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So we, we are at Pinnacle Integrative Orthopedics in Wichita Falls, Texas, and I'm a board certified orthopedic surgeon. But my goal has really shifted from focused on surgery for the last, you know, for the first 15 years of my career to the last three years in this project. Our goal has really been to help people heal their joint pain naturally without surgery. And so we focus on regenerative therapies. We use functional medicine techniques to achieve that. And bas, our goal is to lower inflammation, help patients live longer, be more active, and at the same time prevent what has become really an epidemic of unnecessary surgery in the United States.

One of the things I've been reading about lately is that the biggest growth in knee replacement surgeries have been those under 60. And I know if you get a knee replacement, you're really not supposed to go running and jumping and playing basketball anymore. But what's kind of the longevity of a, because we're talking about joint replacement versus regenerating the joint with some kind of a cellular therapy. But what is the longevity of a joint? Saving from your experience, once you replace a knee or a hip, we tell.

People, you know, we have all these technologies, new technologies like robotic surgery and all of these, what we say are these big improvements, new materials that we're making joint replacements out of. But, but to be honest, to be perfectly honest, the longevity of joint replacements haven't really changed much since the 1980s. So, you know, 10 to 15 years, or I've seen joints last 20 to 25, but I've seen them from the 80s. Like I've actually seen joints that, that long. These are in really minimally active people. If you have a very active person who is going to come in and have a joint replacement and wants to go back to doing an activity like weighted hiking, where we do a lot of backpacking, or we're going to do running, hockey, impact sports, even multi, you know, like a lot of cycles. Like if you're doing, if you're a big time cyclist, joint replacement is going to wear out with time. So we do see them wearing out 10 to 15 years. And it's a real concern, right? So, you know, part of the biggest, one of the biggest problems I see in modern orthopedics is that we're doing these surgeries in people who are younger and younger. And that means that we're going to be doing revision surgeries in people who are younger and younger. And I have a lot of reasons why I don't think that's a good Idea from a metabolic perspective as a functional medicine, I would say functional medicine fan and somebody who applies functional medicine in my practice. I don't want to see downstream problems, right? And we have so many downstream problems from things that we do that we're doing now. You know, if we're doing surgery on people in their 40s with joint replacement, that's really hard to take back.

And I think that's a good point to lead into this because like you say, a lot of people who are very inactive, they might be overweight and their knee goes bad and they want to replace it. And what do they love more? Themselves or their money? Because quite frankly, the biggest issue, the biggest obstacle to doing cellular medicine and joint, which would be stem cells or PRF or something, is the fact that it's not going to be free. Your insurance is going to cover it. And then we have to think about what do you love more, yourself or your or your money or possessions? And the people that I think are their most active, that are exercising, that do want to ride a bicycle, they generally love themselves more than their possessions and they should know there's an option for them. So let's kind of get into the nuts and bolts a little bit. Can you describe platelet rich plasma and PRF in regards to functional orthopedic medicine?

Oh, yeah, absolutely. So platelet rich plasma or prp. And I want to. Can I just comment, just briefly? You just made an amazing point about the value of the human body in American traditional medicine. Right. And you said, do people value their body or their or their money more? And I think it's really a shame that we have been. That we've been, you know, sort of bamboozled and fooled by this insurance industry, this traditional medicine industry into thinking that our body is worth only as much as a copay. Right. If I can't get it paid for by insurance, it's not something that I want to do. And I have patients who come to me and they say, you know, oh, well, I'm 70 and it's not worth it for me to do regenerative therapies for my knee because I'm just going to die in 10 years. I don't understand, how did we get there? That's just such a travesty of just programming and brainwashing that the system has done to us. And I think that's a real shame. And so, yes, the challenge is that it's a cash option. And what we find is that people who do this, they're taking agency in Their own health. They're removing that control from this big corporation in the sky like United Healthcare. Let's take away their control and they're putting it back in their own hands. So when people are deciding to do these types of treatments at a clinic like yours or mine, to me it's sort of the ultimate exercise in freedom, right? It's my body. I could choose what to do with it. I can decide whether to spend my money on an electric truck that may or may not be bulletproof, or I could do this. So I think that's an interesting discussion that we could certainly have more of. But as far as platelet rich plasma, that's basically where we take your whole blood, a patient's whole blood. And it can be, it's a fantastic technique. So we take that blood, we spin it in a centrifuge to really concentrate the platelet. The platelet's the part of the blood, as you know, that helps us stop bleeding. But not only does a platelet help us stop bleeding, but it also has a lot of factors that it releases into that local tissue that enhances local tissue healing. It's a massive anti inflammatory. There are studies that show that PRP injected into a knee joint actually has an effect on the system. It has a systemic anti inflammatory effect. We can see it in a sed rate, we can see it in our crp. And so we take those platelets, we highly concentrate them and it seems like the magic is at 10x10 times what's in a normal platelets patient's blood volume. Then we can use different formulations, we can leave the white blood cells in there. If we're going to do one certain type of procedure that's really good for tendonitis, or we can take those white blood cells out and do leukocyte poor prp, which is really great for joint, then we can also use the other products of platelets. We can do prf, there's other types of formulations. We can do platelet poor plasma, ppp, which can be for trigger point injections and muscular injections. So there's just a lot of versatility in the use of that type of regenerative therapy, particularly in what I do, which is manage patients with joint pain.

