Welcome to the exciting new field of Stem Cell Orthopedics. As a physician who has specialized in Regenerative Injection Therapies for over 20 years, knee pain is the number one problem that I encounter with my patients. The success rate of stem cell therapy, if done properly, is 80-85%. Not only is it highly effective and extremely safe, but in many cases, it may yield far superior results than standard surgical and pain management approaches.
Unfortunately, there are many misconceptions about this new field. Also, few doctors have the right training and experience to do it properly. If you or someone close to you are considering stem cell therapy for your knees (or other areas such as shoulder, hip, low back, neck, ankle/foot, elbow, wrist/thumb) for goodness sake, make sure you do it right! Let’s explore exactly what we mean by that. As with many things, one of the best ways to understand a subject is to ask the right questions.
What is the root cause of the knee pain?
Good medicine starts with making the right diagnosis! In other words, it is vital that we have a clear understanding of the true root cause of knee pain. For example, just to say Arthritis is not precise enough to be useful. What specific part of the knee is the problem? Is it cartilage? Is it the surrounding bone? Or Is it specific ligaments like the ACL or the MCL (medial collateral ligament) that form the capsule that surrounds and holds the knee together? In regenerative orthopedics we believe that the key metric is the stability of the joint. Whether it’s a knee, shoulder, hip, wrist, ankle or vertebral joint, same deal. In almost all cases, the problem can be traced to instability. As the joint subluxates (small dislocation) out of position it pulls on damaged ligamentous attachments and creates micro-tears. Since these attachments are highly innervated, these micro-tears become major pain generators. It is often misdiagnosed and not recognized, but this mechanism is the underlying root cause of 90% of musculoskeletal-related pain.
How can we diagnose the real root cause of the knee pain?
If we are correct and the primary root-cause of pain is microtears in the supporting ligaments and tendons and the resultant instability of a joint, how can we confirm this diagnosis? Unfortunately, MRI and ultrasound are often not sensitive enough to detect this damage. To complicate the picture, MRI may show many other structural abnormalities, which may not be the real source of pain. And of course, if you misdiagnose the real pain generators, and wrongly attribute the pain to something else, what is the chance that surgery etc. is going to solve the problem?
The only reliable way to properly identify the key pain generators is with a little-known but highly effective technique called palpation interrogation. If I examine a patient and directly palpate with my thumb specific structures around the knee and the patient responds with the “jump sign” when I test these particular structures, this is diagnostic that those structures are weak and the true root-cause of the pain. As simple as this technique sounds, it is a very elegant way and indeed the only way to properly identify and prioritize all the pain generators in a given patient.
What are the pros and cons of stem cell therapy for knee pain?
The advantages and benefits of stem cell therapy are many. In many cases regenerative injection therapies may be the treatment of choice and the quickest most elegant way to heal the pain. In most cases, it is the only nonsurgical option and the only way to avoid invasive surgery and its attendant risks. If done properly, it is very safe. We are using the patient’s own tissue and DNA so it is as natural as possible. If done correctly, in a reasonably healthy person, by a properly trained and experienced doctor, the success rate is upwards of 80% and the benefits should last long-term. One of the most important pros is that there is minimal downtime. Most patients can return to daily activities within a day or two, although sports activities may take a little longer.
OK, what’s the downside? Yes, the injections might be momentarily painful but generally, the discomfort attenuates quickly and passes in 10-15 minutes. Truth be known, the goal of the regenerative injections is to hit the pain generators as directly as possible. The pain confirms you are in the right place. If you have regenerative shots and don’t feel it, chances are your doctor missed the key pain generators. The other main downside is, since stem cells and these regenerative treatments are not covered by any insurance, you may pay your money and not get the results that you hope for.
What type of stem cells (or regenerative solution) are best?
The best, most potent stem cells to regenerate the knee are autologous, DNA-matched tissues from your own fat. There are 300x more mesenchymal stem cells in fat than in bone marrow and these are the cells that rebuild cartilage, ligament and even bone. Many patients inquire about the young stem cells of umbilical preparations but the DNA matching is actually much more important than the age of the stem cells. It is also vital that the stem cells are separated gently (so they don’t die) and injected immediately while they are fresh. When we isolate stem cells from fat there are surrounding cytokines which really boost healing. Since cytokines disappear after a few hours, the sooner you inject the stem cells after preparation, the better.
