Dr Blecher Facebook Q&A | Treating Ligament Injuries
Regenexx Cayman visiting physician, Dr. Blecher from Southern California Orthopaedic Institute recently participated in a Facebook Live. During the Q&A, Dr. Andrew Blecher discussed treating ligament injuries with stem cell and blood platelet treatments and answered patients’ frequently asked questions. You can watch his Q&A session in full below. And if you still have questions please don’t hesitate to contact the Regenexx Cayman patient care team directly.
These are just some of the questions that Dr. Blecher answers in the video.
Regenexx Cayman: Hi everyone thanks for joining us on Facebook live today. My name is Emma and I’m a Marketing Supervisor here at Regenexx Cayman, and I’m very pleased to welcome one of our visiting physicians today, all the way from the Southern California Orthopaedic Institute, Dr. Blecher, thanks for your time today.
Dr Blecher: Thank you, hello everybody.
RC: Dr Blecher specializes in athlete care and was recently I believe named one of Los Angeles top doctors by Los Angeles magazine, so congratulations.
Dr Blecher: Thank you.
RC: So today we’re going to be discussing the use of blood platelets and stem cells for treating ligament injuries in athletes. And for those of you don’t know very much about Regenexx Cayman – Regenexx Cayman is an orthopedic stem cell clinic based right here in Grand Cayman. We offer advanced stem cell and blood platelet treatments, as a non-surgical alternative for people suffering from severe orthopedic joint issues and injuries. Such as arthritis, ACL and meniscus tears, degenerative disc disease, cartilage damage, and a whole host of other conditions.
As you can imagine, we treat quite a lot of athletes here from all age ranges and competition levels, which is why we’re glad to have Dr. Blecher here to discuss that with us. And if you have any questions for Dr. Blecher today please drop them in the comments and we’ll try to answer them live or if you’re watching on playback we’ll be sure to come back to you in the future. So, to get started Dr. Blecher perhaps you can tell us a little bit more about yourself and how you came to work in regenerative medicine.
Dr Blecher: Sure, I was trained originally in primary care sports medicine. I did a sports medicine fellowship at the Cleveland Clinic in Ohio where I had the opportunity to work with a lot of professional athletes including the Cleveland Browns, Cleveland Indians, Cleveland Cavaliers, and after that I moved to Los Angeles and that’s where I started working at the Southern California Orthopaedic Institute where essentially, I practice non-operative orthopedic sports medicine. I started there in 2003 and I’ve had the opportunity to work with a number of different athletes from all ages, youth sports; Little League, and collegiate athletes, and then a lead in professional athletes as well.
A lot of what I do includes prescribing physical therapy, brace, and casting, various types of injections, and for many years we were somewhat limited to that in terms of our treatment and then regenerative medicine started taking off – probably around 2007/2008/2009. I started doing PRP treatments, mostly for overuse injuries. There was some evidence that it helped athletes with tendinopathy and we realized there were other potential indications to use PRP. We started using it for ligament injuries and eventually cartilage injuries and then we expanded to using stem cells which are even more effective. So regenerative medicine has become a pretty good-size part of my practice now for treating athletes and all that.
RC: Fantastic. You touched there on our main topic of the day – ligaments. And perhaps for anyone listening at home who may be unsure – what are ligaments, what do they do, where are they in the body, and how do they work with the cartilage muscles in the body?
Dr Blecher: Ligaments are the connective tissue that connects bones to each other, so they provide stability for a joint. They’re not the only thing that provide stability for a joint, your muscles also provide stability, so when muscles contract, they will stabilize the joint. When muscles are relaxed, they’re not stabilizing the joint, so we call muscles dynamic stabilizers, whereas ligaments don’t have the ability to contract so they’re always taught kind of like a rope and they provide static stability to a joint, so they kind of work together to provide support for a joint when your muscles aren’t doing good job, there’s more stress on ligament and ligaments can get injured.
RC: And what is it about sport that may be particularly damaging to ligaments?
Dr Blecher: Ligament injuries tend to happen for two different reasons. You can either have an acute injury which often times is from a trauma – you’re playing football and you get hit on the side of your knee and that can damage a ligament, or if you’re running in one direction and then you twist really quickly and pivot and putt to change into a different direction that can put a lot of stress on the joints and that can give you an acute ligament injury as well.
So ligament injuries in sports oftentimes are these acute injuries from a misstep or twisting your ankle or getting hit by another player, but we can also see chronic injuries as well where there’s overuse. So for example in baseball people who throw a lot, pitchers specifically so when your muscles are starting to fatigue and there’s more stress on the ligament it starts to break down, you can see a chronic ligament injury.