So getting back to that, when we're talking about, we're gonna talk, go a little bit more into stem cells and platelet rich plasma. When you're talking to somebody about platelet rich plasma, are you more likely talking about somebody with soft tissue injuries or, or somebody with mild arthritis? Like, what would be your typical person? Because a lot of times lay people are coming in, they're saying, what's the difference in a platelet and a stem cell? So maybe let's talk about when we might use platelet, not where it can be used. Probably use it for anywhere. But what would be common uses for it?

Oh, it's fantastic. And do you want to talk about the difference between a platelet and a stem cell first? I mean, that's. We could get into. You want to go to that later? We can get to that later.

Let's do. That's a great point. Let's do that now. Platelet versus okay.

So the difference between a stem cell and a platelet. A platelet is a fragment of a cell, right? It's a little. So, you know, in your. In your bone, the platelets are formed and they come out, they break into fragments, and then they're fragments of a cell. In your circulatory system, the fragments of the cell are there to help you stop bleeding. That's what we learned in medical school, right? Very basic idea of platelets. Turns out that they have a lot more functions, right? They do a lot more than just help you stop bleeding. But a platelet is basically a circulating fragment of a cell that will go to an area of injury and it will clump up. It has adhesive characteristics, so they stick together. Platelet is so fantastically amazing because it releases these local. There's, you know, you got a lot of. A lot of local factors that it will release into the tissues to help with healing and inflammation. But then also, we have a cell, a stem cell signaling function in platelets. It turns out that PRP platelets will actually signal stem cells. So the difference between a platelet and a stem cell is one, a stem cell is an actual whole cell, and a platelets a fragment of a cell. Right? A stem cell is a cell in your body that can become other things. We know of two places that we can get stem cells in the human body. I know that you use a lot of fat to create stem cells. We get stem cells from fat, but we also get very robust stem cells. We call them mesenchymal stem cells from bone marrow. In the bone marrow are the types of cells that can become other things. Bone marrow is what creates our cells. So stem cells are essentially cells that can become other things, but they're a whole cell. A platelet, again, is a fragment of a cell that can't necessarily become other things, but can act as a signal to a Stem cell. Right. So that's what's really powerful about prp. And your question was, oh, hey, can we use, where's the best place to use prp? Well, there's, that's a nuanced question. If you're going to use PRP primarily, there's some good places to use it. But one of the coolest things that I find with PRP is that it can actually enhance our treatment when we use stem cell. So when we're going to go in there and we're going to implant stem cells, if we pre treat with prp, the conventional wisdom is that that PRP will actually stimulate those stem cells to deposit more accurately in areas of injury. So that's one of the functions of prp. Right. So, so cool. Like the body's amazing. I don't know who designed this thing, but he's a genius. Right? So the platelet can lay down in an area of entry and then it says, hey, I need some help here. Well, then your bone can or your fat tissue can mobilize these stem cells out into your circulation. And there's actually studies that show they've tagged stem cells in the system, injected them and then they go to, they travel by themselves to an area of entry. So that's being signaled by, in part by the platelets in the local soft tissue injury. So we can actually do that using our regenerative techniques. And so that's one of my techniques is I actually use PRP first even in a more arthritic joint because it makes stem cel more active.

Now, can you clarify when you say first in the same procedure or on different chronologic dates?

Well, we have to be careful because it's not, when we do, we're not allowed to, we're not allowed to modify the tissue. Right. So, and there's, there's some nuance there. You can combine PRP and stem cell. Right. And that can be an extremely effective treatment all in one. But oftentimes we'll do a pre treatment with prp. So in our, in our case, we do a pre treatment with PRP and we'll even do a post treatment with PRP if the local soft tissues need. But yes, I'll do PRP first and then come in with stem cells at a separate setting.

So another appointment, it's going along the same lines. So I just want to ask you briefly about your thoughts on Alpha 2 macroglobulin treatments for joint disease.

Hm. I think by its, it's one of those cofactors that PRP has. Right. And we can certainly concentrate it. It's intensely healing it, It's a potent anti inflammatory and it also potentiates some of the activities that we see in prp. Right. So cartilage redisposition, so reduction in inflammation, synovial inflammation, all of those things are reduced by, by, by that substance. It's naturally in PRP and the, and the idea is that we take that and we highly concentrate just that substance, you know, and it can be, it can be effective. That's not something that I use a whole lot of because in my view if we get a really good dosage of PRP, if we're getting 10x and if we're using it like we need to use it, we don't necessarily need a 2M.

