Prolotherapy and PRP Non-Surgical Alternatives to Arthroscopic Meniscus Surgery

Why consider an alternative to meniscus surgery?

In the medical journal Clinics in sports medicine, doctors report that the number of arthroscopic meniscus repair continue to increase with excellent reported outcomes. However, complications from arthroscopic meniscus repair are sometimes catastrophic. The researchers suggest that catastrophic  postoperative complications may be reduced by “adequate diagnosis, appropriate patient selection, meniscus repair selection, surgical techniques, and postoperative management.” (1)

  • Meniscus surgery failure resulted from:
    • Inadequate diagnosis
    • Inappropriate patient selection (A patient who should not have been recommended to meniscus surgery)
    • Inappropriate procedure (The wrong surgery or too much tissue removal)

A 2018 study in the Journal of Knee Surgery reported on how United States military surgeons dealt with meniscal injury revealed that in nearly 30,000 meniscus surgeries the following occurred:

  • partial meniscectomy was performed in 81.3% of cases, (partial meniscectomy is the partial removal of the meniscus)
  • meniscal repair in 20.3% (Repairing the meniscus tear with sutchure)
  • and meniscus allograft transplantation (MAT) in 0.7% (Meniscus replacement from donor). The study noted a significant decrease in overall utilization of this procedure)
  • With each year of advancing age (the older the patient), there was a 3.7% increasing likelihood of meniscectomy and 6.5% decreasing likelihood of repair.
  • Females were more likely to undergo meniscal repair than males.
  • In this physically active cohort of nearly 30,000 military patients, 1 in 5 meniscal tears were treated with meniscal repair. (2)

Of note to patients seeking meniscus repair is that only 1 in 5 meniscus injuries were treated with surgical repair, the remaining were treated with meniscus removal. This is in a patient population of highly active military personal.

Medial meniscus root tears. Repair is better

A 2018 study in the American Journal of Sports Medicine compared Meniscus Root Repair vs Meniscectomy or Nonoperative Management to Prevent Knee Osteoarthritis After Medial Meniscus Root Tears

At the conclusion of a ten year observational period the researchers found:

  • Meniscus repair led to osteoarthritis in 53% of patients and to knee replacement in 33.5% of patients
  • Meniscectomy lead to osteoarthritis  99.3% of patients and to knee replacement in 51.5% in patients
  • Non-operative treatments led to osteoarthritis  95.1%  of patients and to knee replacement in 45.5%

A study in the Journal of Orthopaedics and Traumatology discusses what non-operative treatments for meniscus root tears are:

  • Supervised sessions of physical therapy – 3 times a week during the first 6 weeks and then at least twice a week for a further 6 weeks.
  • Painkillers were administered for those two 6 week periods and then as required during the follow-up.
    • Celecoxib 200 mg was used unless contraindicated, in which case ibuprofen sustained release 1,600 mg once daily after dinner was the preferred drugs.
  • Patients were informed to perform exercises with some strain but almost pain free and without having any negative influence in the affected knee the following day.(3)

Treatments and similar non-operative treatments are demonstrated in the study above were seen as resulting in 95.1% rates of osteoarthritis and to knee replacement in 45.5% in patients

Non surgical treatments Platelet Rich Plasma Prolotherapy

Research lead by Ross Hauser, MD published clinical observations on Platelet Rich Plasma Prolotherapy as first-line treatment for meniscal pathology in the medical journal Practical Pain Management.(4)

The injection technique of Platelet Rich Plasma Prolotherapy is explained in the video above.

In this study, the 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. Five patient cases are reviewed.

Case Report #1
A 21-year-old male athlete. MRI revealed an oblique tear of the posterior horn of the medial meniscus. Meniscectomy was declined until PRP Prolotherapy could be performed.

  • The patient was complaining of pain with all activities except walking.
  • He had popping in the knee and locking when trying to go from flexion to extension.
  • Physical examination revealed medial joint laxity as well as a positive anterior drawer sign.

