Jason G. Attaman, DO, FAAPMR presents the advantages of using image guidance in Platelet Rich Plasma (PRP) Therapy for tendon, bone, joint and pain issues. Dr. Attaman is a double board certified Pain Management Physician with pain control clinic locations in Bellevue, Seattle, and Auburn, Washington, USA. It is very difficult choosing which physician to see when you are suffering from chronic pain. Should you see a pain doctor, a surgeon, a neurologist, a chiropractor, a naturopath, an acupuncturist? The choices and options are bewildering! If you choose to see Dr. Attaman, you will find a physician that will thoroughly examine your case, and suggest treatment options for you that will draw from every specialty of medicine. Generally Dr. Attaman likes to try conservative treatment options such as physical therapy before invasive options such as pain reducing injections and surgery. Therefore if massage therapy is best for your condition, that will be offered. Though he does everything to prevent it, if Dr. Attaman thinks you require surgery, you will be referred to the best surgeons in the state. Dr. Attaman offers many dozens of treatment options for every type of pain, and takes pride in being honest with his patients about their choices. He will not, however, waste your valuable time. If you have already had dozens of sessions of physical therapy and chiropractic, tried dozens of medications over the years, and in general are “fed up” with nothing working for you, Dr. Attaman will promptly and appropriately offer you much more advanced pain management options in which he is extensively trained. Dr. Attaman is always amazed at the treatment options available to patients who have been suffering from pain for even decades. Dr. Attaman is board certified and Anesthesiology-fellowship trained in the medical subspecialty of Pain Medicine and Interventional Pain Management. He is also residency trained and board certified in the specialty of Physical Medicine and Rehabilitation. He is one of only a few with such extensive qualifications in the state of Washington. He is expert at diagnosing and treating every form of pain, ranging from common back pain to face pain to cancer pain. He uses pain reducing injections and procedures to combat difficult to treat pain conditions. He will guide his treatments to help reduce or eliminate your need for pain medications. He will advise your primary care physician on the best ways to treat your pain. In addition, he has had extensive training in integrative and “alternative” medicine. He has trained extensively with some of the most prominent alternative medicine physicians.

1. Platelet Rich Plasma in MSK Disease
Jason G. Attaman, DO, FAAPMR
www.jasonattaman.com | nopain@soundinterventionalpain.com | 206 395 4422
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2. Overview
About me
Basic Science
Applications
Image Guided PRP
Case Presentations
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3. Pain Medicine is
an official ABMS
Subspecialty
Residency in PM&R at the
University of Michigan
Department of Physical
Medicine & Rehabilitation
Fellowship in Pain Medicine at
Wayne State University
Department of Anesthesiology
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5. 5
Patient
Injection Psychology Medication
RIT (PRP)
Surgery
Systemic
Disease
Excercise Sleep Manipulation
Alternative
Medicine
SocialworkPT
PRP is but one
tool of many!
(a cool one!)

6. PRP Definition
• Platelet-Rich Plasma Therapy (PRP)
is defined as a sample of autologous
blood with concentrations of
platelets in a given volume of
plasma that is above the
concentration found in whole blood
(Arnoczky et al, JAAOS 2010)

7. What is PRP therapy useful for?
Ligaments
Tendons
Joints
Discs?
Nerves?
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8. PRP overview
Platelets release various
chemical signals when needed
These signals cause stem cells
to activate, tenocytes to lay
down new tendon,
chondrocytes to lay down new
cartilage, etc
PRP therapy accelerates this
process by delivering platelets in
a concentration 4-10 X normal
levels.
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Works well for tendonopathy,
ligament injury, hypermobility,
joint degeneration, wound
healing, and possibly disc
healing
Ideally applied in the context of
optimizing biomechanics and
kinetic chain.
Used to “tighten” loose
ligaments and tendons

9. My experience...
10-20% non responders
25% rapid responders
Majority have steady
improvement in symptoms over
a 6-12 week post-op period
followed by a slower
improvement phase
Tendon architecture improves
Overall 80% of those treated with
one session have >70% long term
pain relief.
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10. History
• First introduced in the 1980s for the
treatment of cutaneous ulcers
(Margolis et al, Diabetes Care 2001)
• Use expanded in the 1990s in
the maxillofacial and plastic
surgery fields
(Marx, J Oral Maxillofac Surg 2004)

