Knee osteoarthritis treatment options Prolotherapy and PRP injections

Knee Osteoarthritis treatmentRoss Hauser, MD

In this article Ross Hauser, M.D. examines the medical research about Prolotherapy and Platelet Rich Plasma Therapy as Knee Osteoarthritis treatment

Knee Osteoarthritis treatment options

  • Researchers looked at 327 patients with Knee Osteoarthritis. More than half – 172 of them were referred to a surgeon and 76% of them went on to have total knee replacement.
  • Rush to judgment? “Few conservative management options were tried before referral, indicating the need to enhance pre-surgical care for patients with knee Osteoarthritis.”1

Is the rush to surgery something to be concerned with? According to the medical literature, “there is ‘gold’ level evidence that arthroscopic debridement has no benefit for undiscriminated osteoarthritis (mechanical or inflammatory).”(2,3)

In the opinion of this author, there is a need for  a better alternative to arthroscopic surgery for knee osteoarthritis treatment. That alternative is Prolotherapy, Platelet Rich Plasma Therapy and Stem Cell Therapy.

Dr. Hauser continues his discussion on Stem Cell Therapy as knee osteoarthritis treatment in a separate article.

But what about the patient who has continued knee pain and already had a knee osteoarthritis treatment including a surgery? Can Prolotherapy or Platelet Rich Plasma Therapy help? The answer is yes assuming the knee is correctly aligned.

Prolotherapy as Knee Osteoarthritis treatment

A main reason for knee pain after knee replacement is ligament instability. Ironically, the number one symptom that Prolotherapy and PRP address in pre-surgery patients is ligament instability. This is what we show patients – knee ligament instability before total knee replacement – knee ligament instability after total knee replacement. Perhaps the answer to their problem should have been to treat the ligaments! Not replace the knee!

Here is what the literature says:

“Instability is one of the most common causes of failure of total knee arthroplasty (TKA)…Acute instability is related to intraoperative injuries or excessive release of important coronal stabilizers such as the medial collateral ligament in extension or the posterolateral corner in flexion.” (Note – the surgery itself caused instability!)4

“In 32.6 % of all cases (requiring a revision surgery), ligament instability was the primary reason for revision. In another 21.6%, ligament instability was identified as a secondary reason for revision. Analysis of the different instability forms showed combined instability in extension and flexion as the most common cause, followed by isolated instability in flexion (31.8%) and isolated instability in extension (9.1%).5 The high correlation between instability and malpositioning of the prostheses was obvious.” The surgery itself caused more complications and ligament damage and instability.

As cited above, most of the pain after knee replacement relates to the structures around the joint. Besides the ligaments, the pes anserina tendons can be problematic as they too are stretched during the surgery and often when a person rehabs after a knee replacement these tendons and their muscles are not addressed as a pain risk factor.

Of the endless surgical reports that we’ve read: arthroscopic debridement, meniscus removal, and countless others, the surgeon will remove structures that the joint needs for cushion and stability. It is no surprise that long term results of these procedures include continued knee pain, knee instability, knee popping or clicking, knee weakness, osteoarthritis or bone on bone arthritis. What Prolotherapy aims to do is help the body repair the weakened tissue so the joint can function optimally.

Platelet Rich Plasma Therapy

Recent research highlights Platelet Rich Plasma Therapy’s effectiveness for  knee osteoarthritis, as shown in MRI observations. Researchers like to use MRIs as a scientific means to quantify findings, it offsets the “observational” or empirical findings of what patients report. This factor adds an objective measure to the subjectivity of patient reports.

In a  study entitled “Clinical and MRI Outcomes After Platelet-Rich Plasma Treatment for Knee Osteoarthritis,” researchers looked at PRP for knee osteoarthritis using an MRI as a baseline.5 They set out to investigate the effect of PRP on early knee osteoarthritis, using changes in MRI structural appearances as their method of change. This was a prospective cohort study (they followed people or cohorts with the same problem – knee osteoarthritis) for one year following PRP treatment.

The method of PRP treatment was a single 6-mL platelet-rich plasma injection. This was not similar to a comprehensive Prolotherapy treatment using PRP in that it was not used in a series of treatments, so it was less aggressive than PRP Prolotherapy. This treatment was given to 22 patients who had MRI confirmed early stage knee osteoarthritis. Fifteen were followed during the course of the study and examined at 1 week, then 3 months, 6 months and 12 months,. At the one year mark they received an MRI.

The patients reported that “pain scores significantly decreased, whereas functional and clinical scores increased at 6 months and 1 year from baseline.” However, qualitative MRIs demonstrated no change per compartment in at least 73% of cases at 1 year. Please see Prolotherapy and Platelet Rich Plasma Therapy used together as knee osteoarthritis treatment.

The problem with MRIs in diagnosing chronic pain

In translation: Single PRP treatment after one year showed patient improvement in pain scores and function but the MRI shows no benefit in three out of four people.6 In regards to the MRI,  research has clearly shown that the MRI is limited in showing what the true cause of the patient’s pain was. Recently, we posted an article in which researchers said that treatment of knee osteoarthritis would be better planned and more successful based on a physical examination rather than radiological findings. In another study, researchers found “MRI examination is not currently as important for the diagnosis of knee injuries as expected by both medical and lay communities.”7

So in this research we see that a single PRP treatment has clinical and positive effects for the patients, despite what the MRI confirms. As cited in other research, an MRI could not clearly show what was causing the patient pain,in other words it misses the root cause of pain. And in the current research of this article, an MRI can not clearly show what was benefitting the patient. MRIs cannot show soft tissue damage, the most common cause of chronic pain and osteoarthritis. Prolotherapy is an injection treatment that targets soft tissue damage and addresses the root cause of chronic pain and osteoarthritis. Used comprehensively, Prolotherapy is effective in cartilage regrowth and healing of sports injuries and chronic pain.

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1. Klett MJ, Frankovich R, Dervin GF, Stacey D. Impact of a surgical screening clinic for patients with knee osteoarthritis: a descriptive study. Clin J Sport Med. 2012 May;22(3):274-7.

2. Hauser R. Prolotherapy just makes more sense for cartilage injuries than accelerating arthritis with arthroscopy. Journal of Prolotherapy. 2009;1(1):6-7.

3. Laupattarakasem W, et al. Arthroscopic debridement for knee osteoarthritis. Cochrane Database of Systematic Reviews. 2008, Issue 1. Art. No.: CD005118. DOI: 10.1002/14651858.CD005118.pub2.

4. Del Gaizo DJ, Della Valle CJ.Instability in primary total knee arthroplasty. Orthopedics. 2011 Sep 9;34(9):e519-21. doi: 10.3928/01477447-20110714-46.

5. Graichen H, Strauch M, Katzhammer T, Zichner L, von Eisenhart-Rothe R. Ligament instability in total knee arthroplasty–causal analysis. Orthopade. 2007 Jul;36(7):650, 652-6.

6. Halpern B, Chaudhury S, Rodeo SA, Hayter C, Bogner E, Potter HG, Nguyen J. Clinical and MRI Outcomes After Platelet-Rich Plasma Treatment for Knee Osteoarthritis. Clin J Sport Med. 2012 Dec 12. [Epub ahead of print]

7. Cellár R, Sokol D, Lacko M, et al. Magnetic resonance imaging in the diagnosis of intra-articular lesions of the knee. Acta Chir Orthop Traumatol Cech. 2012;79(3):249-54.