve completed a course of rehabilitation, and they are still showing symptoms. With MRI or ultrasound showing scarring in that area, PRP can be used and works very well in that situation. With this, you are resetting an inflammatory response, stimulating the patient’s own body to heal that area. In an acute injury, your body naturally creates that inflammatory response.

Q: In Curry’s case and possibly other pro athlete’s treatment, would you say proceeding with PRP on top of the body’s natural response to an acute injury is more of a confidence booster or security blanket?

Dr. Pecci: It’s more an issue of Do we have all the information on PRP treatments? I don’t think we do; we are still learning more. We know it’s not going to hurt. Pro athletes have a strict time table to return to activities and they are going to seek all choices and resources. If it doesn’t hinder or hurt, you might as well try! Research is premature to confirm any benefits in acute onset cases.

PRP use beyond Steph Curry

Q: Could you give us more explanation about how PRP works?

Dr. Pecci: PRP stands for platelet rich plasma and has been around for a while, more than 10 years. In a PRP injection we use the patients’ own platelets that are obtained by drawing their blood, then a special system spins it down to concentrated platelet components that are blood products. When your body has a broken bone or muscle, a tendon tear or inflammation injury, platelets are created and mobilized to that injury to stimulate tissue repair. They also release growth factors that help stimulate tissue to heal. So, platelets are important factors that help our body heal internally. The thought about using PRP for injury is that we are going to try and put a high concentration of these factors that help injury healing into affected area hopefully to make it heal quicker.

Q: You’ve used PRP injection options for Achilles, hamstrings and tendons, so can it be used in other joints? Can it be used in other diagnosis instances?

Dr. Pecci: So, tendonopathies are usually what we end up using it for, which means you’ve had chronic inflammation in a tendon, and now you have a kind of scar tissue in that tendon. That can be anywhere and it is most studied in epicondylitis (tennis elbow). But it can be rotator cuff, quadriceps, hamstring, gluteus tendons, Achilles, plantar fasciitis, truly any of those areas. The exciting thing about PRP is that we are beginning to use treatment intra-articular (injection in a joint) for cartilage, such as meniscal tears and arthritis. The thought is that you put in the PRP to create an inflammatory response to stimulate your body to heal tissue that is not a good healer, such as cartilage. I’ve used it intra-articular a fair amount for arthritis and cartilage tears, and have had really good outcomes. I’m excited about that.

Q: Does it grow back the cartilage? Does it give the body a catalyst to recreate it?

Dr. Pecci: That is exactly the thought of how it should work. It doesn’t necessarily go in there and ‘form’ cartilage … What it would do is release factors for an ideal condition, for cells to turn back on in the chondrocytes, which would produce cartilage.

Q: Would PRP be an option for ankle sprain or ligament issues with the ankle?

Regarding using PRP for ligaments such as the ankle, we don’t have sufficient information on that. In this case where a ligament has stretched or been damaged, I don’t think PRP would be the best option. You can try as a conservative choice versus surgery, but it’s not going to tighten the ligament per se.

PRP treatment for tendons, yes; for cartilage, yes. It could be tried for ligaments but that usually is more of a stability issue, where there are other treatment options. PRP would not be an ideal choice.

Q: Are PRP injections a one time treatment? Do you ever do a series? Is there an option to do more than one to treat an injury?

Dr. Pecci: That’s an area we don’t know fully about. We don’t have sufficient data that can confirm the effectiveness of a series of these injections. There have been providers that will do an injection monthly for three months, six months; sometimes they will set up a series and do an injection every two weeks for three injections. I don’t think we really have enough data on what would be the ideal protocol.

Typically, my PRP treatment is a one-time injection, and then allow that tissue to heal. It usually takes about two months to assess a response from the treatment, and at that time we could reassess. In certain situations, if the patient has had improvement but not complete healing, it may justify another PRP injection. Doing treatments more frequently doesn’t justify the science of why we use it.

Q: Have you seen PRP being covered as a benefit under insurances?

The instance in which I’ve seen it covered is for tennis elbow. We have the most studies on its effectiveness for that. I’ve only ever seen it covered by select insurances for other treatment areas (mostly approved through Worker Compensation insurances). I rarely see it covered under private insurances.

Depending on the area needing treatment, the cost can vary. PRP injections come in kits where you can draw up to 20 cc’s of blood. That amount only produces 2-3 cc’s of platelets. Each kit costs upwards of hundreds of dollars. If you’re treating a small tendon, you usually would use one kit. If you’re talking about a larger injured area, such as a hamstring, you may need two kits, wanting 6-8 cc’s of platelets. Platelet treatment for joints is a bit specialized and may cost more. Typical costs I’ve seen run upwards of $1,500-2,000.

I hope you’ve enjoyed this insightful and informative Q&A session with Dr. Preston and Dr. Pecci. Please contact us with any questions or if you’d like to make an appointment to further discuss treatment option for you.

Further Reading

About PRP injections What is a PRP injection?