11. History Cont’d
• Its use in orthopedic surgery began a
decade ago
– Initially used with bone grafts
to augment spinal fusion
and fracture healing
– Indications have expanded
widely

12. Public Awareness
• Its appeal has soared ever since Tiger Woods
and Cliff Lee swore that PRP cured them
• Public awareness was raised after The New
York Times detailed the use of PRP to treat
the injured Pittsburgh Stealer players Hines
Ward and Troy Polamalu before the 2009
Super Bowl
– The New York Times, February 17, 2009

13. • Blood components:
– 93% RBCs
– 6% platelets
– 1% WBCs
– Plasma (liquid component)
• PRP:
– 94% platelets and plasma
– 5% RBCs

14. 14
Whole Blood Vs. PRP

15. PRP Components
• PRP contains not only a
high concentration of
platelets, but also the full
component of clotting
factors and secretory
proteins

16. Platelets
• Important in hemostasis / clotting
• Platelets are normally activated during the
inflammatory phase to begin healing
• Role in the normal healing response via the
secretion of local growth factors
• Growth factors released by platelets recruit
reparative cells (stem cells) and augment
soft-tissue repair
(Eppley et al, Plast Reconstr Surg 2004)

17. Creany & Hamilton, Br J Sports Med 2008

18. Platelet Activation
• Platelets are stimulated to release these
growth factors and cytokines by exposure
either to collagen or to thrombin and
calcium

19. PRP Preparation
• “Not all PRP preparations are created equal”
• PRP can be affected by:
– Variations in blood volume taken (5-120 ccs!)
– Platelet recovery efficacy
– Final volume of plasma in which the platelets are suspended
– Presence and/or absence of RBCs and WBCs
– The presence of absence of anticoagulant in the sample
– The addition or absence of thrombin or calcium chloride
– The addition of pH-altering compounds
(Arnoczky et al, JAAOS 2010)
•

20. Lopez-Vidriero et al, Arthroscopy 2010

21. Autologous Blood Collection

22. Pre Centrifuge

23. Post Centrifuge

24. Withdraw PRP into procedure
procedure syringe

25. Technique

26. Technique

27. Risks and Side Effects
Bleeding; <<1%
Infection; <<1%
No effect; <<1%
Worsening pain; <<1%
Weakness; <1%
Paralysis, death, or stroke;
<<<<<<1%.
27
IF image
guidance
employed
for injection!

28. Safety
• No studies have documented any cases of
hyperplasia, carcinogenesis, or tumor
growth
• Some systems use purified bovine thrombin
to activate the platelets, which may produce
coagulopathies
– Most now have converted to human recombinat
thrombin
(Mei-Dan et al, Phys Sports Med 2011)

29. 99% of MY procedures are
done under image guidance
to confirm needle location
and increase efficacy

31. When image guidance is not used

32. Needle Tenotomy
• Several case series concluding it is effective.
• McShane, J Ultra Med, 2006,2008
– ~ 60% effective
• Zhu, Adv Ther, 2008
– 54% excellent outcomes
• Housner, J Ultra Med, 2009
– Decrease in VAS scores at 4 and 12 weeks
• Most physicians peforming PRP do not perform an aggresive
tenotomy, which in my opinion limits outcomes.
– mild to no pain when local anesthetic administered

34. PRP & Doping
• In January of 2011, the World
Anti-Doping Agency removed
intramuscular PRP injections
from its prohibitions
• There is a “lack of any current
evidence concerning the use of
these methods for purposes of
performance enhancement.”
– Irish Medical Times 2011

35. Applications
• Tendinosis and tendon injuries -- Lateral epicondylitis,
Achilles tendinosis
• Ligamentous injuries and reconstructive surgery -- ACL
• Cartilage injuries
• Osteoarthritis
• Muscle injuries
• Bone augmentation – fusions, nonunions
• Wounds – Chronic non-healing
• ETC…

