Platelet rich plasma injections for meniscus tears

Ross Hauser, MD, Danielle R. Steilen-Matias, MMS, PA-C

Platelet-rich plasma injections for meniscus tears

In this article, we will explore research on Platelet Rich Plasma therapy for meniscus injury. This article is for people exploring the possibility of:

Patients will contact our office with questions about their meniscus injury and ask what our recommendations are for treatment. Of course, the best recommendations are made after we perform a physical examination and check for a range of motion, popping and clicking sounds, and catching and other issues of knee instability where the meniscus may be considered a culprit.

The patient may already have an MRI showing a meniscus tear, a recommendation for arthroscopic meniscus surgery, or a history of physical therapy and other conservative care treatments including anti-inflammatories and/or a recommendation from a surgeon that they really need to wait until their knee is worse before an operation can be performed.

One of the treatment options the patient may have researched is platelet-rich plasma therapy or commonly referred to as PRP. PRP is an injection treatment that re-introduces your own concentrated blood platelets into areas of chronic joint deterioration.

Many questions about the “White Zone Tear”

Many people will email our office and will make a clear distinction about the type of tear they have by using the designation “red zone tear,” or “white zone tear.” More people will say they have a “white zone tear.” Why? Because they have been given the explanation that white zone tears are very difficult to treat and that these tears usually require surgery to cut out the damaged area of the meniscus.

Emails of this nature go something like this:

We discuss below why PRP is not a “one-shot wonder treatment,” and should not be thought of in this way. This helps prevent an over-expectation of what one treatment can do and presents a more realistic treatment path to the patient.

Menisci have two zones. The red zone is outside and the white zone is inside. Meniscus tears are characterized by their placement within these two zones.

A red zone tear lies within the blood-rich portion of the meniscus. Where there is a blood supply there is healing as blood brings the healing and growth factors needed for wound repair.

If you have a red zone tear, there is a chance arthroscopic surgery can go in and sew it up. If you have a white zone tear, it is most likely that your meniscus will be removed. All or some of it. The great majority of meniscus arthroscopic surgeries are to REMOVE meniscus tissue.

If you have a red zone tear, there is a chance arthroscopic surgery can go in and sew it up. If you have a white zone tear, it is most likely that your meniscus will be removed. All or some of it. The great majority of meniscus arthroscopic surgeries are to REMOVE meniscus tissue.

In the research below we will show that when you address the problems of the whole knee, Baker’s cysts, ligament laxity and damage, cartilage deterioration, patella problems, nephropathy, you can address problems of the white zone meniscus tear without surgery.

A brief explanation of PRP treatment by Danielle R. Steilen-Matias, MMS, PA-C


“I am just doing my research”

When we talk to patients with a meniscus injury, they have already been well conditioned that surgery is their ultimate fate. Why?

Now if you are reading this article, we understand that you are doing your research. You are looking for other options. Why?

How we utilize PRP to repair your knee. The difference between INJECTION vs. INJECTIONS

Before we get into the research of PRP for Meniscus injury we want to demonstrate, in the videos below how we offer PRP injections. You will notice that the treatment is injections, not AN injection.


In this video, Ross Hauser, MD explains how one injection of PRP will likely not work

We will often get emails from people who had previous PRP therapy without the desired healing effects. We explain to these people that their treatment probably did not work because the single PRP injection did not resolve knee instability. The PRP may have tried to create a patch in the meniscus but the instability and the wear and tear grinding that tears at the meniscus remained.

When a person has a ligament injury or instability, the knee becomes hypermobile causing degenerative wear and tear on the meniscus and knee cartilage. In other words, the cells of the meniscus and cartilage are being crushed to death. When you inject PRP into the knee, without addressing the knee instability, (treating the ligaments,) the injected PRP cells will also be subjected to the crushing hypermobile action of the knee. The single injection PRP treatment will not work. The knee instability needs to be addressed with comprehensive Prolotherapy around the joint.