RC: And are there any sports injuries that you see yourself treating more than others or more frequently?
Dr Blecher: Knees and ankles and shoulders are typically what we see the most of in sports. For ligaments specifically, however, I would say knees are probably the number, one especially with sports like football and soccer, a lot of twisting and contact injuries, basketball as well. And then we see a lot of ankle injuries. Ankle sprains are very common, that’s a ligament injury and those can be treated with PRP, so we see a lot of those. And then when it’s baseball season, lots of throwers … that oftentimes lead to Tommy John surgery … and we treat them with PRP or stem cells.
RC: Hi everyone sorry if you were just watching us live on Facebook, we did lose signal for a second there. But we have had some questions come in while we were offline so we’ll just jump straight back into those before continuing our live Q&A with Dr. Blecher. So one question said “my friend is having the plasma treatment (PRP) next week and he’s having it on his left shoulder, neck, both knees, and right ankle” so quite a lot of joints, “he’s been in quite a bit of pain since November – what can you expect immediately after treatment from plasma treatment?”
Dr Blecher: Yeah, so PRP is somewhat pro-inflammatory, and remember the inflammation process is the healing process, so initially after treatment, we’ll see the inflammatory response so there will be pain and swelling – I usually tell patients they’re gonna feel worse before they feel better. Oftentimes it depends on what structure we’re actually injecting. Some structures hurt more than others, so injecting a muscle may not hurt nearly as much as injecting something like a meniscus – so as opposed to just knowing which joints were treated, knowing which structures gives you a better idea of how much pain to expect afterward.
But usually the pain is not too bad and not for too long, often we will give patients pain medication just for a day or two – usually Tylenol is enough after that, we want them to avoid ice because we don’t want to again reduce that inflammatory response, so they usually have a little bit of discomfort for the first week or two at the most – then we try to get them into some type of rehabilitation process, again it depends on what structures we’re treating in terms of how long they need to rest but usually we’ll start with strengthening and range of motion as soon as we can. In certain instances, we keep them non-weight bearing if need be for a short period of time. Then usually by 12 weeks they’ve made significant improvement, a lot of the structures heal fairly well in eight to twelve weeks.
RC: Okay. And a second question we had before we went offline was “how important is it to wear the metal braces after stem cell injections in the knees versus a sleeve knee brace?”
Dr Blecher: Alright. Again it depends specifically what we’re treating, so if we’re using stem cells to treat in the knee, if we’re trying to inject these stem cells where the cartilage is breaking down and we don’t want you to serve those stem cells immediately, after the procedure we’ll try to unload the area that we injected meaning that when you’re walking around you don’t want to just squish away all those stem cells, so we use a special type of brace to push the knee over from one side to the other to unload the specific part of a knee that we just injected. So again, it depends on which structures we’re injecting as to what type of brace is required but oftentimes, we do want to unload one part of knee for a good 4 weeks after a procedure.
RC: So you’d possibly recommend the stronger brace if you’d like to see like you know the stem cells do their job in the best possible way?
Dr Blecher: Correct.
RC: We have just had another question come in “how long does it typically take for results from stem cells injected into a spinal disc?”
Dr Blecher: Again, it depends on the indication. There are few indications for using stem cells into a disc and we’re learning more and more about how to use that. A lot of the treatments that we do are PRP based in the spine, but again it depends on how you determine results. Immediately after the procedure, there’s going to be a lot of discomfort in patients, you know [patients] might feel a little bit worse before they feel better. It takes a while to heal and for that inflammatory process to kind of calm down, so it may be several months before there’s a significant improvement – although some patients do you feel better within a couple of weeks.
RC: Yes. Ryan, we’ll drop you a message after this just with our outcome data for spine treatments as well. I think that might be very useful for you. And if anyone else has any specific joint outcome data requests and you’d like to see how those joints feel after three months after twelve months, please drop us a message and we’d be happy to show you our infographics.
And so getting back to the questions about ligament injuries in athletes. We got cut out as you were finishing off talking about PRP and how that helps and ligament injuries, but how is it that stem cells comparatively can help ligament injuries?
Dr Blecher: Right. So we talked about PRP – one of the major function they have is to recruit stem cells to an area, which requires adequate blood flow for the stem cells to be able to reach the injured tissue, so in certain injuries there really is not adequate blood flow to the area, so your body’s own stem cells can’t get there so when we do stem cell treatment we’re getting over that hurdle by taking your body stem cells and putting them right at the site of injury.
