top of page

Evidence-Based Aspirations: PRP & Orthopedics

Samuel G Oltman, ND, RMSK



“Evidence based medicine” is an aspirational term. It is widely assumed by patients and promoted by doctors as the actual state of medical practice. In reality most of modern medicine is not based on high quality evidence. The gap between perception and reality creates a double standard and blind spots in the medical landscape. This harms research, health outcomes, and patient choice.

Evidence based medicine is a process, a way of operating-- not something to believe in and not a final destination. It is a term that was invented in the 1980s and popularized in the late 1990s as the way to modernize medicine from authority-based knowledge to scientific-based knowledge.

The process requires time, intellectual creativity, and personal attention in addition to scientific literacy and technical prowess. At Cascade Regenerative Medicine, we have built a patient experience that allows for real evidence based medicine to take place because we prioritize things that our current medical system has all but cast aside in the name of "cost efficiency".


Where Is The Evidence?

In orthopedics and sports medicine, this double standard results in an asymmetry between perception of treatments that are poorly supported but done routinely and treatments with reasonable support that are considered “alternative”. For example, “There’s no scientific evidence for PRP” is a misinformed refrain that I hear from patients and/or their doctors commonly. Importantly, it is misinformed in multiple ways: 

  1. There is strong evidence for properly-made PRP in many conditions including knee arthritis, plantar fasciitis, rotator cuff injury, and more. 

  2. This statement insinuates that the rest of orthopedic care IS, by contrast, evidence-based when in fact it is not.


I spend a lot of time flushing out the specifics of number one. This is simply competition between ideas. “What is the best treatment for knee osteoarthritis?” There are PubMed studies linked throughout the website for the treatments we provide, I personally do literature reviews weekly, and we are always updating our protocols and procedures to deliver the best, most evidence-based care possible. For example, within the last year I have changed the way we make PRP in response to the evolving scientific evidence and we will change again when/if necessary.


What goes unexamined almost all the time is number two. Most of orthopedic medicine is not evidence based. Here are some facts:

PRP better than surgery
Outcome Measures For Orthopedic Surgeries
  • 6 of the top 10 orthopedic surgeries have no evidence of being superior to conservative care. 2 are inconclusive and 2 out of 10 show benefit in controlled trials. This is in a review from 2021 in the BMJ (1). Surgeries that are not evidence based:

    • ACL repair

    • Meniscectomy 

    • Rotator cuff repair

    • Subacromial decompression

    • Lumbar decompression for stenosis

    • Lumbar fusion for DDD

  • There are about 700,000 meniscectomies performed annually in the US, totaling $4 billion in healthcare expenditure. The Cochrane review for this procedure from 2022 concludes: “Arthroscopic surgery provides little or no clinically important benefit in pain or function” (2). This procedure increases the risk of osteoarthritis and is no better than sham surgery yet continues to be recommended (3, 4, 5, 6).

  • Only 18% of all recommendations in the Primary Care setting are based on high quality evidence. Within that, a mere 11% of musculoskeletal recommendations are based on high quality evidence. Broadening the criteria gives us 48% of musculoskeletal recommendations in the primary care setting having decent evidence (level A and B combined) (7).

  • On a scale of 1-5, 1 being best, 5 being low, the average level of evidence in the top six orthopedic journals is 3 (8).

  • The average primary care visit is 18 minutes and does not allow for evidence based medicine to occur even if possible in theory. Longer visits are associated with more inappropriate prescriptions. PCPs need 27-hour days to practice evidence based medicine according to JAMA last year (9).

  • For arch supports, one of the most common recommendations for a wide array of foot problems, there is not a single study supporting long term benefit or improved foot function.


Importantly, this is not an "alternative media" member’s blog post re-analyzing data using their own methodology. This is not my own analysis. This is in the British Medical Journal and the Journal of the American Medical Association, two of the top medical journals in the world. This is from the Cochrane Review, the definitive evidence based medicine evaluator. It’s not fringe, it’s fact hiding in plain sight. 


Why Is This The Case?

Trying to explain the “why” is important to address because just being presented with facts is often not enough to convince people unless they know the “why”. 