This image shows the blood draw and centrifuging in the preparation of a platelet rich plasma treatment for knee pain. This is also known as PRP Therapy

This image shows the blood draw and centrifuging in the preparation of a platelet-rich plasma treatment for knee pain. This is also known as PRP Therapy


Why do we give injections and not a single shot?

In the many emails we get from people looking for information on his/her meniscus tear, we often hear of their meniscus injury, and then we hear about the other structures of the knee that have been damaged. Sometimes we hear about this other damage almost as an afterthought. For instance:

A meniscus injury is usually not an isolated injury

This PRP treatment addresses the ligament instability of a loose knee

The reason patients are seeking out alternatives to conservative care or surgical intervention for meniscus injury is that these treatments have come under intense scrutiny in the medical community for failing to help patients achieve long-term knee repair. The most serious of the long-term consequences is an acceleration of joint degeneration.

One option is to introduce Platelet Rich Plasma into the surgery. For some of our patients, this is in fact where they heard about PRP the first time, when a doctor discussed with them surgical possibilities and the use of PRP for accelerated surgical healing.

What are we seeing in this image? The impact of knee instability on squeezing the meniscus out of the knee joint

We use an ultrasound image to demonstrate the motion of the knee. When the knee is bent in one direction, the meniscus is squeezed out of the joint or extruded as you would extrude toothpaste out of a tube. The meniscus belongs within the knee joint. When the knee is in valgus or knock-knee position, the meniscus returns to the confines of the knee joint. This person’s meniscus would pop in and out the knee on certain motions.  FIXING the meniscus only would NOT prevent the meniscus from popping in and out of the knee. Fixing the knee instability would address this problem.

PRP for meniscus repair, best during surgery or in-office injection?

Often a patient will come in for a consultation asking about PRP treatments during an arthroscopic procedure. Why would surgeons be eager to use PRP during the time of surgery? A team of Polish medical researchers helped answer this question in the journal BioMed Research International. (1) These are the learning points:

The most important finding of this study is that PRP augmentation improved the healing rate of complete vertical meniscus tears located in the red-white zone. Additionally, the functional outcomes at 42 months were better in patients treated with PRP-augmented meniscus repair than in those treated with only meniscus repair; however, pain levels were comparable between these patient groups.

What does all this mean to the patient who is exploring treatment for a meniscus tear, especially a tear that extends from the blood-rich meniscus to the blood-deprived meniscus white zone?

Continue reading the evidence for injection treatment is below.

Doctors at the Department of Orthopaedics, Xiangya Hospital, Central South University in China published their research in the journal Medical Science Monitor. (2)

In this research, they discuss the meniscus white-white tears which they describe as “a meniscus lesion completely in the avascular zone (white zone) are without blood supply and theoretically cannot heal.”

They hypothesize that doctors need to get blood to this meniscal zone for healing to occur but face the task that the problem of promoting meniscal healing in the avascular area has not yet been resolved. The possible answer? Platelet-rich plasma (PRP). The Chinese team supports the idea that the application of platelet-rich plasma for white-white meniscal tears will be a simple and novel technique of high utility in knee surgery.

Platelet-rich plasma (PRP) can be the answer for some surgical patients during the surgery to address the healing challenges of the “white-on-white” meniscus tear.

So the idea is to bring PRP in during the surgery, apply it to areas where normal blood supply is limited and this should accelerate healing. In theory, should work great. But it does not.

Meniscus arthroscopic surgery with PRP augmentation


Meniscal Surgery: a poor option that PRP intervention at the time of surgery may or may not help

There is no question that cartilage heals slowly and poorly this includes the meniscus. Recommendations for surgeries involving shaving or removing the torn portion of the tear using arthroscopic surgery, or sewing the tear together is flawed because it does not repair the deteriorated meniscus.

By failing to heal the damaged meniscal cartilage, surgery does not alleviate the chronic pain that people with this condition experience.

