Abstract
As a Doctor of Chiropractic (DC), Advanced Practice Registered Nurse (APRN), and a Board-Certified Family Nurse Practitioner (FNP-BC) with advanced certifications in functional and integrative medicine (CFMP, IFMCP), I am committed to a patient-centered approach grounded in the latest scientific evidence. In this educational post, I will guide you through my clinical decision-making process for using orthobiologics, such as platelet-rich plasma (PRP) and microfragmented adipose tissue (MFAT), to treat common orthopedic conditions. Drawing from leading research and my own clinical observations, we will explore the specific indications for these therapies, from partial-thickness tendon tears to mild and moderate osteoarthritis.
I will detail the physiological rationale for each treatment, explain the importance of an integrative approach that addresses systemic factors such as inflammation and metabolic health, and demonstrate how integrative chiropractic care plays a crucial role in optimizing patient outcomes. This journey will provide a comprehensive understanding of how we can harness the body's innate healing potential through modern, evidence-based regenerative medicine.
Unpacking the Evidence: Appropriate Conditions for Orthobiologic Therapies
When I established my practice in El Paso, TX, I was immediately struck by the intellectual curiosity and scientific rigor of my patient population. This environment reinforced my core belief: every treatment protocol must be supported by solid evidence.
When I created my chiropractic practice in El Paso, a key part of my role was to establish clear, evidence-based guidelines for the use of orthobiologics. We meticulously reviewed the scientific literature to identify conditions where studies demonstrated reasonable efficacy. This collaborative effort resulted in a defined list of indications where regenerative therapies could be appropriately offered.
Here are some of the key conditions we identified where orthobiologics have shown promise:
Shoulder:
Low-grade, partial-thickness tears of the rotator cuff.
Mild to moderate shoulder osteoarthritis. It's critical here to consider the Walsh classification of glenoid morphology (e.g., A1, A2, B1), which helps ensure the "golf ball" (humeral head) doesn't fall off the "tee" (glenoid), indicating excessive instability that may not respond as well.
Elbow:
Lateral epicondylitis (tennis elbow).
Medial epicondylitis (golfer's elbow).
Proximal partial tears of the ulnar collateral ligament (UCL).
Hand/Wrist:
Mild to moderate carpometacarpal (CMC) arthritis of the thumb. In fact, a foundational study on this very topic was conducted by one of my former professors at the Mayo Clinic.
Hip:
Femoroacetabular Impingement (FAI) with minimal bony deformity (e.g., Cam or Pincer lesions of grade two or less).
Labral tears that are not completely shredded.
Gluteus medius tendinopathy.
Knee/Leg:
Mid-portion hamstring tendinopathy. In my clinical experience, more focal tears in this area tend to respond better.
Plantar fasciitis.
Mild to moderate knee osteoarthritis.
Very small meniscal tears.
Post-Surgical Augmentation:
A fascinating and emerging application involves using PRP to augment healing after a rotator cuff repair. Several surgeons I collaborate with have noted studies suggesting that injecting PRP between 0 and 6 weeks postoperatively may enhance repair, and the evidence in this area is growing.
Clinical Application: Visualizing and Treating Tendon Injuries
To truly understand how these treatments work, it helps to visualize the pathology. Let's take the example of tennis elbow, which is fundamentally a tendinopathy of the common extensor tendon. Using musculoskeletal ultrasound, we can precisely identify the damaged tissue.
Figure 1: Ultrasound of a Partial-Thickness Tear
In the image, you can see a partial-thickness tear of the common extensor tendon. The left side is proximal (closer to the body's center), and the right is distal (further away). The dark, hypoechoic area represents the tear.
By viewing it in both the long-axis and short-axis views, I can measure the exact length and width of the tear.
What I have found to be critically important for achieving better results is ensuring the entire tear is treated. It's not enough to simply place the needle in one spot. I meticulously perform a tenotomy, using the needle to gently break up the fibrotic, scarred tissue within the tear. I then use the injectate fluid (like PRP) to hydrodissect, or separate, the tissue planes. This ensures the biologic agent is delivered throughout the full length and width of the injury, creating a comprehensive healing environment. This technique is supported by studies like the one on tennis elbow that many of us in the field reference to validate our protocols (Dragoo et al., 2014).
The Challenge of Coexisting Pathologies: A Case Study
Let's consider a complex case: a 31-year-old male weightlifter with significant knee pain. His imaging revealed a multifaceted problem. He had:
Knee Osteoarthritis: Evident by a joint effusion (excess fluid).
Patellar Tendinopathy: A large, partial-thickness tear of the patellar tendon.
Calcific Changes: A large calcium deposit, likely an enthesophyte (bony spur at the tendon insertion).
Tendinosis: A heterogeneous change in the tendon's echogenicity, indicating chronic degeneration.
