BBB to PRP: A PRP Doctor Explains the Lonzo PRP Procedure

Recently, we found out about a Lonzo PRP procedure on his left knee which kept him from participating in full basketball activities for a month afterwards.

This Lonzo PRP procedure was likely stemming from the two left knee injuries he suffered during the 2017-18 Lakers season.  He missed a little over 5 weeks due to a grade I MCL tear (all sprains are tears, don’t let that word scare you) and missed the last 8 games of the season with a “lateral knee contusion”, almost certainly a bone bruise.

The latter occurred when Lonzo was holding up Dirk on a screen and came away limping afterwards:

Lonzo PRP
Credit- Spectrum SportsNet

There’s no clean shot of the contact point with Julius blocking our view.  However, what’s key to note is that this seemingly innocuous play resulted in an injury.  It’s an indicator that informs the rationale behind why the Lonzo PRP procedure was done (much more on that below).

For a deeper look at Lonzo’s MCL grade I tear, check out my piece on it here. For an in-depth look at bone bruises, check out the piece I wrote here.

The focus of this piece is on PRP and the Lonzo PRP procedure.  I had the good fortune of sitting down with and picking the brain of Dr. Shounuck Patel, DO who is a trusted PRP practitioner, running the Health Link Medical Center in Beverly Hills, CA.

Lonzo PRP
Not Shounuck. Credit – 90210 Wikia

With his expertise and interjections, we’ll answer the following questions:

  • What is PRP?  What is it used for? Are there different types?
  • The Lonzo PRP procedure was most likely which type?
  • What’s the rationale behind the Lonzo PRP procedure?
  • What are the risks and benefits of the Lonzo PRP procedure?
  • Why did Lonzo need to take a month-long break from full basketball activities?
  • Are there any short or long-term implications from the Lonzo PRP procedure?

Without further ado, let’s get right into it…

Me (RB):  Lets start with the basics.  What is PRP?

Dr. Shounuck Patel, DO, (SP):  PRP stands for “platelet-rich plasma”. It’s a procedure that harnesses your body’s natural healing factors to aide in restoration and repair.  It’s done by extracting the person’s own blood and then concentrating the platelets that contain healing growth factors.

Most PRP providers use a simple automated centrifuge for this separation but we have a lab and skilled technicians that results in a more customizable PRP mix that is tailored for each specific patient’s problem.

For example, most centrifuges concentrate the platelets by a factor of 2 to 7 times baseline, but our Regenexx process increases that factor by 6 to 40 times baseline. Since we’ve found that different concentrations are better for different tissues, we find better results with this ability to customize.

RB: I’ll get to the details of the injection procedure itself in a second but first, lets talk about platelets.  I know they cause your blood to clot (for example when you have a cut and the blood stops) but I’m assuming there’s more than meets the eye? (*Insert Transformers reference*)

SP:  A lot more than meets the eye.  Platelets play a key role in the body’s healing process by releasing growth and healing factors at the site of an injury (referred to as a “healing cascade”).

Here’s a picture (don’t worry about the details, just appreciate the extent of growth factors):

lonzo prp
Credit – Selphyl

SP: Further, they create an inflammatory response (the first part of the healing process) that calls stem and other cells integral to repair into the area.  After the process has run its course, the platelets then signal for inflammation to subside.

RB: To clarify, because I get this question and have to explain it a lot, inflammation isn’t bad.

SP: No, it’s not – it’s a key part of the body’s healing process.  That being said, it can be very painful and hinder movement when excessive in the acute (immediate) phase following an injury and certainly also if inflammation lingers for a longer time.  The beauty of PRP is that we can harness and dose the inflammation response appropriately, and when done right, precisely target the affected area for optimal affect.

RB: “Precisely target the affected” area, tell me more.

SP: With PRP injections, precision and technique matters a lot.  The more targeted your injection is, the more optimal the effect with better outcomes.  In order to achieve that level of precision, I’m using image-guidance (like Ultrasound for example) during my procedures to know exactly where I’m injecting.  Otherwise, it’s almost like you’re flying blind to an extent.

