Morning everybody. Everybody awake yet? I've got the privilege of starting off this morning and I want to thank again Brian and Jason and Rachel and the entire staff. I mean, I think we're incredibly lucky to have this opportunity to talk about biologics, something I've loved for a long period of time. I've got two videos I'm going to show you, but I'm actually going to start with just what do I do. Okay, so what do I do? And the number one thing I do is indication. Okay, so I get a lot of people who just call my office or show up for an office visit, give me the PRP, give me this, give me that, but you've got to stick tight to what works. So if you're going to learn one thing from this 10 minute thing, it would be indication. The second thing is just have a workflow about how you're going to do it. People ask me all the time, I don't have anybody take any anti-inflammatories for the week before and try to not have it for four weeks after. The majority of what I use PRP for is for chronic tendinopathy and I actually want some of that inflammation because I think that helps with the healing process. So somebody may come in from a different part and they said, oh, I've been on high dose anti-inflammatories for five weeks or whatever. I'm like, I can't take care of you right now because that's not going to work. So then the other part is the logistics in your office. And so like Monday morning I have a PRP case for gluteal tendinopathy. And so somebody had to have it on Monday morning so I had to back up my office a little bit more. And the number one thing I'm worried about is I didn't look at this woman's arms because the blood draw is important. So when you look at somebody and you say, hey, I'm going to do a biologic procedure in your office, you don't want to spend a half hour trying to draw their blood. I'm very lucky we have a blood draw phlebotomy lab right in my office, but there are times when even those people can't get the blood out of somebody's arm. And you don't want that to be the rate-limiting step in a long day, especially if you're having a lot of them set up. The other thing is just to try and set people's expectations. So when people come in and say to Jason or Brian or any of us, give me that PRP or the stem cell injection, they think they're going to be dramatically better perfectly, you know, perfect and in no time. They want it to be either like Botox or Lasix. So somebody out here in the audience has got to turn all our biologic stuff into Botox or Lasix so we can take care of our elite athletes and take care of our weekend warriors so they can go back within a few days, not a few weeks or a few months. So with that caveat, I'd like to start with just exactly how I do it. And I think I just pushed – oh, there we go. So this is how I do it exactly in the office. I'm going to stand out here if that's all right. Okay, so the first thing I do is draw a little ACDA and a coagulant, I gotta come out here, sorry, and then I draw the blood, and as I said, this is the component of it that you really, thank you. The component of it that I really, it has to be a challenge if you look at somebody's arms and they don't have any veins or they've had chemo or something, it can be quite challenging. But it's about 27 cc's, total of 30, drawn out of the arm. And then you put it into a sterile canister, and then we're just gonna go through the very specific steps, and there's different systems that you can use for different things, but this is just what I've used in my practice for over 15 years. And then you balance this canister with the second one, you drop it in a centrifuge for 15 minutes at 3200 RPMs, and then at the end of 15 minutes, you see the separation. Now what I'm doing while this is going on is I go back and I numb up the patient, okay, so that you can get them all prepped and ready to go. So once you've got your PRP, you can inject it, and I think I go into this and the technique later. But this separates it out into the platelet-poor plasma, the platelet-rich plasma. I do draw that off. I think Kristen's gonna talk a little bit more about why this is something you shouldn't completely discard, especially if you're gonna treat any sort of muscle tendon injury or myotendinous junction. Remove the PRP, and with this particular system, you shake it for about 30 seconds to resuspend the platelets. And then what you do is you draw the platelet-rich plasma, leukocyte-rich in this particular version, out of the syringe, and you get about three cc's. Now it took me a while to figure this out, but when you put that ACDA in there, you turn that into orange juice or worse. It's about 6.9 or 7. So for my patients, I put in a small amount of sodium bicarb into the syringe, and then I did a little titration on that just to get it back to about 7.4. I found it's dramatically different in terms of the amount of pain the patients have immediately after. So this is what I call buffered leukocyte-rich PRP, and that's the formulation that I've used in the studies that I've done. So the next one is just a variety of techniques that I've used of how to do PRP specifically. And again, if you look at this, this is just probably the top two or three things that I use it for and exactly how I do it. And so if you look at tennis elbow again, which is the number one thing I do in the office, but I also do patellar tendinopathy and