Yeah, just my personal thoughts are pretty much aligned. I've read the studies, they do have some compelling nature to them, but not more so than prp. In addition, inexpensive procedure to do so. I just don't know that the juice is worth the squeeze for a 2m. So just move patch anyways, a 2m just for the listeners. It's kind of obtained similar to PRP where we draw your blood and extract it. It's a much bigger molecule than PRP or bigger tissue to make prp and it gets injected in the joints. The idea is it's kind of sucking up these things called proteases or enzymes in the joint. So we talked about PRP and when you might use it. So get back on that. So you're talking about pre treating a person that has say bone on bone, arthritis or arthritis. Talk about some of your uses for say hydrodissection of a nerve injury or like a carpal tunnel or in my case I did. I had a subscapularis tendon 70, torn seven years ago or no, 2007 2011. And Dr. Kehoe, he's an orthopedic doctor like yourself. I was his first case. He did, he came to my office and we did it under ultrasound guidance. He completely grew back. I was actually scheduled for surgery and I never had surgery. So give me some of your experiences, maybe some anecdotal cases too of using PRP to heal things that people thought they had to have surgery for.

I think the best example and for us at Pinnacle, it's not just that we're doing local joint treatments. Right. We really focus on. Our goal is metabolic optimization. In addition, I maintain that if we're going to use a regenerative therapy to heal somebody's joint pain, that it's going to be much, much more effective if they're optimized.

Right.

And so we have a whole plan and a method on how to achieve that optimization and make our injections work better. But I have done. You know, my pa's husband tore his quadricep tendon. He's a pilot, and he was walking around an airplane. He trips on the ice. He fell on his knee, and he tore his quad tendon. He had a 75% tear of his quad tendon. And in the orthopedic literature, we're really. It's recommended that we do quad tendon repairs if we have more than about 50 of the tendon. And he had actually torn his tendon on the other side about five years ago and had to have it repaired.

Bad luck.

Yeah, bad luck. Right, Right. One could say possibly there's a metabolic problem there that we can address. And for him, we actually did. There's a lot of things that we found in him. When we. When we looked at him under ultrasound, I felt like we could treat this with stem cell. And he did not want to have surgery, so we put him in an extension brace. We treated him with. We treated him with mesochymal stem cells. We did bone marrow as we did a PRP injection to start bone marrow aspirin about two weeks later. And at about six weeks, I ultrasounded his. I ultrasounded his quad tendon, and it was completely intact.

Yeah. Amazing.

Just incredible.

My experience has been, most notably with rotator cuffs, doing a PRP rating to the torn, torn tendon. And it's like, it seems. I mean, everyone say 100% effective. I think when it's not 100% effective, we didn't get in there properly because it seemed work. I personally had moralgia paresthetica, which is actually kind of a rare orthopedic condition where the lateral cutaneous femoral nerve gets pinched in the inguinal groove. And it usually occurs in, like, people wearing, like. Like, say cops wearing a belt and gun or athletes. And I'm kind of athletic. And I treated it back in 2015. It kind of came back about a year again and did a second hydrodissection with. With platelets and a Puts it under control where there's really no good surgery for that. So sometimes we're doing this to avoid surgery, and sometimes we're doing. To treat things that there's really no surgery for. So let's get back into the stem cells. And you briefly touched on bone marrow stem cells. Bone marrow derived stem cells. What we call adipose derived or fat derived stem cells. We do liposuction and get the stem cells.

That.

That's my experience. We do a lot of plastic surgery. You from orthopedics, you're used to getting into the bone. And then there's umbilical or umbilical cord stem cells, which we buy from, from a laboratory that, that stores them. So can you kind of go into. I mean, I know we talked about this separately. That's. You can say there's difference between two of them, but really the biggest difference is are you new surgery or not? And then what selection of stem cells might be based on who you're seeing because they have different abilities. Like we have an ability to collect fat and you have to click extend bone marrow. Give me your thoughts on the differences between the two, the three products.