RB:  I’ve seen some of your image-guided injection videos online.  Readers, here’s an example of an injection into the hand:

RB: From my understanding, image-guided targeted injection is the backbone of an emerging paradigm known as interventional orthopedics.  Tell us more about that.

SP:  Interventional orthopedics is the intersection of osteopathic, physiatric, and regenerative medicine.  Viewing the body as a unit where structure and function are interrelated and utilizing the body’s self-healing abilities and processes to repair damaged tissue and restore maximal function, all via non-surgical interventions.

Here’s a visual from a presentation I gave which shows where interventional orthopedics slots in – focus on the bottom part:

lonzo PRP
Credit – Dr. Chris Centeno, Regenexx

SP: In order to maximize the efficiency, efficacy, and outcomes of these non-surgical interventions, we use image guided precision injections to precise targets in order to change mechanics, induce healing, and optimize the movement.

RB: Does everyone utilize the principles of interventional orthopedics and image guided precision in their PRP procedures?

SP: Unfortunately no.  As tends to happen when something becomes popularized and more into the public eye, PRP is being marketed and used by more providers who are legally allowed to penetrate a joint with an instrument (such as surgeons, nurse practitioners, and in certain states naturopathic doctors).

Many of these providers are injecting PRP without image-guidance as if it is a simple cortisone injection rather than purposefully targeting specific tissues. Without image-aided procedures, it’s really difficult to be precise with your targeting.

RB: So it’s almost like a shotgun blast hoping to hit the right spot compared to the sniper shot of interventional orthopedics.  It’s similar to what we’ve talked about in other conversations about the importance of precise manual diagnostics and musculoskeletal assessment.

SP: Exactly.

RB:  What’s the difference between interventional orthopedics and surgery?

SP: Surgery is also targeted but it’s invasive – even with the most “minimally invasive” surgeries, you’re still physically opening the person up which comes with longer recovery times, inherent risks of infection and scar tissue, and irreversible changes to structure, not to mention having to undergo anesthesia which comes with its own recovery and risk implications (and, of course, added cost).

RB: Here’s the analogy I thought of to compare surgery vs image-guided PRP (part of interventional orthopedics).  Lets say your car’s alternator was having problems and needed to be replaced. Surgery would be like ripping open the hood and then delving through the parts to find it and fix it or replace it. On the other hand, image-guided PRP would be like using imaging to see through the hood, threading an instrument to precisely find the alternator without interrupting any other parts, and injecting it with a self-repair serum.

SP:  It’s a rough one but yeh, I’ll allow it. To finish that off, we could say that non-guided PRP approach is like threading that instrument and then showering the general area with that self-repair serum….hoping it hits the target.

RB: Boom, advance to go and collect 200 platelets.  Alright, so we’ve talked about the basic rationale behind PRP, but now lets talk about some of the nuances.  Are there different types?

SP:   For the sake of the audience, I’ll keep it really short and simple. There are two types of PRP that we create in my clinic.

  1. Our Regenexx-SCP (Super Concentrated Platelets) is an advanced form of PRP that can be customized for different conditions and made to a higher concentration as I mentioned above.
  2. We also make a different category of platelet solution called platelet lysate (PL) which results in a very fast release of growth factors producing a net anti-inflammatory effect.  However, it’s a rare procedure because it’s specialized and requires a certain type of laboratory to create PL.  At Health Link Regenexx, we do have access to the required equipment and there’s emerging evidence of its benefit with nerve injuries and muscle re-growth.

RB:  Got it, PL is  pretty rare so we’ll leave that alone for now.  What about stem cell injections?

SP: Stem cell injections introduce new stem cells capable of healing AND activate stem cells that have gone dormant (stem cells are living throughout our body at all times).

Here’s a basic overview of the process:

lonzo prp
Credit – Advancells.com

RB:  When is a stem cell injection indicated vs PRP?