So some injuries such as ACL tears or you see all tears in the elbow or specific ligament injuries, like an injury to a meniscus or labrum or articular cartilage, and very little if any blood flow to them, so PRP on its own doesn’t work very well – so we need to combine the PRP with stem cells put both of them in the exact location of the injury in order to get tissue healing.
RC: What’s the main deciding factors between a Regenexx physician choosing to recommend PRP over stem cells?
Dr Blecher: Specifically, for a ligament injury, for the more mild ligament injuries, ligament injuries are often referred to as sprains – so it’s a grade one or two sprain, or ligament injury, oftentimes we can treat that with PRP because there still is adequate blood flow. A lot of the overuse chronic ligament injuries can be treated with PRP as well. For the more severe injuries, the grade three injuries where you have a complete tear or rupture of the ligament with no structure left or no blood flow to the area, then PRP alone is not going to work very well.
Another situation is even if there’s just a grade two injury, but the ligament is very loose, so oftentimes we can test the ligament while we look at it under ultrasound and see how loose it is, and if the ligament is extremely loose that may not be a good candidate for PRP either and we may decide that we need to use stem cell therapy. So for a lot of ligament injuries we can get away with PRP alone, but for some we need to jump straight to doing stem cell treatment.
RC: Are there any injuries then that we can’t necessarily treat with stem cells with blood platelets, and what are your thoughts then on treating sports injuries with surgery?
Dr Blecher: Right. So there are some in ligament injuries where the ligament is completely torn and the ends of the ligament have been pulled apart and there’s kind of nothing left in the middle, and without any structure there at all it doesn’t really matter what we inject into an open space we’re not gonna get any tissue healing so those instances PRP or stem cells don’t work very well, and surgery would be required. So, for example an ACL tear is a common ligament injury that has always been treated surgically. There are some ACL tears that we can treat with PRP and/or stem cells but if the ligament is completely torn and pulled apart, the ends aren’t close to each other then surgery would be the only option.
RC: Every patient is different, but what sort of results have your patients experienced from Regenexx treatments on ligament damage?
Dr Blecher: Yeah, patients do very well. We are careful of that – you know, choosing the right patient. We don’t want to give patients unreasonable expectations that we can cure everything because we can’t. There are certain things that do require surgery. But if you choose your patients correctly and we do appropriate treatments, by providing the right treatment, either PRP or stem cells or a combination of both and we treat accurately with some type of guidance either fluoroscopy or ultrasound and patients generally have very good outcomes.
Oftentimes you know we treat athletes, we have a hard time holding them back, they often always want to get back to sport quicker than you’ll let them so that oftentimes is a challenge, but they do the appropriate rehab they have a very good success rate. The injuries that we treat with PRP or stem cells make a complete recovery and go back to elite level athletics.
RC: Great, and we’ve had another question come in “what is the benefit of Regenexx bone marrow stem cells as opposed to umbilical mesenchymal stem cells?”
Dr Blecher: Yes so there’s a lot of debate about that. Now we’ve been using bone marrow stem cells for a long long time and if you go on our website you’ll see all of our outcome data so it’s been very well researched. We know what the outcomes are, there’s not really been any outcome studies using umbilical based products it’s kind of a new fad now, unfortunately, it’s not very well regulated. If you see a physician who is offering you this, ask them to see what their outcome data is because I’m sure you’ll be surprised to see that they have none – so right now we stick with what we know we can get outcomes with bone marrow. In the future I think there potentially is promise for umbilical, or placental, or amniotic based therapies.
RC: Is there an impact on using bone marrow mesenchymal stem cells if you’re aging, if you’re a little bit older already?
Dr Blecher: Our bone marrow mesenchymal stem cell counts are good until we get into our 50s, then they slowly start to decline. A lot of it depends on your health status as well. You know how often you diet and being active supports your stem cells. You’ve got heart disease or diabetes or hypertension, those things can affect your stem cell counts as well. So certainly, the younger and healthier you are the better your stem cell counts. There are obviously a lot of athletes that we treat tend to be on the younger, healthier side so we get very high stem cell counts.
RC: Yeah but then that’s one of the advantages of what we offer here with Regenexx-C and the culturing process, so would you be able to talk a little bit about that.