36. PRP & Tendinopathy
What Does The Literature Say???

37. Laboratory Evidence:
Human Tenocytes
• de Mos et al, Am J Sports Med 2008
– In-vitro study of human tenocytes treated with
PRP
– Results:
• PRP stimulates tenocyte proliferation
• PRP-treated tenocytes produced increased collagen

38. Normal Achilles Tendon

39. Neovascularization on Power
Doppler

41. Laboratory Evidence:
Achilles Tendon
• Virchenko & Aspenberg, Acta Orthop Scand,
2006
– Rat Achilles tendon defect model
– Results:
• Greater initial regeneration in a rat Achilles tendon defect
treated with PRP than without
• Greater increases in tendon strength vs. controls at 14 days
• Authors concluded: PRP may accelerate the initial
inflammatory phase of tendon repair, thus making cells
more receptive to earlier mechanical loading

42. Laboratory Evidence:
Achilles Tendon
• Lyras et al, Foot Ankle Int 2009
– Rat Achilles tendon model investigating the
effect of PRP injection vs. saline on
angiogenesis during tendon healing
– Results:
• Significant increase in angiogenesis in PRP group
at 2 weeks compared to control group
• Shorter healing process in the PRP group
• Better organization of collagen fibers in the PRP
group

43. Achilles Tendon Repair
• Sanchez et al, Am J Sports Med 2007
– 12 athletes s/p Achilles tendon repair
– 6 patients treated with PRP at repair site
– Results: PRP group demonstrated:
• Earlier functional return of ROM
• Earlier return to jogging
• Earlier return to training
• No wound problems
• Less scar tissue based upon Achilles tendon cross-
sectional area at 18 months

44. Achilles Tendonitis
• Gaweda et al, Int J Sports Med 2010
– Prospective study on 14 patients with Achilles
tendonitis (15 tendons) treated with PRP
– Results: Significant improvement in pain
scores and increased tendon vascularization
on ultrasound imaging

45. Achilles Tendinosis
• De Vos et al, Br J Sports Med 2010
– Randomized, double-blind, placebo-controlled
trial of 54 patients with Achilles tendinopathy
who were treated with PRP vs. control (saline
injection), in addition to eccentric exercises
– Results: At 6 weeks, there was no significant
improvement in tendon structure and no effect
on neovascularization in the PRP group,
compared to the control group

46. Achilles Tendinosis
• O’Malley, Presented at: American
Orthopaedic Foot & Ankle Society 2010
– Retrospective study of 34 patients with Achilles
tendinosis
• Symptoms greater than 6 months
• Failed conservative treatment
– Results:
• 19 / 34 had improvement and no
longer required treatment
• 5 went on to surgery

47. Plantar Fasciitis
• Barrett & Erredge, Podiatry Today 2004
– Pilot study of 9 patients with plantar fasciitis
– Used ultrasound-guided PRP injections
– Results:
• 6/9 patients had complete symptom
resolution after 2 months
• 77.9% of patients had complete
pain resolution at 1 year

48. Lateral Epicondylitis
Hypo-echoic
Radial
head
Joint
space
Extensor
tendon origin
Distal
humerus

50. Lateral / Medial Epicondylitis
• Mishra & Pavelko, Am J Sports Med 2006
– Prospective, nonblinded study of 20 patients who
failed non-operative treatment for medial or lateral
epicondylitis
– 15 patients: single PRP injection
– 5 patients: single bupivicaine injection
– Results in PRP group:
• 8 weeks: PRP group statistically significant improvement
in VAS and Mayo Elbow Performance scores

51. Lateral Epicondylitis
• Mishra et al, Clin Sports Med 2009
– Double-blind RCT of PRP vs. cortisone
injections of 100 patients
– Results: The PRP group demonstrated greater
improvement on VAS and
DASH scores at a minimum
follow-up of 6 months

52. Lateral Epicondylitis
• Peerbooms et al, AJSM 2010
– Double-blinded randomized control trial of 100
patients treated with either PRP or cortisone
injection
– Results at 1 year follow-up:
• VAS scores
– 73% PRP group successful vs. 49% in cortisone group
• DASH scores
– 73% of PRP group successful vs. 51% in cortisone group
• Cortisone group declined with time, while the PRP
group progressively improved