  • Relevant to this particular phenomenon is: experts tend to be less inclined to change their preconceived notions when confronted with new data. Those who declare themselves expert in the area relevant to the intervention are particularly resistant to new information that the treatment is ineffective (10).

In orthopedics I think this can explain the meniscectomy data: resistance to new information showing that the treatment that took years to learn is ineffective. It's understandable why surgeons doing it don't want to throw it out: sunk cost. Unlearning old information is harder than learning new information. They will say “well it works for me and my patients”, succumbing to confirmation bias, which is what alternative healthcare professionals are accused of the most: anecdotal evidence guiding practice. There’s simply no difference here. For a single procedure, orthopedic surgeons are responsible for $4 billion in annual healthcare costs based on anecdotal evidence and resistance to change. But they say, “we practice evidence based medicine”. 


  • There is a phenomenon called the “naturalistic fallacy” that describes the misguided attribution of anything that is considered natural to be good for you. You can see it all over the alternative medicine landscape, and it is a fallacy– just because something is “natural” does not mean it’s better than some synthetic equivalent. There are plenty of poisons that are natural and plenty of synthetic compounds that help us live better, healthier lives. It is an understandable bias, as we humans are a part of the tree of life and evolved in exclusively natural (non-man-made) environments. 

Equally important but rarely recognized or discussed is the flip side of the coin, the "synthetic fallacy": the belief that because something is uniform, homogenous, industrially manufactured, regulated, and created by the human mind, means that it is safer and better for you. This is the root of the bias toward drugs and surgery as “legitimate” medicine and everything else being “alternative”. This too, is a fallacy: we do not yet (and may never) have a deep enough understanding of science and the human condition to synthesize all we need. We do not have mastery over nature. Being biased against things because they are natural is just as detrimental as the other way around. 

I believe the synthetic fallacy is partially explanatory as to why certain drug and surgery treatments persist in the face of negative evidence.

  • Historically speaking, I don’t think the role of the success of antibiotics can be understated. Antibiotics made modern-technological life possible. It is arguably the single most important medical discovery in human history. The unintended consequence of this success is that it gave rise to the approach of “a pill for every ill”, and this does not translate well to large parts of medicine and human health. The success of antibiotics have created a very deeply-rooted bias toward pharmaceutical approaches that are “opposite-disease” which doesn’t work for complex chronic conditions (see the commercial success of Ozempic), including most orthopedic conditions.

Surgery started to be recognized as a legitimate medical profession around the time of the industrial revolution and surgical approaches reflect this time period’s thinking: the human body is a machine and if we just fix/replace/remove that broken part, the machine will run smoothly again. It corresponds to the new technology of the time, the combustion engine (not coincidentally we now frequently use computer analogies to explain brain science which is similarly flawed). Many common surgeries today were developed before the idea of evidence based medicine was created and have been carried forward under flawed logic. We are not machines, we are biologic, tensegrity systems capable of adaptation.


  • A primary factor in exacerbating the mismatch between perception vs reality in evidence based medicine, are deep flaws in the mechanics of scientific translation and medical publication bias: 

    • The average time it takes to integrate evidence into practice is 17 years (11). The integration of new evidence requires learning new information and unlearning old information. Much of the evidence doesn't even make it into clinical guidelines.

    • We never know how many studies are run and then not published because the results don’t turn out how the researchers thought they would (12, 13). 

    • Research funding and interpretation is biased toward drug therapies (14, 15).


All of these factors: expert resistance to change, the synthetic fallacy, the success of antibiotics, and the short-comings of translational science provide some explanation of how we get to the over-estimation of evidence-based practice. It's complicated because humans are complicated and not only are we studying humans, we are humans studying humans.


What Are The Implications?

The assumption is that if the big research hospital does it, then it must be evidence based. This is the aspiration but not where we are in reality. This is where we get into the dangerous territory of “evidence based medicine” as a dogma and not as a useful tool for intellectual and scientific inquiry. We simply do not have the level of understanding that many assume we do. The loss of epistemic humility is dangerous. 