Here is research from the University of Virginia Health System. Here doctors focused on the problem of increased contact stresses in the knee after meniscectomy. (3)

They note that since Platelet-rich plasma has received attention as a promising strategy to help induce healing, the doctors then sought to:

In this study, the experiment was to remove meniscus tissue and see if PRP treatment made a significant impact on the surgical outcome. Before we go on, a quick citation is needed to help with the understanding of the dilution of PRP during surgery.

So theoretically, during surgery, a weakened PRP treatment is asked to heal the surgical and meniscal damage

Returning to the University of Virginia Health System research, its conclusion should then not be surprising:

“Patients who sustain meniscus injuries should be counseled at the time of injury about the outcomes after meniscus repair. With our limited study group, outcomes after meniscus repair with and without PRP appear similar in terms of reoperation rate.”

In the two above studies, researchers sought to improve the surgical outcomes in meniscal surgery by applying a PRP solution to the torn meniscus during the procedure. PRP could not be confirmed as effective – the culprit for non-conclusive results was not the PRP but the surgical procedure.

Let’s wrap up this section by reviewing the February 2019 research from the same Polish researchers we cited earlier. This time published in the International Journal of Molecular Sciences. (5)

Here are the learning points:

There is still a high failure rate.

What are we seeing in this image?

The knee in this MRI had prior meniscus surgery. Post-surgical changes in the meniscus are demonstrated because the meniscus is smaller than it should be. Part of the meniscus is missing. This MRI followed another post-surgical MRI which revealed similar meniscus damage. (MRIs after surgery are to confirm the success of the surgery or to look for reasons the patient continues to have). The problem for the radiologist is they he/she cannot tell if this person’s meniscus is still degenerating or the damage that is in the meniscus now is the surgical damage.

Medical reviews of PRP meniscus injections without surgery

Research has shown that the damaged meniscus lacks growth factors to heal. Research has found that injections of PRP bring the healing components to the site of the injury.

These components are:

Animal studies with these same growth factors have confirmed that meniscal tears and degeneration can be stimulated to repair with various growth factors or solutions that stimulate growth factor production.

In order to understand how growth factors affect the treatment of meniscus injuries, it is first important to understand the role that they play in the natural process of healing.

Each platelet is made up of an alpha granule and a dense granule. For lack of a better term, these are “vessels” that contain a number of proteins and growth factors that are “poured” out onto the wound or injury. The growth factors contained in the alpha-granule are an especially important component of healing. When activated by an injury, the platelets will change shape and develop branches to spread over the injured tissue to help stop the bleeding in a process called aggregation, and then release growth factors, primarily from the alpha granules.

At this point, the healing process then proceeds in three simple stages: inflammatory, fibroblastic (formation of new connective tissue), and maturation (completion of the healing process).

In the case of the injured meniscus, it is clear that the damaged tissue can not repair itself. Healing in the meniscus depends on having enough of a blood supply and/or growth factors at the site of the injury. Since less than 20% of the meniscus is vascularized by the time a person reaches the age of 40 years, meniscal healing is generally incomplete.

In a recent study, German and Swiss doctors publishing in the Muscles, Ligaments and Tendons Journal(6) The doctors sought to demonstrate that Platelet Rich Plasma injections have the ability to regenerate tissue; as already shown in several experimental studies.

In this study:

Recently, doctors at a military hospital in Pakistan treated patients with PRP and published the results: (7) In their paper, they evaluated the clinical effects, adverse reactions, and patient satisfaction after intraarticular injection of platelet-rich plasma in a small group of patients with internal derangements of the knee. (Torn cartilage and Meniscus)

They concluded intra-articular PRP injection is a safe and effective method in the conservative treatment of internal knee derangements.

An August 2019 study from Macedonian researchers (8) evaluated the effect of the PRP injections in the treatment of knee joint cartilage injuries and degenerative meniscus lesions as well as pain relief.

Here are the summary learning points:

Conclusion: “The application of PRP in the field of medicine is widely applied, and it will continue to be because the understanding of PRP therapy is increasingly refined. This therapy represents a potential and latest method in short-term pain reduction, but additional studies are needed to prove its long-term effectiveness.” This study stopped its assessment at six months. Other studies mentioned in this article went a little further.