Dr Blecher: That’s one of the benefits of doing the cultured stem cell therapy is that we’re able to culture out stem cells, we can get up to a thousand times what we can get without culturing. So, patients who need to treat multiple joints or may not have very high stem cell counts we can get around that by culturing out their bone marrow and getting very nice stem cell counts, usually we have plenty left over that we can save and use for future use.
RC: A little bit earlier you discuss the kind of acute and chronic differences in ligament injuries. How is it that someone might be able to tell if they’re suffering from acute versus chronic and how [physicians] would choose to treat them differently?
Dr Blecher: With acute injuries typically you’ll know when that happens, so you sprain your ankle, or you twist your knee, or you get hit playing football, they’ll have acute pain and swelling, you’ll know an acute injury happens and typically these acute injuries if they’re going to heal on their own will heal in about 8 to 12 weeks, so if they haven’t healed by that and you’ve got chronic pain that’s persisted for months and months and months it may at that point be a chronic injury.
The other type of chronic injuries we see are the overuse injuries reasons we talked about especially with throwers are a good example, so if you’re a pitcher and you kind of slowly start to develop elbow pain over time you don’t recall there was an acute episode where you there once and felt sudden pain but have developed pain over time, that may be a chronic injury.
RC: We’ve had a question come in again, “I already did PRP on bone marrow stem cell treatments for a degenerative disc. It’s been 3 months and I’m still in pain” and we said the results can take some time but “I still can’t move as naturally as I used to and my question is – does Regenexx Cayman provide a choice of more protein stem cells since legislation is different from the U.S.?” I suppose that’s again discussing the Regenexx-C implications.
Dr Blecher: Right, so the benefit of the cultured treatment that we can do here is we can get many more numbers of stem cells or stem cell counts are much higher. The other benefit is that we can actually isolate the stem cells when we treat in the U.S. we can’t actually isolate the stem cells without culturing them out so we’re really using something called a bone marrow aspirate concentrate, so although what we’re injecting contains stem cells, there are other things in there as well. Blood products precursors which can be very pro-inflammatory and cause discomfort, so here in Grand Cayman we can get rid of all those other unnecessary cells that we don’t need and reduce that inflammatory component which can cause a lot of discomfort so there definitely are a lot of benefits to treating here.
RC: A little earlier you talked about the kind of advantages of the fluoroscopy, the ultrasound, that image guidance which we do here. A lot of other stem cell clinics don’t use these techniques, whereas Regenexx doctors are trained in ultrasound and fluoroscopy image guidance to ensure accurate injection placement during procedures. But perhaps you can talk about the kind of difference this makes in terms of treating sports injuries, what does that image guidance do?
Dr Blecher: It makes a tremendous difference. So, a lot of things that we have treated in the past using something such as corticosteroid, the steroids are kind of like hand grenades – as long as you get close they work. You get in the general area and they’ll reduce inflammation and reduce pain. But when we’re treating with orthobiologics like PRP and stem cell treatment, it’s really important that we’re injecting those exactly to the site of injury.
Platelets and the stem cells need to interact with the damaged tissue, they can’t be closed, they need to be exactly [in] the site of injury, so stem cells have the ability to stick to tissue, so they’ll come into contact with tissue and they’ll stick to it. So if the first tissue they come into contact with is not tissue you want to treat, then you’ve wasted your stem cells so it’s very important that we get the treatment exactly to this to the site of injury – which is why we use guidance, whether it’s fluoroscopy or ultrasound, we want to make sure that we’re putting a needle in the exact spot and actually see that the fluid we’re injecting is going where we want it to go.
RC: Moving a little bit away from the topic of ligament injuries perhaps we can talk about arthritis and sport, because I suppose if people are suffering from arthritis they might be put off practicing sport, it might be painful or uncomfortable, but despite the pain, isn’t exercise good for arthritis? And what’s your advice for people in this situation?
Dr Blecher:We see a lot of arthritis in athletes. People tend to conceptualize that arthritis is a disease of older folks and that’s not necessarily the case we see younger and younger people developing arthritis. A lot of people who have ligament injuries like tearing their ACL, for example, will develop arthritis and sometimes they can develop arthritis within five to ten years, so if you think about the quote-on-quote epidemic of ACL tears that’s occurring in in young athletes you know age 15/16/17, within 5 to 10 years they may develop arthritis in that joint, so we’ll see patients in their 20s and 30s with arthritis. Particularly since people are more athletic younger ages they specialize in one particular sport and play it year-round.
Once you’ve injured a joint and you continue to pound away at it, you’ll break down your cartilage and we’ll see these arthritic changes occur fairly early. We are seeing a lot of athletes with cartilage damage and arthritis and that’s something that we do need to treat. And PRP and stem cells provide great promise for that.