Well, to me, I love mesenchymal stem cells because I'm used to the bone, right. But the harvest of mesenchymal stem cells, like when we do bone marrow aspirate, you got to get into the bone. So that can be a little nerve wracking for people. We find that our patients really do not, do not have a problem with it. It's a very powerful and versatile treatment. And basically what we do is a numb up an area of the pelvis here, and then we go in with a small needle and drop about 180ccs of the bone marrow and process it here in the office. It's really a pretty quick process, as you know, for fat aspiration we have to do. It's like a little bit of a mini liposuction. So you take some fat, then you process it that way. And then as far as allogeneic stem cells or stem cells from somebody else, right. Like Wharton's jelly and those types of things, those are typically young stem cells or embryonic stem cells. And the idea is that they're very young, right. They're from cord blood or placenta or something of that nature. In my opinion, you need to use human out there. There's bovine stem cells, there's porcine, there's like cow stem cells. And I've heard of pig and all of that thing. I don't have any personal experience with that. To me, that's a little funky. Just because we have such great options for human derived stem cells. The Wharton's jelly and those stem cells from other sources, they can be very powerful. I think one of the arguments against them, they have a lot of the growth factors, the same growth factors that we find in other stem cells. I think that the argument is that when they freeze them, you may kill the stem, you may kill the cells. So the cells may not be viable or living when they're injected. My personal experience with IV stem cells has been very positive at this point where we're really interested in using those types of stem cells to optimize the whole system and using a more focused bioactive for that particular patient. Treatment for the joint. Right. So bone marrow or fat adipose. And then you might, you might say, well, in our older patients, are those going to be effective? Because you might have what, you know, cellular senescence. You might have older cells that aren't as active. But, but what we find is that even in patients who are in their 80s, there's, their stem cells are still working pretty darn good. They still get amazing and long term relief. So to me, I feel like there's still great options for using a patient's own stem cells. I'm also very interested in the technologies that you mentioned that we can use from other sources because not having to harvest is definitely a positive.

Yeah. So back say 10 years ago, these labs selling us the umbilical stem cells could actually say we're giving you 10 million or 20 million viable stem cells. And the FDA and the FTC have said, you can't even say that. If you use that word, we will shut you down. So now they don't even report. So we have to go and get a laboratory evaluation of it because the FDA is really wanting to regulate this because there's not a lot of money for the FDA in these, in these umbilical stem cells. There is a company called Cellularity and they're gonna have a, they're gonna have a placental based stem cell product that will be FDA approved in mass manufacturer. It's gonna be crazy expensive, but I think that's coming. And their goal is to get it covered by insurance, make it more mass market. I'm going back to this thing. And you know, you made a good point about, you know, older stem cells are still active. A case in point is your skin turns over every 30 days. So you have a basement membrane where there's a basal cell and it turns into a squamous cell and into a keratinocyte and every 30 days that skin changed over. So if an 80 year old person did not have active stem cells, they would run out of skin in 30 days and be skinless.

Thank you.

We know they're still active and there might be less active ones. So now they have wrinkles, but they still have a lot of active stem cells. And looking at comparisons to young and older stem cells, typically older stem cells are senescent, so they're not really doing anything positive or negative. They're sort of laying there. But we overcome that by we're using millions of stem cells and nobody knows a sweet spot. But I've heard Talk of about 5 million stem cells seems to be enough and we're usually injecting 10 million. So if there's some sleeping ones, probably doesn't make a difference. You and I had kind of a talk about differences. Like we know that there's more stem cells per ML in fat than bone marrow, but you're telling me well, but yeah, but some of the bone marrow stem cells are more active and you think that not only neutralize, it might be in some way superior. You want to go into that a little bit?

Maybe that's, you know, I, I have looked at several studies that, that show very little difference in outcome between the two.

A clinical outcome. I totally agree with that. There is no difference. But you know, getting, when I wrote my book was in 17, I was kind of not bad mouthing bone marrow stem cells. But I was like, well there's 500 times more. But it didn't take into consideration there's differences. The stem cells not as like you have, you know, hemopoietic stem cells and you have, you know, mesenchymal stem cells. We have, we call it SVF homo vas refraction, which has mesenchymal stem cells. Probably like 2% of the cells are actual stem cells. But I think that's. That we could probably agree on. That is clinically we're comparing this to surgery, not stem cell to stem cell. And we have frankly have not found a difference. I've been using umbilical and fat derived stem cells. We have not seen a clinical difference between the two in, in 14 years. Now there's exosomes and are you using any exosomes?

I, I have a lot of interest in exosomes and we are currently researching how to apply that in the Pinnacle method. I mean it's just a really interesting technology.

We found exosome. I would say I've had experience for, for about 10 years. And exosomes work great in our business, which is cosmetic where we're doing laser resurfacing in the skin. It works for somebody that's not bald like me, but it's got thinning hair, works good for thinning hair. But we didn't find exosomes worked as good in the joints.

That's. And that's been, that's been the, that's been the common wisdom. Exosomes in my understanding are more of a vehicle. So what are we putting in the vehicle to get them in, you know, to get them to cross barriers ecologically?