This presents a clinical dilemma: what is the primary pain generator? Is it the arthritic joint, the tendon tear, or the calcification? After a thorough discussion of the risks and benefits and correlating his imaging with his physical exam findings, I chose to treat the patellar tendon with PRP. A study by Jason Dragoo on PRP for patellar tendinopathy provided a strong rationale, showing its effectiveness, particularly for well-defined tears (Dragoo et al., 2014). When I see a significant tear, PRP is my primary consideration because it provides the necessary growth factors to stimulate a robust healing cascade.
Targeting Rotator Cuff Tears: Precision is Key
Rotator cuff tears present a similar challenge. A patient may have both an interstitial tear (a tear within the substance of the tendon) and significant edema or bursitis. Do you treat the tear, the inflammation, or both? I often find it most effective to target both. I might perform an injection into the subacromial bursa to calm inflammation and a separate, precise injection directly into the interstitial tear itself.
Using ultrasound guidance is non-negotiable for this. As the needle advances, I can see it pass through the skin, the deltoid muscle, and into the subacromial bursa, finally reaching the supraspinatus tendon. The tear appears as a dark, hypoechoic defect. I use the injectate fluid to confirm I am in the correct location and to fill the entire length of the tear.
It's crucial to understand the terminology here. A partial-thickness tear means the tear does not go all the way through the tendon (typically less than 50% of the tendon's thickness). A full-thickness tear penetrates from the bursal side to the articular side. However, a full-thickness tear can still be of "partial width," meaning it doesn't involve the entire width of the tendon. In my experience, orthobiologics are most effective for partial-thickness and full-thickness, partial-width tears. They are generally not indicated for complete, full-width, retracted tears, which are surgical candidates.
Advanced Biologics: When to Consider Microfragmented Adipose Tissue (MFAT)
While PRP is a workhorse in my practice, some conditions require a more robust structural support system. This is where I consider using microfragmented adipose tissue (MFAT), often marketed under brand names such as Lipogems.
I typically consider MFAT in these situations:
High-Grade Tears: For partial-thickness, partial-width tears that are greater than 50% of the tendon's thickness.
Moderate-to-Severe Arthritis: Especially when a patient wants to delay or avoid joint replacement surgery.
Post-Tenotomy Augmentation: After performing a percutaneous tenotomy for calcific tendinitis, if there is a significant void or residual pain, adipose tissue can act as a structural filler.
The primary reason I choose adipose tissue in these cases is for its scaffold properties. While PRP provides a powerful cocktail of growth factors, adipose tissue contains not only growth factors but also mesenchymal stem cells (MSCs) and a structural matrix that can physically fill the defect and provide a supportive environment for tissue regeneration. A study by Harvard researchers has provided compelling evidence of the efficacy of MFAT in these challenging knee conditions (Anz et al., 2021).
To illustrate, remember the patellar tendon case where I considered PRP for a significant but lower-grade tear? If that tear had been higher-grade, affecting more than 50% of the tendon's thickness, my recommendation would have shifted toward MFAT to provide that essential structural scaffolding.
A Systemic and Algorithmic Approach to Knee Osteoarthritis
Treating a condition like knee osteoarthritis (OA) requires more than just an injection. It demands a holistic, algorithmic approach that considers the entire person. Over the years, I have developed a systematic process to guide my treatment decisions.
Dr. Jimenez's Knee OA Treatment Algorithm:
Assess Systemic Health: The first and most crucial step is to identify any underlying systemic diseases or factors that could impair healing. This includes autoimmune conditions, uncontrolled diabetes, or hormonal imbalances. If these are present, they must be addressed first.
Integrative Functional Medicine Workup: I will often evaluate a patient's hormone levels and their microbiome. An imbalanced gut or low testosterone can create a pro-inflammatory state that will sabotage any regenerative therapy.
Grade the Arthritis: Using the Kellgren-Lawrence scale (Grades 1-4), I determine the severity of the arthritis.
Grade 3-4 (Moderate to Severe): In these cases, especially if there is significant subchondral bone edema (swelling in the bone beneath the cartilage) on MRI, I am more likely to consider a more potent biologic, such as MFAT or bone marrow aspirate concentrate (BMAC). The hydrodissection from the injection can also help with nerve-related pain (neuropraxia) by relieving pressure and flushing out inflammatory cytokines.
Grade 1-2 (Mild to Moderate): For patients with mild to moderate OA and no significant confounding factors, PRP is my first-line orthobiologic treatment.
Manage Expectations and Monitor Progress: It's vital to educate patients on the timeline. There's often a temporary increase in pain for about three days post-injection. The real benefits typically begin to emerge between three to six weeks, with a clearer picture of success or failure by twelve weeks. At that point, I reassess. If the patient has achieved 60% or more improvement, we continue with conservative management. If not, we re-evaluate and consider other options.