53. PRP vs Corticosteroid in Lateral
Epicondylitis: Netherlands Study. AJSM
Feb 2010
l Results:
l VAS scores: 49% improved in steroid group
l VAS scores: 73% in the PRP group improved
l DASH: 51% in steroid group improved
l DASH: 73% in the PRP group
l PRP group kept getting better over the next year!!!
l PRP patients: 64% improvement in pain, 84% disability
l Steroid group: 24% improvement in pain, 17% disability

54. Patellar Tendonopathy

55. Evidence: Patellar Tendinopathy
• 2 animal studies showed increased strength following
PRP
• Kon et al. (2009): Prospective pilot study of 20 patients
with chronic patellar tendinosis (20+ months)
– 70% patients improved
• Fiardo et al. (2010): Non-randomized trial, PRP/PT vs PT
alone
– PRP group did better

56. Knee Osteoarthritis
• Sanchez et al. (2008)
– retrospective cohort design
– PRP vs. Hyaluronan
– 53% improvement in PRP vs. 10% hyaluronan
• Kon et al. (2010)
– prospective cohort design
– intra-articular PRP injections
– significant improvement at 6 months, less at 1 year

57. Supraspinatus Tendonopathy

58. PRP and Muscle

59. PRP and Muscle
l Sanchez M, et al; “Application of Autologous Growth
Factors on Skeletal Muscle Healing”, World Congress
on Regenerative Medicine Podium Presentation, May
18, 2005
l Study: 20 patient prospective acute muscle injury
pilot study with 6 month follow-up - Ultrasound guided
injection of PRP.
l Multiple, serial prp injections at one week intervals to defect sites
after hematoma evacuation
l Ultrasound demonstrated injured muscle healed fully without
fibrosis. Functional capacities 50% faster than the control group.
l The athletes had full recovery in half the expected times

60. PRP and Muscle
l Wright-Carpenter et al 2004. IntJ of Sports Med
l Pilot study
l Professional athletes with muscle strain
l Administered autologous conditioned serum
l Control group received actovegin/traumeel
l Found a reduction in recovery time in return to 100%
activity in competitive sports. (16 days vs 22 days in
the control group)
l MRI recovery time was accelerated as well.

61. PRP and Muscle
l Hammond et al. Am J Sports Med. 2009
l Tib anterior of rats injected with PRP or PPP for
treatment of acute muscle strain (high repetition
multiple small strains vs single large strain)
l Conclusion: “local delivery of PRP can shorten
recovery time after a muscle strain injury in a small
animal model.”
l Recovery of muscle from a high repetition model has
been shown to require myogenesis. This may explain
why PRP was more effective in the high-repetition
protocol.

62. PRP and muscle
l Cugat: unpublished case series 2005
International society of arthroscopy
l 14 professional athletes
l 16 muscular injuries (soccer and basketball)
l PRP injected under ultrasound after
hematoma aspiration
l 50% reduction in time to return to play in less
severe injuries.
l RTP diminished in each group according to
severity

65. Subacromial Bursagram

66. Glenohumeral Injection

67. Piriformis Myogram

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Iliopsoas bursa

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Pubic Symphisis block
for osteitis pubis

70. Radiocarpal Joint
Injection

71. Subtalar Joint

72. Ankle Joint

74. Patient Selection: who will benefit?
Who do you want to “tighten
up?” aka your hypermobile
patients
Any tendonopathy
Labral injuries
Facet capsule injuries
Meniscal injuries
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75. Rehabilitation Protocol
Ideal protocol is not yet
established
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Advanced PRP

81. What is the pain generator?

86. Treatment

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114. Jason G. Attaman, DO, FAAPMR
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www.jasonattaman.com | nopain@soundinterventionalpain.com | 206 395 4422
Offices in Seattle, Bellevue and Auburn

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Jason G. Attaman, DO, FAAPMR
801 Pine St, Suite 100, Seattle, WA
1600 116th Ave NE #202, Bellevue, WA
202 N. Division, Auburn, WA
206 395 4422 phone
888 688 4167 fax
nopain@soundinterventionalpain.com
WWW.JASONATTAMAN.COM

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