If you think about it, it seems like it should work, but it didn't. And the reason we started using exosomes is that we were with Cell Surgical Network when it really in its early days and we had our own lab where we made our own stem cells. We basically would liposuction somebody we call it, harvesting the fat and we put it in the incubator, heat it up, and then we'd add an enzyme called collagenase to break the fat cells loose to free up the stem cells, and we'd spin them and harvest them. And then the government started saying, well, we think you're making a drug, therefore you've got to be a drug manufacturer. And they sued about 29 doctors and they lost every time. And finally in Miami they won a case and that became the law of the land. Well, fat derived stem cells, you can't use them with enzymes, right. And so we had to find other methods and we did different methods to use it without enzyme. And then another doctor, Dr. Berman, who was leader of the group I was in, sued the FDA and he actually won. And then it became that was on again. And then when he passed away, the FDA sued back. There's nobody to defend it. So now it's off again. So what we're using now is a lab where we take your fat, we send it to the lab, they extract the stem cells under principle that's legal and allowed to do, and then they bank them for you for the rest of your life. We have to order them. That being said, you can take fat just like your bone marrow, but we can unprocess it and basically just break it up through what's called a venturi device and inject it in the joint. It clinically works as good as stem cells, which is remarkable. And there's factors manufacturers, one's called lipogems, which is designed just to basically process the fat to go into the joint. In the short term, it works as good as stem cells. Like long term, maybe not as well, but it does work as well in the short term. When I say short term, one or two years of pain relief. So a lot of times we'll do is give patient that immediate relief by Using this fat that's minimally processed in the joint, and then send the fat to a lab where they'll bank their stem cells, which is really cheap. It's $250 a year to bank the cells, and you gotta pay to get them shipped back to you. Now, in your case, do you do any banking or are you just getting more. More stem cells when you need them?

We haven't done any banking. The bone marrow is such a, you know, such a robust source of stem cells. I started into this space about three years ago, so I'm. I have a very learner's mindset. We're always adding cool new things, new, better ways to take care of our patients. And that's part of what I love about talking to you, is that I get to learn so damn much about this, about the space, banking stem cells. I've actually just had a call with a company that will bank. They'll bank bone marrow, too. Yeah. So they could. They'll. They'll culture them, grow them out. Then you have almost an infinite amount. So that's definitely something that I. I have been talking to patients about doing.

Yeah. So let's talk about that. So that the. Because, you know, you say it's not that painful to do bone marrow aspirin. It's not. It's not that painful to do liposuction. It's not. But it's painful. So it's not painful. And that is the more scary part. Injecting the joint is actually less intimidating. So I'm just going to give some terms that you refer to. You talk about expanding them in culturing. So they. When you send the tissue, which could be bone marrow or fat, to the lab, they basically separate the stem cells from the rest of the tissue and they identify these are likely mesenchymal stem cells. And then expanding means they grow them. So they could take, you know, a million stem cells and turn into 100 million stem cells. And these can turn over almost indefinitely. And then they freeze them at 80 degrees below zero, and then they ship them out to medium. So I think that's. That's an option for people that if you're going through the bone marrow aspirate, it's not that expensive to bank them. And yeah, it's actually, in our case, because we're doing a liposuction procedure, it's actually cheaper to bank them than go get them again. So that's. That's.

I think that's. Yeah, especially with the. I think lipo gems, not those kits are more, much more expensive than just, you know, bone marrow aspirate. We're not at the kits aren't as, aren't as pricey.

And to be clear, when we're doing the harvesting, we're not using the lipo gems kit. So we're actually just using a syringe. So yeah, it costs nothing in terms of materials just to be audience. The lipo gems, the name of the kit that you pull the fat up, it's got these like, basically like steel marbles in it. You shake it up and it breaks the fat up. We actually run it through a three way stopcock, saves the patient 1100 bucks and works exactly the same. So getting back to your ideal candidate, I liked how you talked about you're looking for people that are going to want to be active and I think that's really the main target for the early adopters for stem cells. Because if somebody's active, their orthopedia is less likely. Recommend replacement surgery because then you got to tell them, hey, running is over, jumping is over, basketball's over. We see people with minor arthritis to what's called bone on bone and kind of describe the audience what, what is actually meant by bone on bone? Because sometimes people think there's nothing there to grow and there's, there's, there's a, maybe an X ray finding or an MRI finding. Can you go over that?

So if we, if we look at, if we look at a patient with what we call bone on bone arthritis, when we look at an X ray, we can't see the space. We can't see the cartilage itself, but we can see the space it makes. So on an arthritic X ray you would see, you would basically see a significant narrowing of that space to where the bone appears like it's touching on the X ray. And that's what we call bone on bone arthritis. That doesn't necessarily mean that there is no cartilage to regenerate or to treat. It's just that it's extremely thin or extremely damaged. The bone surfaces are. And cartilage itself doesn't have good blood supply. It doesn't have good blood supply, so it doesn't heal itself once the cartilage is damaged. Unless you do an intervention like a regenerative therapy or something happens, the cartilage is not going to heal by itself. I think that's important for people to recognize that arthritis is a progressive problem, that there's a lot of factors in our own health that can contribute. We know that things like hormone levels, estrogen and testosterone levels can affect how your joint progresses. We know that different medications that you take can affect your arthritis progression levels. But when we get right down to it, arthritis is very simply just that the cartilage surface overlying the bone has been damaged over time and it goes away. And the result of that sometimes can be that we can develop a deformity. So you see people who are like really bow legged or really knock kneed and in those situations the bone actually remodels. In orthopedics we have some big words. This one's not too big. It's called Wolf's law. Bone actually remodels along lines of stress. So if you push on it too hard, it'll remodel. It'll either get harder or softer. And in some cases it gets softer. And so then you end up having the bony deformity that develops with arthritis.