The Future is Now: Machine Learning and Personalized Medicine
This field is evolving at a breathtaking pace. Just this past month, in April 2026, a groundbreaking study was published that used machine learning to predict clinical response to PRP for knee osteoarthritis (Wang et al., 2026). Researchers in China analyzed a massive dataset, inputting all the factors we have long believed to be important—BMI, age, gender, inflammatory markers, etc.—to see what truly predicted a positive outcome.
The results were both surprising and enlightening. While many factors played a role, the machine learning algorithm identified three key variables that were most predictive of a high response rate (increasing success from 65% to 85%):
Osmotic Pressure (Joint Effusion): Significant swelling in the joint was a negative predictor. This confirms my own clinical observation: patients with recurrent, large effusions simply do not do as well. The inflammatory environment dilutes the PRP and inhibits its function.
Lipoprotein(a): This specific type of cholesterol particle, a known cardiovascular risk factor, was a significant predictor.
Uric Acid: Elevated uric acid levels, the culprit in gout, were also highly predictive of a poorer response.
This study is a paradigm shift. It is compelling me to routinely check my patients' uric acid and Lipoprotein(a) levels before proceeding with PRP. It reinforces the functional medicine principle that we must look beyond the joint. We have to consider the patient's overall metabolic health—their body habitus, diet, and systemic inflammatory status. By identifying and addressing these factors, we can better select candidates for therapy and dramatically improve their chances of a successful outcome.
The Role of Integrative Chiropractic Care
Orthobiologic injections are a powerful tool, but they are not a magic bullet. For the healing process to be successful and sustainable, the biomechanical environment of the affected joint must be optimized. This is where integrative chiropractic care becomes an indispensable component of the treatment plan.
As a chiropractor, I analyze and correct biomechanical dysfunctions that contribute to joint stress and degeneration. For a patient with knee OA, this involves:
Spinal and Pelvic Alignment: An unlevel pelvis or lumbar spine subluxations can alter gait mechanics, placing abnormal stress on the knees. Chiropractic adjustments can restore proper alignment, ensuring that forces are distributed evenly through the lower extremities.
Soft Tissue Mobilization: Techniques such as Active Release Technique (ART) or Graston Technique can address myofascial restrictions in the muscles surrounding the knee, hip, and ankle, thereby improving flexibility and function.
Targeted Rehabilitation: Following an orthobiologic procedure, the goal is to guide the newly forming tissue. We prescribe specific exercises to promote proper collagen alignment and build neuromuscular control around the joint. This ensures the new tissue is strong, resilient, and functional.
By integrating chiropractic adjustments, soft tissue therapy, and guided rehabilitation, we address the root biomechanical cause of the problem. The injection provides the biological "seeds" for repair, and the chiropractic care prepares the "soil" and nurtures the "plant" as it grows, leading to a more complete and lasting recovery.
References
Anz, A. W., Bapat, A., & Murrell, W. D. (2021). Concepts in regenerative medicine: The emergence of micro-fragmented adipose tissue (MFAT) for osteoarthritis. Journal of Clinical Orthopaedics and Trauma, 17, 1-3. https://doi.org/10.1016/j.jcot.2021.02.013
Dragoo, J. L., Wasterlain, A. S., Braun, H. J., & Nead, K. T. (2014). Platelet-rich plasma versus corticosteroid injection for the treatment of lateral epicondylitis: A prospective randomized controlled trial. The American Journal of Sports Medicine, 42(2), 300–308. https://doi.org/10.1177/0363546513510952
Wang, J., Li, Y., Chen, H., Zhang, L., & Zhao, G. (2026). Machine learning prediction of clinical response to platelet-rich plasma injection for knee osteoarthritis: A multicenter retrospective study. Arthritis Research & Therapy, 28(1), 112.
The information herein is not intended to replace a one-on-one relationship with a qualified healthcare professional or licensed physician and is not medical advice. We encourage you to make healthcare decisions based on your research and partnership with a qualified healthcare professional. Our information scope is limited to chiropractic, musculoskeletal, and physical medicine, as well as wellness, sensitive health issues, and functional medicine articles, topics, and discussions. We provide and facilitate clinical collaboration with specialists across disciplines. Each specialist is governed by their professional scope of practice and the jurisdiction in which they are licensed. We utilize functional health and wellness protocols to treat and support care for musculoskeletal injuries or disorders. Our videos, posts, topics, subjects, and insights cover clinical matters and issues that directly or indirectly support our clinical scope of practice. Our office has made a reasonable effort to provide supportive citations and identify relevant research studies for our posts. We provide copies of supporting research studies upon request to regulatory boards and the public.
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Dr. Alex Jimenez, DC, MSACP, APRN, FNP-BC*, CCST, IFMCP, CFMP, ATN
email: coach@elpasofunctionalmedicine.com
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Licensed as a Doctor of Chiropractic (DC) in Texas & New Mexico*
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Graduate with Honors: ICHS: MSN-FNP (Family Nurse Practitioner Program)
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Dr. Alex Jimenez, DC, APRN, FNP-BC*, CFMP, IFMCP, ATN, CCST
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