The stem cells are always combined with PRP (Platelet rich plasma). These PRP growth factors are spun down and concentrated from a patient’s blood. Stem cells are the seed and PRP is the fertilizer. In addition, in the case where the stem cells are healing slowly, we have the option to add PRP on its own as a booster. Once we inject a patient with stem cells, they remain alive for at least 4 or 5 months so if a patient is progressing slowly after 6 or 8 weeks we would generally recommend a PRP booster to reignite the sluggish healing.
Prolotherapy with a dextrose-based solution can also be very useful to assist the healing of knee pain. In cases of severe instability, Prolo can be used as a stem cell primer and help set the stage for the stem cells to complete the healing. It can also be used as a booster. Also, in the rare case where a patient does not respond sufficiently well to PRP or stem cell-PRP biologic solutions, Prolo may complete the tightening of the joint. It works in a different way to biologics and acts as an osmotic shock that increases the blood flow to critical areas. It should be noted that particularly for younger patients where the degeneration/damage is not too severe, PRP or Prolo primers may be used on their own to solve the problem and heal the pain. It may take 4 or 5 treatments and the healing may be slower, but it definitely can work.
How do stem cell and regenerative injections work for knee pain?
Regenerative therapies, whether stem cells, PRP or Prolotherapy, all work at a cellular level. They work slightly differently but they all repair ligamentous and tendinous attachments and tighten the joint or attachments. Prolo works as an osmotic shock that brings more blood flow to attachments. This may work great if microtears are smaller. If the tears are bigger and degeneration/damage and instability is more severe, more powerful regenerative solutions such as PRP or stem cells/PRP might be the treatment of choice. Since the regenerative power of stem cells-PRP are about 10x the power of PRP alone, I will generally start with this combination. If a patient asks me why I am a stem cell doctor, I will say that I like to use the appropriate solution for the problem at hand. After all, I only have one chance to make a first impression. My intention with the stem cell/PRP combo is to try and make the most improvement possible in a single session. Once a patient feels substantial improvement, they appreciate the power of stem cells to heal.
Regardless of what solutions one starts with, one of the first signs that its working is the increased stability of the joint and a reduction of the pain with movement.
How quickly can people notice an improvement in knee pain after a stem cell treatment?
Healing depends on mother nature and the exact timing will depend on the individual and the structures involved. There are also two phases to the healing and improvement in the knee pain. The tightening phase can kick-in anywhere from 2 hours to 2 weeks. The regenerative phase where new tissues are regenerated takes about 6-8 weeks to be noticeable .
What kind of follow-up/rehab is required?
Proper rehab is very important to a great outcome. It is very important that people have optimal orthotics so they are not re-spraining the knee every time they walk. Once the alignment is corrected, walking and movement should start right away although we don’t want to overload the healing knee too much for at least 6 weeks. Cycling and swimming exercises can often be great rehab exercises. As discussed above, if a patient is healing slowly after stem cell therapy, we usually recommend a PRP booster 6-8 weeks post stem cell
How long will the improvements last?
Long-term, structural, not pain management!
This is not a pain management therapy like cortisone, it’s a structural solution. Once we are successful at rebuilding and strengthening the tissue that was the major pain generator, there’s every reason to believe that the improvements should be long-term.
How much does it cost?
Unfortunately stem cell therapy and regenerative treatments are not covered by medicare or any insurance plan. Primer treatments can start at $1,000. per session. The total cost for a full blown stem cell therapy is 7-8K for one joint/region and up to 10-12K for multiple joints/regions. (It gets cheaper the more you do because you are paying for the procedure setup). Follow-up boosters are $1200.-$1500, depending how many areas are involved.
In the end this is a personal decision. It comes down to quality of life. Is it worth that amount of money to give you pain relief and regain the ability to live life to the fullest.
How can I choose the right stem cell knee doctor?
I often consult with patients who have had previous stem cell and regenerative therapy. If it didn’t work, my first question is, who did it? Stem cell treatments for knee pain are very sophisticated and highly specialized. It’s like surgery. The outcome of a surgery is totally dependent on the skill and technical support of the surgeon. So, it is in the stem cell orthopedic field. There are very few doctors who have the right training and experience to do it right. As with any new field, there are dabblers who are new to the field but do not yet have the training and experience to do it right. Doctors with a background in Prolotherapy have a big advantage. They have the basic methodology and diagnostic skills to properly identify the key pain generators.