When we have cartilage injuries and arthritis we tend more to use stem cells with PRP as opposed to just PRP alone and we see good results, especially in younger patients before their cartilage is broken down you know what I always tell patients is we can’t really grow back cartilage loss, so if we can treat it early before the cartilage has all gone away and it’s kind of in the earlier stages we can really do that athlete a great service. So treating these earlier and earlier and younger and younger gets good results.
RC: And bringing things back to your own professional career – you’ve treated a lot of professional athletes and is there… perhaps no naming names… but is there any particular case that’s left a lasting impression on you on just how successful like PRP and stem cells can be for an athlete’s career or that career longevity?
Dr Blecher: Yeah, so it’s always great to see an athlete get back to the sport they love. I’ve been an athlete myself my entire life and I’ve had lots of injuries and a few surgeries so I know it’s like to be out of the sport you love, so you know anytime we can get an athlete back onto the field and participate at a high level and you know prolong their career it’s a great thing so we see that a lot.
One of the most memorable probably, however, is going to be a little bit different than your typical athlete, obviously I practice in Los Angeles and being in Hollywood we treat a lot of people in their entertainment industry, and a lot of people around this industry are athletes themselves. We treat a lot of stuntmen who really beat up their body and do a lot of damage, the way a lot of professional athletes do, so you treat a lot of stuntmen and we use PRP and stem cells.
One particular case I had was a stuntman who had torn his ACL and he was a stuntman for a major motion picture, and he was part of the original movie cast and they were doing the sequel and he very much wanted to reprise his role as the stuntmen in the film but they were set to shoot in about 12 weeks, and he had completely torn his ACL, and if he had gone a typical route of having an ACL reconstruction then there’s no way he would have been able to participate in the film, as a recovery from ACL reconstruction is at least 6 months, so they didn’t have that kind of time so they was looking at other options so we decided to pursue stem cell treatment for him. And we were able to completely heal his ACL in 12 weeks and back out on set, performed all kinds of stunts, running and jumping, and you know falling off of buildings, and crashing cars, and he did great.
RC: On purpose though right?
Dr Blecher: On purpose. He was 40 years old, he’s out there performing like a professional athlete and you know unfortunately I think it was a year later he was injured on set. He was hit by a car and injured his knee again, this time he injured his meniscus. But we ended up getting an MRI to see the new damage to his knee and the torn ACL that we had originally treated still looked perfect despite beating it up and despite getting hit by a car his ACL was fine. He injured his meniscus, but his ACL was fine.
RC: Amazing. We’ve had another question come in, “will it be uncomfortable to travel or fly 2 days after treatment. Is it safe to fly?”
Dr Blecher: It is safe to fly. It might be a little bit uncomfortable, again depends on what structures you’re treating. Some structures are more painful than others immediately after the procedure, so that’s some advice you should get from your physician based on what structures are being treated how much discomfort you’ll have. But we do have patients all the time will fly within a day or 2 of treatment.
RC: Just in closing, how can people take care of their ligaments? How can they keep them healthy and injury free?
Dr Blecher: Well, unfortunately, the nature of sports is people get injured. A lot of ligament injuries tend to be acute injuries which are unpreventable especially in contact sports. But there are injuries that are preventable, and those are the chronic overuse injuries and especially the throwing injuries as we discussed in baseball – remember the muscles provide stability to a joint. When your muscles are fatigued and they’re not doing their job then there’s more stress in the ligament and that’s when you’re gonna injure them. So it’s very important that you pay attention to that fatigue.
When your muscles are fatigued, when you feel tired, when you’re starting to get the soreness or achiness, or feeling like your joint is weak. If you continue to push through that’s when you’re at risk of injuring the ligament because the muscles aren’t supporting the joint there’s more stress in the ligament. So it’s important to pay attention to your body, pay attention to what you’re feeling. You know skiers are a good example, everyone remembers that last run of the day where you get the injury when you’re tired and fatigued, so you want to pay attention to that.
RC: Well thank you very much, Dr. Blecher, I know you have to get back to the clinic and treating our patients. If there are any more questions that have come in, we’ll be sure to come back and answer them in a short while. Or feel free to message our patient care team and they’d be happy to answer any of your questions. For more information about Regenexx Cayman, or the full list of conditions that we treat you can find them on our website at regenexxcayman.ky. And thanks again, Dr. Blecher.
Dr Blecher: Thank you very much.