Ten patients with degenerative meniscal tears

A March 2020 study published in the Diagnostic and Interventional Imaging (9) described “the preliminary results of intra-meniscal administration of platelet-rich plasma (PRP) in patients with degenerative meniscal tears of the knee.”

Here are the learning summary points of this research:

Results:

Conclusion: “Intra-meniscal administration of PRP under ultrasound guidance directly into meniscal degenerative lesions is feasible and safe. Further randomized controlled studies are needed to definitely confirm the effectiveness of this procedure.”

In our experience, using dextrose Prolotherapy with PRP together enhances the effectiveness of the meniscal repair. When treating a meniscal tear with PRP Prolotherapy, the concentrated platelets (PRP) are placed at the site of the tear. Growth factors are released which will stimulate healing of the tear. The growth factors in the PRP will cause proliferation and regeneration of the injured tissue. This boosts fibroblastic events involved in tissue healing causing these tears to heal.

Five Platelet Rich Plasma Prolotherapy meniscus treatment cases presented in the medical literature

In 2010, our Caring Medical research team published our clinical observations on Platelet Rich Plasma Prolotherapy as a first-line treatment for meniscal pathology in the medical journal Practical Pain Management. (10)

In our paper, our goal was to not only show the effectiveness of PRP for meniscal tears but also provide evidence that treating the whole knee for instability by utilizing Prolotherapy, would lead to better PRP results.

Case Report #1
A 21-year-old runner athlete sustained a medial meniscal tear during wrestling. MRI revealed an oblique tear of the posterior horn of the medial meniscus. Because the patient failed physiotherapy and other conservative care the orthopedic surgeon recommended a partial meniscectomy. The patient’s parents were prolotherapy patients and hoped that prolotherapy would offer a non-surgical option for their son as well.

The patient received one session of 3.5cc of platelet-rich plasma prolotherapy to the inside of the knee. The anterior cruciate ligament and medial collateral ligament were treated with Prolotherapy using a 15% dextrose, 10% Sarapin, and 0.2% procaine solution as previously described.

Case Report #2
A 39-year-old squash player sustained a right knee injury while playing squash about one year prior to the visit. An MRI revealed a horizontal flap tear in the body of the lateral meniscus and the patient had a trial of physiotherapy without success. The patient did not want to get an arthroscopy which was suggested but instead sought out prolotherapy after an internet search.

Case Report #3
A 50-year-old chiropractor sustained medial and lateral meniscal tears after falling in a bicycling accident two years prior. He had tried previous conservative therapy without success in relieving his severe left knee pain. He was completely disabled as far as his previous activities of running and cycling. He did not want to undergo arthroscopy because of a poor response to an arthroscopy on his right knee several years before.

Case Report #4
A 52-year-old athlete presented after sustaining an MRI-documented horizontal tear of the posterior horn of the lateral meniscus and oblique tear involving the postern horn of the medial meniscus after falling during running. He had a past history of partial lateral meniscectomy 20 years prior. His symptoms included diffuse knee pain and a feeling of his knee giving way. He also had occasional locking of the knee.

Case Report #5
A 46-year-old male with a history of three right knee surgeries and two on the left including partial meniscectomies on both knees presented for a prolotherapy evaluation because of presumed recurrent meniscal tears on both knees. The patient’s main sport is soccer but had a recent skiing injury that caused bilateral knee swelling and pain for one month prior to the first visit. The patient saw an orthopedist who ordered an MRI which showed the medial meniscal tears.

The patient was adamant about not wanting another knee surgery. He was on nonsteroidal anti-inflammatory medication, which was stopped once PRPP was begun. The complaints in both knees (the right was worse than the left) were swelling, popping and snapping and inability to run at all without significant pain. He felt both knees were unstable. The patient was completely disabled in regard to sports because of the injuries.