SP: Stem cells are indicated for long-standing issues like severe arthritis or more significant injuries like ACL or other soft tissue tears, whereas PRP is indicated for milder arthritis or recurrent or lingering soft tissue issues, like tendons strains or ligament sprains.

PRP can be used to “jump-start” or “re-start” a stalled healing process.  Common procedures include lateral or medial epicondylosis (tennis or golfers elbow), hamstring injuries, and numerous other conditions including MCL injuries.

RB: That’s a perfect segway into the Lonzo PRP procedure (almost like we planned that out or something).  Based on your experience with his type of injuries, what do you think was the impetus for the PRP procedure?  Obviously we’ll never know because we didn’t treat him directly, but what’s the most logical inference?

SP: Lonzo’s injury history and mechanism of injury with his bone bruise give us good indicators of what’s going on.

The first thing is the MCL grade I tear.  A grade I ligament tear can actually linger longer than a grade II tear because the body doesn’t take it as seriously, there’s not an “all hands on deck” approach to mobilizing the body’s resources.  If a player is rushed back, the grade I tear can linger and cause pain for awhile.  However, that wasn’t the case with Lonzo as the team was very conservative. Full credit to Marco Nunez and Lakers medical staff for that for that.

RB: He was out for a little over 5 weeks and he was meticulously taken through incremental progressions until he could complete each without any pain.

SP: Right, but that being said, the ligament being pain-free doesn’t mean that it’s exactly the same as before.  Ligaments, when stretched, can heal and re-tighten but may not be as tight as before. I think of it like those rubber bands that are placed around vegetables in the grocery store. If you over-stretch the rubber band, it will re-tighten and still  be able to get the job done but they aren’t as tight as before.

RB: So in other words, Lonzo may have had some increased knee laxity (looseness) even after he got back and the MCL was pain free.

SP: Exactly.

RB: Is that something you would consider a red flag?

SP: Absolutely not, but that looseness in the MCL could decrease the buffer against injury when the knee goes into an inward (valgus) position.

lonzo PRP
Credit – Omaha Physical Therapy Institute

SP: The primary function of the MCL is to resist this valgus (inward) force.  When the knee goes inwards, the inner (medial) aspects of the tibia (shin bone) and femur (thigh bone) gap/pull apart and the MCL is tensioned.  Simultaneously, the outer (lateral) aspects of the tibia and femur come closer together.

lonzo prp
Credit – Omaha Physical Therapy Institute

SP: If the MCL is looser than usual, the valgus (inward) force could result in the outer edges of those bones actually hitting together and creating a bone bruise.

RB: And you think that’s what happened to Lonzo right?

SP: Based on how he got hurt, I do.  For a direct external force (like getting hit by someone else’s knee) to create a bone bruise, it takes a high amount of force.  Like we saw with Iguodala in the Western Conference Finals when Harden’s knee caught him hard.

Here’s the video:

And the moment of contact:

lonzo PRP
Credit – NBCSN Bay Area

SP: On the other hand, in Lonzo’s case, Dirk is just walking when there’s contact between his leg on the outside of Lonzo’s knee. There’s no reason that would cause a direct impact bone bruise. Rather, it’s much more likely that Lonzo’s MCL was a little loose from the MCL grade 1 tear which made it less capable of resisting the inward (valgus) force from Dirk’s contact – resulting in the lateral edges of Lonzo’s tibia and femur hitting together, creating a “lateral knee contusion”.

This, of course, is all speculation though.

RB: So to recap, Lonzo likely had some laxity in his MCL after coming back (which is normal after that injury) so when he got hit on the outside of the knee by Dirk, his knee went inward and the outer edges of the bones that make up the knee hit together.

SP: Right.

RB:  If Lonzo was a patient, I know you’d go through a comprehensive manual diagnostic and bio-mechanical assessment to assess the knee laxity and other potential deficits.  However, we aren’t privy to that so based solely on these logical inferences, how would that inform your decision-making when it came to the Lonzo PRP procedure?

