Saturday, November 2, 2013

Pincushion me!

The three letters that convinced me to try PRP. 
On the right is my MRI.  On the left top is my Boston acceptance. 
On the lower left is a totally unexpected check from
the bank that held the mortgage on my recently sold home.
I've been fighting multiple injuries over the last few months, including a) a combination of tendonitis/plantar fasciitis/ligament issues on my right foot, and b) a low grade tear in my left hamstring tendon at the attachment.  Yesterday, I had my first treatment with PRP to address these issues.

PRP stands for Platelet Rich Plasma.  You extract normal blood from someone, process it in a centrifuge to concentrate the platelets, then reinject it at injury sites.  The theory behind it is that the increased platelet concentration stimulates a healing process that is faster and/or more complete than what your body is doing on its own.  It's been used all in sort of locations (joints, muscles, tendons) with the greatest effectiveness noted in cases of tendonosis and/or ligament damage.

At least that's the theory.  In humans, there's just not that much evidence, especially from large scale studies.  Just lots of anecdotal experience.  And as for how it works?  Well, no one's quite sure about that either.

I wasn't too worried about not knowing how it works - that holds for lots of proven treatments, including aspirin.  I was more concerned about the lack of large scale studies that supported its use.  However, the lack of evidence may be linked in part to the lack of standardization for the PRP process.  Not all PRP is the same - there's a wide variance in a) platelet concentration, b) what else is taken out of the blood (red blood cells?  white blood cells?), and c) the recovery process.

Of course, that begs the question: how do you know you're getting the best process?  Every practitioner will tell you that their process is superior to others, and there's not much research comparing the different methods.  In the end, I decided to take comfort that I was going to a doctor that effectively used PRP to treat my same injury in another athlete.

***

PRP usually involves a single appointment per injection - you show up and have your blood drawn.  Then you wait about 15 minutes while they process it in their centrifuge, and then get the injection.  Whole thing should take an hour or less.

In my case, we decided to do it a bit differently, for a few reasons.  For one thing, I'm a very difficult blood draw - I have Raynauds, low blood pressure, a low resting heart rate, and veins that are deep, narrow, move around, and collapse.  It made sense in my case to schedule a blood draw the day before, to ensure that we had plenty of time to get what we needed, and also so that I could come back the next day if we couldn't get enough.

Doctor Wagner also wanted to be absolutely sure that he was treating the correct area for the hamstring.  So he proposed that I set up a diagnostic appointment where I'd run some, then get a shot of lidocaine (short duration local anesthetic) in my tendon, and then run some more, keeping track of how I felt on each run.  Then I'd report back to him when I came back in for the PRP.

So, we scheduled three appointments:
  • Thursday at noon: get blood drawn
  • Friday morning - run for about 20-25 minutes, get a shot in butt at 6:45 am, run some more.
  • Friday afternoon - PRP.
And then, of course, rest for the weekend.

***

The blood draw on Thursday went as I expected, of course.   Poorly.

I went in right at noon; an hour and seven sticks later, we had about 3/4ths of the blood needed.
The residue from
Thursday's bloodless draw
At this point I was told I had my choice of a) going with a mix of PRP and prolotherapy or b) coming back at 6:00 am on Friday morning to take a second try at the blood draw.  I chose the second.  Dr. Wagner had recommended PRP rather than prolotherapy - I was going to get PRP.

Fortunately, when I returned at 6 the next morning, the blood was flowing more freely (it was ridiculously warm outside, which I think helped).  With two more sticks (9 sticks total so far), we had enough blood, and I was dismissed to go run laps of the office park in the dark.

Laps done, I returned for two ultrasound-guided shots into my hamstring (we're up to 11 jabs), and then did some more running before returning home to work for the morning.  The hamstring was improved, though still weak and tight.  That same afternoon, I returned for the grand finale.

***

During my previous visits to this doctor, I had filled out normal forms - insurance information, HIPAA disclosures, diagram of where I hurt, etc.  But now I had new ones to fill out - they basically fell into two categories - those that said VERY CLEARLY that this was an experimental procedure and not part of the standard process of care, and those that said EVEN MORE CLEARLY that insurance would not cover this procedure and that I was responsible for the cost in full.  Then they collected my payment before I went back.

The magic cart.
When I returned to the examination room, I was greeted by the physician assistant and a cart with syringes.  She showed me the bag that my syringes had been provided in, to demonstrate that it was my name on the bag,  and  then I got up on the table.