gluteal tendinopathy. I mark the injection with a Sharpie. I slap a lot of iodine on there. And then, as I said, while the PRP is being spun down, I inject into the skin and subcutaneous tissue short and long-acting combination of lidocaine and marcaine. And then I don't do it under ultrasound. I really think that the pathology is easy to find for tennis elbow. You can do it under ultrasound, but as you can see, what I'm doing is I basically go right at the lateral epicondyle. I go through the tendon, try to poke down to the bone a couple, three times. And then what I do is just redirect the PRP into and around the entire tendon. And I've actually gone now down to injecting a little bit more towards the myotendinous junction, one or two cc's. And then the other thing I've done for the last probably five years in the operating room is if somebody doesn't want PRP but wants surgery, I have an ongoing series now doing this with PRP. So what I do is draw the blood, soak the suture that I'm going to use in PRP, expose the extensor tendon, get down to the level of the pathology, open up the tendon longitudinally, remove any of the degenerated tendon, decorticate the lateral epicondyle, and then I repair it. But I repair it with that suture that I've been soaking in PRP for 20 minutes while I've done the procedure. And this is what I was alluding to yesterday. This is where I inject the PRP. And you've got to wait two, three minutes. But it does create sort of the version of the crimson duvet for the elbow. And then at the end, I'll inject the last two cc's into and around it. This is exactly how I do patellar tendinopathy. I do use ultrasound to diagnose it and occasionally use ultrasound to inject it. But, again, it's a similar thing. If you've debrided this surgically, I kind of use the needle as my probe to find out where the most dense portion of this tendon is. So a normal tendon is not the same as something that's got tendinopathy. So, again, I get the inferior pole, the patella. I poke into and around it, go through gently through the tendon, and then try to put one or two cc's in and around it. And this is just the same sort of thing but done under ultrasound, just as a nice little video of where it goes into and around. This is a patient before. And, again, these are like snow globes. But I'm starting to get a little bit better at trying to understand if ultrasound is useful. This is an MRI of a patient I did. And he came back five years later with a meniscus tear, but he had significant resolution of his symptoms. And then the final thing I do with all of my Achilles tendon repairs now is I do the same thing. I soak the suture in PRP while I'm doing the repair, and then I put another one or two cc's into and around the repair site. And then this is just one that's been very difficult to deal with, insertional tendinopathy. But you can see here this is an elite runner and treated with a single injection of leukocyte-rich PRP who went on to return to high-level activity. So that's the specific technique that I do and how I do it. And I think I've got about a minute or two left. Somebody's going to have to tell me. Yeah, I've got a minute or two left. So I wanted to leave it for – or I'll leave it up to you if you wanted any questions now or you want to wait. Yes, sir. You sort of did a differential yesterday, and you didn't speak much about radial tunnel syndrome. But I've been in situations where that often gets uncovered once you treat the lateral epicanthalitis. Maybe I just missed it. But maybe some diagnostics, since I like how you really start out with indications and trying to figure out what the patient's needs are. So tell us a little bit about how you differentiate radial tunnel from true lateral epicanthalitis and how often you see it together. That's an excellent point. I think that's one of the benefits of this conference is – you're right, Brian, so I'll try to look for that. If they have a vague aching in the back of their wrist and if they're tender, distal to their lateral epicondyle, that's more consistent with radial tunnel syndrome. Obviously, if they have neurologic findings, it's easier. But if I'm confused at all or I shouldn't – you're probably taping this. But the other thing I'm allergic to is squirrels, okay? And so I will inject their tendon if I'm really concerned about whether I'm right or not with just some lidocaine. And for me, if you don't have pain with resisted wrist extension, you don't have tennis elbow. You can be tender over your lateral epicondyle, but if you don't have some pain with gripping or resisted wrist extension, your MRI, your ultrasound, everything else may or may not be normal. The one other thing that I would leave you with, and I think this is something we need to think about in terms of tendinopathy, is there's a very small study out there. I think it's, again, from Australia. But they stuck somebody – I think they stuck 10 people in a PET scanner with tennis elbow. And then they gave them a neural inflammatory ligand. And guess what happened? Their entire arm and forearm lit up like a Christmas tree. So I actually think tendinopathy, the pain associated with tendinopathy, is a neural inflammatory disorder in addition to being a tendon disorder, and that may be what we're treating. But thank you very much.

biologics

platelet-rich plasma

tendinopathy

ultrasound

diagnosis