SP:  Based off these inferences and having seen very similar series of events in other patients, it tells me that the main thing to be addressed in a Lonzo PRP procedure is, more likely than not, the looseness of that MCL.  You precisely target the MCL with the PRP injection to re-tighten the ligament.  This restores optimal mechanics and brings that injury risk buffer back to where it was prior to the injury.

RB: What about the bone bruise?  Would you do anything specifically for that with PRP?

SP: Not directly.  A bone bruise will heal with time and re-tightening the MCL will further help that process by taking pressure off the lateral compartment of the knee.

RB: In my head I’m imagining the knee joint as a ship that is slightly tilted to one side and then after the PRP procedure, it’s now back in neutral.

SP:  That’s one way to put it.

RB: Anything else you would do or think was done during the Lonzo PRP procedure?

SP: Yeah, it would’ve made sense to also inject the knee joint itself, known as an intra-articular injection.  This would directly address any inflammation that may exist in the knee joint, bringing the environment from a negative inflammatory one back to neutral.  It would also indirectly address the lateral compartment bone bruise.

RB: Got it – so targeted precision injection into the MCL and then one into the knee joint itself.  So how long would this procedure take?

SP: The procedure would take about 30 minutes, give or take.

RB:  Once the Lonzo PRP procedure was done, what was his recovery process like?

SP:  For the first 2-3 days, there’s an increase in pain due to new inflammation process. After that, pain will wax and wane for the next 2-3 weeks as the inflammation process continues to play out.  Around 3-4 weeks, the process is complete and the inflammation response is dialed down.

RB: What’s his activity level looking like through this month or so?

SP: During the month after a PRP injection, patients go through rehab of the knee including physical therapy to incrementally strengthen and condition their body, while addressing any major mechanical deficits that could have contributed to increased stress on the knee.

RB: Like hip abductors (like the gluteus medius or minimus, to a lesser extent) that are weak, fatigued, or not activating?

lonzo PRP
Credit – Ashworth Chiro

SP: Right.  So that month off from full basketball activities for Lonzo was to allow the healing process to play out while continuing to work on his strength and conditioning.

RB:  Alright, so now we’re coming to the questions that everyone has been waiting for.  What are the short and long-term implications of the Lonzo PRP procedure?

SP: In the short-term, the only real concern is the increase in pain from the inflammatory process but that’s very short lived. If he’s following rehab protocols, like he definitely seems to be, then there aren’t any other issues.

RB: What about in the long-term, any implications for the Lonzo PRP procedure?

SP: The PRP procedure itself says nothing about his long-term injury concerns. In fact, I argue that as long as precise interventional orthopedic concepts were used to target the MCL, it likely reduces his injury risk going forward because it’s tightening up the ligament to restore optimal mechanics.

RB:  To add onto that, his MCL grade I tear was an impact injury rather than a non-contact mechanism.  The latter would be far more concerning and indicate some underlying mechanical problem

I’m pretty sure you agree but I’m gonna ask anyway because I yearn for approval, agree?

SP: 100%.  An impact related mechanism of injury is often less concerning than a non-impact mechanism. Analyzing his movement mechanics would be far more useful in determining his injury risk whereas getting a PRP injection has no bearing on that.

RB:  That’s about all the questions I got for you man, much appreciated.  One last request – if you could sum up PRP in one blurb and then how it applies to Lonzo.

SP: Image-guided PRP is a key component of interventional orthopedics that can precisely target and address tissue level problems using your body’s own healing properties, with minimal drawbacks.

In Lonzo’s case, it’s very likely being used to address the root cause of his bone bruise while reducing future injury risk via tightening up an MCL that was loosened from the grade I strain.

RB: Would you ever consider a BBB PRP co-branding?

SP: …

Thanks for reading, until next time.

If you want to learn more about Dr. Shounuck Patel, click here, and/or you want to learn more about his practice, click here.

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