Okay, that's great. I would like to learn about this myself for our clinic and our patients as well. So we have patients that have pretty straight legs and we feel really confident. Then we have people with a severe we call a genu valgus or varus, which is basically bowlegged or, or the opposite of, they're kind of bent in knees. How do you manage the person that is bow legged because of arthritis when they want regenerative therapy?

So there's a lot of different ways to do it. One, you have to tell them, hey, you have this deformity. We're going to do our very best to preserve your joint as best we can. But at the end of the day, if you have a severe deformity, regenerative therapies may not be as effective as you want. They almost always get some percentage of relief. Like I have done some, I've had people who come into the office and I've really tried to talk them out of doing regenerative therapies. You know, like, hey, we need to, we need to really think more seriously about having a knee replacement. Your knees really badly deformed and, and they, and they go through with a biologics therapy and they do great, they get pain relief. But the problem is the research suggests that when we have a significant deformity, it doesn't last as long and that that deformity can progress. You know, it doesn't do much to slow down the deformity. What we do when we manage a patient with a big deformity or when we have, when we have a pretty various patient or something like that, we can put you can put them in a brace, like an unloader brace. The problem is patients don't really love to wear that brace. And they're kind of coming to you because they want an option that's, that's, you know, not going to really impact their lifestyle. Super like a whole lot. But a hinge knee, but a big brace is oftentimes impacts their lifestyle. So that's, that's not often what they're looking for.

So kind of question I get from patients is, how long is this going to last? And just to preface it, we've got prf, which we might use as a standalone or as an adjuvant therapy. And then we have stem cells. We're talking really about PRF first. If you have a patient just doing prf, the clinical studies show people get some relief for even more severe arthritis for about a year. So that can be repeated, obviously. And then stem cells studies have been all over the board. So what's kind of your take on how do you answer that question for people?

It's a tough one and it depends a lot. One of the reasons why we are so focused on optimization, why we so focused on the functional medicine approach is it's, it's my sincere belief that if we can get the patient healthier, right, if we deal with, if we deal with gut inflammation, if we deal with, if we deal with other things in the system, that these biologic treatments that we're using are going to be more effective and longer lasting. Right. So that's one way we can cheat the system. The party line for PRP is 12 to 18 months. We've had great success using our method. I actually do two injections between three and six weeks apart. And we have some other ancillaries that we do in there. And I've had great Success out to 24 months so far with a lot of patients.

And you're talking about with prp. Prf?

With prp. Prf. And that's in arthritis. It's important to recognize that PRP can be a cure for tendonitis. So if you have elbow tendinitis, if you have shoulder tendinitis, if, if you have, if tendinitis is the problem, then PRP may be the cure for that.

Yeah. In my case, rotator cuff, the subscapular 70 torn. It's, it's been cured. It was interesting. We got it done. I had read about, it was brand new back then. Tiger woods had it done and so like that. And I've had this orthopedic friend of mine come out and do it. And I sent my ultrasound tech to learn musculoskeletal ultrasounds. We were the probably first case in Michigan. And he told me, well, we got to do it twice. Like, okay, so we did it the first time. You can see that that tendon was torn. And two months later it felt perfectly normal. So he did it a second time. So he sticks that needle into a healthy tendon. Man, it hurt like hell. The arm was stiff for a week. I didn't need to do it a second time. But this was 2011. It's 2025. It has been perfectly normal. It has been perfectly normal all those years. I'd have to tear it again, basically.

Yeah, I think you would. I'd like. I actually. So the, the other part of your question was stem cell therapy. So bone marrow aspirate. The initial studies that were done in France by Hernagall, he, there's, there's studies that show that bone marrow aspirate can slow or reduce arthritic progression for between six and 10 years, depending on your overall health. There are good studies that, that, that he did to, to show that it reduces the need for knee replacement. He did a lot of work in the knee for, for the same amount of time. And that's even for pretty end stage arthritis. So, I mean, it's, it's, it's a really robust treatment. It works really, really well and it's an amazing alternative to what would be a really invasive surgery.

So here's an interesting story you might not have heard about. There's a company, and they're actually NASDAQ listed, where they've got a patented process where they get bone marrow aspirate and they inject paraspinal. Paraspinal, not intradiscal. They published a paper on it. Paraspinal for lumbago, or basically back pain, with or without radiculopathy, Providing the people did not have more than a 50% extrusion of their disc and they did not have spondylosis and they had a. About 85% success rate. Injecting in the region of the back, which is really, to me, just remarkable because we've been sending people for intradiscal injections and they just can't get in. But this paraspinal thing could be a breakthrough. I remember telling my, my pa, Danielle, when she's working on hard joints like the hip, like really, you just got to get it close. That works its way in there. Whereas the knee is an easy target.