The landscape of medical knowledge is like a sea dotted with archipelagos and islands. The sea is ignorance and the land is scientific knowledge. It seems to me that many think they are on dry land most of the time– they are not. The illusion projected to patients is that medicine is a science built on perfect knowledge– it is not. Medicine is an art and a science. The art of medicine lies in navigating the vast sea of ignorance we find ourselves in between the islands of knowledge. The winds and stars by which we navigate are as changing and idiosyncratic as the individual patients we treat. 


2 wrongs do not make a right. Just because something does not have perfect evidence does not mean we should jettison it for something with equally bad evidence. The point I’m making is the opposite:

  • While imperfect, the evidence for PRP is strong (and growing) for many conditions when made properly (a crucial distinction).

  • Given the vast amount of unknowns and uncertainty in all of orthopedics, PRP stands on much more equal footing with other standard treatments than most people realize (16).

  • Within a clinical decision-making process, PRP is superior to treatments like ineffectual surgeries because the downside is so much less. 


Who Do You See?

Within this landscape of uncertainty, imperfect scientific knowledge, and biases of all kinds, who should you seek out when you have an orthopedic problem? I would argue it's not a choice between doctors. It is a choice between the level of constraint in models of thinking and practice. The choice is not between evidence-based medicine and non-evidence based, “alternative” medicine. The choice is not between me and another doctor. It is a choice between an adaptive, unbiased, creative, person-centered approach and a slow, constrained, ossified algorithm determined by insurance companies for financial reasons.  


It’s not a problem of bad doctors. I’m not claiming to be smarter than the providers at big hospital systems. I am claiming that I am capable and encouraged by the context I’ve set up for myself to think freely, adapt and change quickly, respond to your needs, make time, and pivot strategies when needed. Practically speaking, this means being able to offer enough time to do it right; more detailed exams; more nuanced explanations of your treatment choices; and the ability to provide the full range of standard choices (cortisone, hyaluronic acid, etc) along with things your insurance won’t cover (PRP, MFAT, perineural hydrodissection) all done with the highest level of technical acumen.  


How Do We Move Forward?

The message is not that we should move away from evidence based decisions as the goal. It is a worthy aspiration, really the only logical aspiration. This is, however, a reality check for patients and for medical professionals of all stripes: we are not there yet and epistemic humility is the only justifiable stance. The majority of recommendations regarding your orthopedic and musculoskeletal concern are not evidence based. The insinuation that PRP, or regenerative medicine in general, is not evidence based but all surgery and/or things covered by your insurance is– is false. It’s misleading and misrepresents the state of medical research. 


“Never ascribe to malice that which can be adequately explained by neglect, bias, ignorance, and incompetence”. There isn’t a conspiracy here. It’s simple, mundane ignorance. Really smart people with blind spots and biases that are carried forward through force of habit and intellectual inertia. 


I am also acutely aware that I am susceptible to all of the biases and self-deceptions that I describe above. We are all imperfect humans. I do what I can to constantly challenge my own beliefs and engage in self auditing. I am not the right doctor for everyone but I always do what I feel is in the patient's best interest, in partnership with the patient, being as explicit as possible about my reasons and biases.


The evidence for PRP is imperfect. The evidence for everything is imperfect. We have a lot more work to do. This is why at Cascade Regenerative Medicine we analyze the platelet count of every PRP treatment we do and participate in real world data collection. We must keep evidence based practice as the north star of clinical medicine– as the highest aspiration. We must also recognize with much more acuity the limits of scientific knowledge, the slow adaptation of change, the influence of the synthetic fallacy, the publication bias, and the trap of epistemic hubris. 


If your doctor says “there’s no evidence for PRP”, I hope you think of this article and understand all that that statement entails. There is evidence for everything we do at Cascade Regenerative Medicine. When the evidence changes, we will change. We are nimble, we are humble, we are responsive, and we are focused on YOU.



References:

Recent Posts

See All

Keep Moving Pod: Episode #3

Dr. Oltman explains the incentives in the US healthcare system and the fundamental misalignment between insurers, hospitals, and patients. The role of capitalism, American culture, and good intentions

bottom of page