We have found PRP Prolotherapy to be a dependable and reliable treatment for meniscus tears.

Questions about our treatments?

If you have questions about your knee pain and how we may be able to help you, please contact us and get help and information from our Caring Medical staff.

This is a picture of Ross Hauser, MD, Danielle Steilen-Matias, PA-C, Brian Hutcheson, DC. They treat people with non-surgical regenerative medicine injections. Offices are located in Oak Park, Illinois and Fort Myers, Florida.

Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C

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References: 

1 Kaminski R, Kulinski K, Kozar-Kaminska K, Wielgus M, Langner M, Wasko MK, Kowalczewski J, Pomianowski S. A Prospective, Randomized, Double-Blind, Parallel-Group, Placebo-Controlled Study Evaluating Meniscal Healing, Clinical Outcomes, and Safety in Patients Undergoing Meniscal Repair of Unstable, Complete Vertical Meniscal Tears (Bucket Handle) Augmented with Platelet-Rich Plasma. BioMed research international. 2018;2018. [Google Scholar]
2 Wei LC, Gao SG, Xu M, Jiang W, Tian J, Lei GH. A novel hypothesis: the application of platelet-rich plasma can promote the clinical healing of white-white meniscal tears. Medical science monitor: international medical journal of experimental and clinical research. 2012;18(8):HY47. [Google Scholar]
3 Griffin JW, Hadeed MM, Werner BC, Diduch DR, Carson EW, Miller MD. Platelet-rich plasma in meniscal repair: does augmentation improve surgical outcomes?. Clinical Orthopaedics and Related Research. 2015 May 1;473(5):1665-72 [Google Scholar]
4 Stopka SS, Wilson GL, Pearsall AW. Dilution Effect of Intra-articular Injection Administered After Knee Arthroscopy. Dilution Effect of Intra-articular Injection Administered After Knee Arthroscopy. J Surg Orthop Adv. 2015 Winter;24(4):209-12. [Google Scholar]
5 Kaminski R, Maksymowicz-Wleklik M, Kulinski K, Kozar-Kaminska K, Dabrowska-Thing A, Pomianowski S. Short-Term Outcomes of Percutaneous Trephination with a Platelet Rich Plasma Intrameniscal Injection for the Repair of Degenerative Meniscal Lesions. A Prospective, Randomized, Double-Blind, Parallel-Group, Placebo-Controlled Study. International journal of molecular sciences. 2019 Jan;20(4):856.
6 Blanke F, Vavken P, Haenle M, von Wehren L, Pagenstert G, Majewski M. Percutaneous injections of platelet-rich plasma for treatment of intrasubstance meniscal lesions. Muscles, ligaments and tendons journal. 2015 Jul;5(3):162. [Google Scholar]
7 Razaq S, Ejaz A, Rao SE, Yasmeen R, Arshad MA. The Role of Intraarticular Platelet Rich Plasma (PRP) Injection in Patients with Internal Knee Derangements. Journal of the College of Physicians and Surgeons Pakistan. 2015 Sep 1;25(9):699-701. [Google Scholar]
8 Mitev K, Longurov A. Intra-articular platelet-rich plasma injections for treating knee pain associated with articular cartilage and degenerative meniscal lesions. Open access Macedonian journal of medical sciences. 2019 Aug 15;7(15):2484. [Google Scholar]
9 Guenoun D, Magalon J, de Torquemada I, Vandeville C, Sabatier F, Champsaur P, Jacquet C, Ollivier M. Treatment of degenerative meniscal tear with intrameniscal injection of platelets rich plasma. Diagnostic and interventional imaging. 2020 Mar 1;101(3):169-76. [Google Scholar]
10  Hauser RA, Phillips HJ, Maddela H. Platelet-rich plasma Prolotherapy as first-line treatment for meniscal pathology. Pract Pain Manag. 2010 Jul;10(6):53-64.Pract Pain Manag. 2010 Jul;10(6):53-64. [Google Scholar]

This article was updated March 17, 2021

 

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