I like to tell my staff, we Want to get it in there. That's really.

No doubt, no doubt. But it was totally. That is that, that if you, if you have a situation where you have like she had a patient with a labral tear, it just bathed the area, you know.

Absolutely.

You don't want to stick a needle in the labrum. But in this case the paraspinal, I think that's very exciting. I'll send you the paper. But it was like.

I'd love that.

That's really compelling that you can just do a paraspinal injection and get back. Because the back pain relief is such a difficult thing to deal with. It leads to so much disability and narcotic use and obesity. I want to kind of briefly go into this, this wellness aspect and I think you're doing something that most say regenerative orthopedic doctors are not doing, which is taking care of the patient outside of their joint.

Absolutely.

We probably could talk about this for hours. We're going to do like 10 minutes on evaluation and typical things that you see happen and in terms of your intervention.

Oh yeah, absolutely. One of the fascinating points that you just made on the spine, paraspinal injection, I think it's important and you said it right, get close because that's because stem cells will migrate. They go into different areas. And that's part of the point of using PRP or a signaler. Right. If we bathe the joint with PRP then we get those stem cells moving in the right direction already. So I, I think that's a really cool point that that's what's so powerful about them is we can inject them just into sort of a general area and they can make a big difference for patients. Okay.

So I'm just going to size segue on that. So PRP we think about and again PRP and PRF are essentially the same thing as prp. We're always activating it. But there's three, three growth fact know work well in prp. One is platelet derived growth factor which actually causes cells to migrate. So it's actually a growth growth factor that tells cells in the immediate area, which is your growth cells, your stem cells to move in. Then it's got something called vegf, vascular endothelial growth factor which causes your blood vessels to start giving circulation to an area like the knee that doesn't have much and then transcriptive growth factor which has those stem cells that migrate in turn into the proper cell. So the PRP is actually creating the environment that your own natural stem cells have A blood supply can move into the area and start growing. And that's exactly how your skin heals when you cut yourself.

Yes.

So back into the. I get so excited about hearing about that because I would get back into the subject of. I forgot we were talking about. Oh, yeah. About the other health stuff you're doing.

We're going to get to it. Don't worry. Yeah. So. So it. In the Pinnacle method, we have developed a very directed but robust approach to functional overall metabolic health and wellness with a real focus on helping patients with joint pain and longevity at the same time. So our goal is sort of hormonal balance, nutritional balance, gut biome optimization, and then environmental toxin reduction, you know, so you want to, you want to clean out a lot of that stuff. And then we want to, and then we want to really support the system in helping us heal our joint pain. And very simply, I mean, it's, it's, it's not complicated. It's just never been done before. Just, we're the only people that are doing it. And, and it's, it's really great because I talk at, I talk at conferences and, you know, we talk about the Pinnacle method and, and it just blows everybody's mind. And I'm saying to myself, well, I'm just talking about diet, I'm talking about mobility, I'm talking about things that can really move the needle, like bioidentical hormone replacement therapy. People, if you're not thinking about it and you're in the age where, between, heck, between 35 and 65, it can change your life. It's changed a lot of patients, lives. For me, it's changed my life personally. And then we're learning more and more that patients with low levels of hormones, like particularly estrogen, testosterone, are more prone to arthritic progression. So their arthritis gets worse. Right. And there's even a diagnosis of perimenopausal pain syndrome. And in my opinion, fibromyalgia. This is often misdiagnosed as fibromyalgia because a lot of providers are so resistant to doing hormone replacement therapy. Right. So we have to give them a different diagnosis doses. But it's been really, it's been proven that, that low levels of sex hormones increase your risk of joint pain significantly. And it's not just one joint, it's a bunch of joints.

Right.

So that's, that's one of our tenants. And then nutrition, Mark Hyman says it, right. Food is medicine. It truly is. And we know that we can lower. We, I have patients when we start our process, we start them on an anti inflammatory diet. I have many patients whose pain gets 30% better within two weeks just from starting the diet. Now is that necessarily sustainable for most Americans it can be really difficult, but it really optimizes our treatments. And so if we're coming in with a clean slate and then we're going to use your body's ability to heal to do just that, it just makes everything a lot better.

So that brings us into, you know, I wrote a book on how we treat ms, which is a passion of mine because my grandmother and aunt had it. And we know that your own body's derived stem cells given intravenously seem to have immunomodulation or something, that they settle down the immune system for about nine months. And we always found their Ms. Patients and other autoimmune patients, they get better for about nine months after we treated them. But unless we dealt with these other things, and specifically gut health, hormone imbalance and their diet, how they were eating. And I get patients who had rheumatoid arthritis or Ms. And they got better for about nine months and they were kind of sliding backwards and I find out they didn't really comply with the other stuff. So we, instead of getting another stem cell treatment, we just kind of work with them. Let's give you, we put them on a little minocycline that actually is the only antibiotic that improves your microbiome. Put them on galactoligosaccharide and something like inulin or beta thylakoids to help their microbiome in their gut. Put them on women on testosterone and estriol and men on testosterone replacement. Pretty much all men with Ms. Have low testosterone, so do all women and they start going to remission again. And that's not even considered. Ms. Is one of the most expensive diseases you can get. It used to be it was rare to have a disease that costs more than 50,000 a year for medication. Not even psoriasis has 50 and a hundred thousand dollar year medications that really can be managed with the microbiome, which there's no money in it, so doctors aren't even talking about it.