The patient received one session of platelet rich plasma prolotherapy to the inside of the knee. The anterior cruciate ligament and medial collateral ligament were treated with Prolotherapy.

  • Prior to prolotherapy the patient reported pain and stiffness levels of 5 (on a scale of 0 to 10) which decreased to 0 and 1, respectively.
  • Prior to prolotherapy, he was completely incapacitated related to sports and after prolotherapy he was back to running and exercising longer than 60 minutes.
  • When he was questioned 15 months after the PRP prolotherapy session, he said prolotherapy had met his expectations.

Case Report #2
A 39-year-old squash player. 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 complained of pain when running and was unable to play sports. He had crepitation in the knee but no locking. He complained of a deep ache within the knee. Physical examination revealed slight medial ligament laxity but no heat or swelling.
  • He received two sessions of PRP prolotherapy to his knee and Prolotherapy to his medial collateral ligament. The patient stated his pain and stiffness levels went from a 6 to a 1 after the Prolotherapy. He reported that prior to prolotherapy he was completely incapacitated from running or playing squash but now, 17 months after his PRP prolotherapy treatment, has no limitations.

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 get arthroscopy because of a poor response to an arthroscopy on his right knee several years before.

  • Beside pain with any type of activity other than walking, he had popping and crepitation in the knee but no locking. He had pain deep within the knee as well as both laterally and medially. He had some generalized laxity of his knee throughout on physical examination.
  • He received a total of four sessions of PRP prolotherapy to his knee over a one year period of time. His general laxity was also treated with Prolotherapy. The primary reason for such a long time span is that each treatment gave him so much improvement he thought it was his last as he increased his physical activity, only to have some of the pain return. He was contacted twenty-four months after his last PRP prolotherapy session.
  • Before the prolotherapy he had a pain and stiffness level of 8 and 7 respectively, both of which decreased to a 1 after prolotherapy. He was unable to exercise before prolotherapy but after the PRP prolotherapy he is able to engage in unlimited cycling and is able to run, but has chosen not to run because of his right knee (the one that had arthroscopy). He also said that PRP prolotherapy met his expectations.

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.

  • On physical examination, he was found to have medial joint laxity as well as significant crepitation especially on the medial aspect of the knee. He received a single PRP prolotherapy treatment to his knee. At that time he also received Hackett-Hemwall prolotherapy for his medial knee instability.
  • His pain level before prolotherapy was a 7 and stiffness also a 7 but, fourteen months post PRP treatment, his pain level is 0 and stiffness is 1.
  • He was unable to exercise at all before prolotherapy but after treatment he can cycle for two hours and has no limitations with most weight lifting, all swimming and all cycling. He cannot run currently because of an Achilles injury that he is thinking about getting treated with prolotherapy.

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 causing 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.

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1 Blake MH, Johnson DL. Knee Meniscus Injuries: Common Problems and Solutions. Clinics in sports medicine. 2018 Apr 1;37(2):293-306. [Google Scholar]
2. Pekari TB, Wang KC, Cotter EJ, Kusnezov N, Waterman BR. Contemporary Surgical Trends in the Management of Symptomatic Meniscal Tears among United States Military Service members from 2010 to 2015. The journal of knee surgery. 2018 Mar 7. [Google Scholar]
3. Faucett SC, Geisler BP, Chahla J, Krych AJ, Kurzweil PR, Garner AM, Liu S, LaPrade RF, Pietzsch JB. Meniscus Root Repair vs Meniscectomy or Nonoperative Management to Prevent Knee Osteoarthritis After Medial Meniscus Root Tears: Clinical and Economic Effectiveness. The American journal of sports medicine. 2018 Mar 1:0363546518755754.
4. Ross Hauser, MD,  Phillips H, Maddela H. Platelet Rich Plasma Prolotherapy as first-line treatment for meniscal pathology. Practical Pain Management. 2010;July/August:53-64.