Dr. Wagner walked in, and after some pleasantries and an update on my morning run, he pulled the cart over.

"My apologies in advance.  I'm afraid this is going to hurt."

I've heard that before from doctors, and usually dismiss it.  The normal population's pain tolerance isn't the same as a runner's, and many times I've gotten this warning and the procedure itself has been nothing.  But something about his tone (and knowing that he had done PRP on a lot of athletes) told me this was different.

Oh well.  Needed to be done.

And so we began.  And yes, it wasn't pleasant.  For each place I got injected (the ligaments on the outside of my right ankle, my right plantar fascia, and my left hamstring at the insertion onto the pelvis) he first applied two-three shots of an activator.  Then the PRP itself as 2-3 ultrasound-guided injections in the area - it wasn't the shot itself that hurt as much as the extended injection of the fluid, which made each location feel like it was "too full."

[I lost count of injections at this point.  I'm pretty sure I ended up with 6 injections of PRP - 4 in the foot and 2 in the hamstring tendon.  Plus multiple activator shots.  Combine these with the preceding 11 jabs, and I'm gonna put myself at 20-25 needle pokes over a bit more than 24 hours.  It's a truly wonderful thing that I'm not trypanophobic]

Since people are always curious as to just how much it hurt, I'll express it this way.  In terms of pain ranking, I've had the following at various points: deep tissue massage, cross-frictional massage, dry needling, Graston technique, ART, cortisone shot, nerve conduction study.  I've also raced both mile races and a marathon, and have broken bones.

I want to be here.  I'm not.
I'd rank the PRP above most of these.  It definitely hurt more than a cortisone shot, ART, Graston, or dry needling (or marathons and mile races).  I'd rank it slightly less painful than cross-frictional massage on an inflamed tendon.  It's probably about equivalent to a masseuse's use of his elbow on a really deep muscle knot, but imagine that the pain continues on, and even increases, after he's done. 

So yeah. not pleasant.  But it hurt less than missing the Sunday long run.

***

Then I was done, and Brian carted me home, where I've been ever since.  Tips for others that get PRP, based on my experience:
My foot apres-PRP. 
No, I didn't take any ass shots.

1) Don't plan on driving yourself home afterwards, even if you're not getting work done on your right foot.  You'll be pretty sore.  Sore enough to distract you from concentrating on the road.

2) It's a pretty good idea to plan on being home (and couch) bound for a day or two. You'll be sore, and you're also supposed to be resting.  Don't plan on going back to work the same day.  Don't plan on coming home and catching up on your housecleaning or laundry.  I stocked up before hand on groceries, reading materials, and plans for internet use, and I'm glad I did.

3) I do wish I had brought Tylenol with me to the appointment, so I could have taken it right away.  I won't make that mistake again.

As for the recovery?  It seems that everyone that gets PRP gets different advice here, which I think ties back to the fact that there is no set standard for how to manage it.  In my case, in addition to the standard advice to avoid NSAIDS for at least a week, I was told 24-48 hours of just rest.  After that, I can return to activity by starting off with swimming with a pull buoy.  After that, I can shift to swimming, then to weightbearing activity and rehab exercises, and then to running, letting discomfort be my guide. 

Dr. Wagner explained that there were two reactions that occurred from the PRP.  The first is an immune reaction that causes the pain and swelling.  That's at its worst for the first several hours before trailing off - the total duration of this reaction is about 7-10 days.

Separately, there's a stimulus to the body's healing process.  That is no by means instant - it starts slowly and ramps up gradually over time (and time is weeks and months).  PRP is NOT an instant fix or a way to get back to running workouts within the next week.  It IS a way to hopefully shorten the healing time for tendons and ligaments substantially, increasing my chances of starting a marathon training cycle after the new year.

Whether it works for me?  We'll see.  In the meantime I'll be parked on the couch on my side, watching streaming horse show and the NYC marathon.

3 comments:

  1. This was fascinating and the most complete read on PRP I've seen. Thanks for keeping us updated. I really might fork this cash over if it works for you!

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  2. Ouch! I really hope it works for the pain it causes!!! Rest Up, and huge hopes you'll be out with the group soon!

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  3. You know what's funny? Your chosen distractions, which to most people are on par with watching paint dry ;-) Here's to a speedy recovery!

    Caren Jew

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