So why, why everybody? Why do you, why do you, what does insurance not want functional medicine to be covered? Right. Why, why can't you get, why can't you get these tests with your insurance? And that's the reason. Because insurance companies are much more interested because they're insurance companies and pharmaceutical companies, you can almost consider them the same entity. Many of them are owned by the same investment firms at this point. Right. BlackRock is invested in a lot of these companies across the board. So the reason why these treatments and these tests are not covered is because they can make a lot more money charging you $50,000 a year or $100,000 a year for a rare drug. Right. Like a drug for a rare condition.

Yeah. A little known fact is the Affordable Health Care act, so the so called Obamacare act had the 8515 rule which is insurance companies can only collect, can only keep 15% of the premiums. The rest has to go to pay for the patient's health. If insurance premiums come down, they're out of business insurance. So they're really disease in companies. So that, and I'm not badmouthing, that's just, I mean Congress set this up, Congress signed it that health care had to go up and I think even in an unintentionally they wanted so that we'd have eventually universal health care. Because once the insurance companies go bankrupt they'll have to be a public option. But I'm not sure a public option. We want people to be healthier either. Medicare definitely has interest in health care savings but they're in the same machine everybody else is.

In my opinion. It's sick care in this country. It's cyclic. You have to, it's, it's always after the fact. I, I, I can't tell if it's on purpose or if, if, if it's just a really stupid mistake. But basically the whole system is set up for you to have to have a problem before you can have a solution, before you could have a treatment. Right.

Well, let's look at the insurance industry. Your car insurance does not check your pressure of your tires or your windshield wipers or make sure you change your oil. And your house insurance doesn't check your CO2 monitor, your fire detect fire fire monitor. So they might require you to have it but not going to pay for your batteries and smoke detector. And health insurance was designed to cover catastrophic financial losses. It was really never designed for health.

Right.

So in fact with the Obamacare or the Affordable Health Care act that was the first time screening tests were ever paid for a mammogram. Not a covered entity. Until the Obamacare kid came out, there was about 52 preventative tests that were the first step forward in terms of preventive health care. And I'm not necessarily a fan of insurance companies paying for everything, but I would think that I would consider what could you save money on? So when insurance Companies, if they started paying for, say, stem cells and joints, the number of people seeking treatment would go up 20x if stem cells were free, because then people would have a lower threshold. And they've got to consider that because they know if you do a knee replacement, there's a 2% major, you know, morbidity rate and there's about 20 of people still have some symptoms afterwards. So you got to think about it. I mean, you did court concepts for your patients like, don't jump into this if you're simping, you know, if you're not gonna have a huge improvement, your quality of life. Yeah, lower that bar that everybody's going to want it done. And then insurance companies would, would, would be foot in the bill. I mean, right now, a good example is these GLP1 agonists, the drugs like Ozempic and Wegovy and Zeppbound for weight loss. Everybody wants it. If insurance covers it, everybody's going to use it, and then the cost is going to put a pressure on. So people paying out of pocket.

I think another way to look at the surgery, I mean, it, it's really interesting because we're doing more orthopedic surgery in this country than ever before. We're doing more joint replacements in this country than ever before on younger patients. So, and, and interestingly, orthopedics is one of the most profitable specialties in a hospital system. Right. So even though, even though Medicare is lowering reimbursements, reimbursements have gone down by almost 30%. And in just a matter of 15 years for orthopedics, it's still very profitable for hospital systems. And the majority of orthopedic surgeons now are employed. So 80% plus are employed. Whereas when I came out, I think I was one of the 20%. I came out and became employed and was employed for 15 years. So what we've seen in my career, we've seen this major shift from trying to do more conservative management in a younger patient to actually doing surgery early. So the first thing that you said was that we have a lot of patients getting joints really young. And that's a problem. Right. Up to 35% of joint replacements done in the United States are done prematurely. And so that's a real issue. The question is why is insurance so willing to pay for this very expensive joint replacement and not for a probably less expensive regenerative therapy that's going to prevent the joint replacement? And in my opinion, part of it, it seems to be that there's a really robust hospital lobby and these equipment companies have probably a pretty robust lobby as well. Right. So there's a lot of impact that those multibillion dollar companies can have on our political system.

Well, I mean, if the PRP and PRF was not so easy to make and insurance covered it, it'd be 5,000 an injection. Right, 5,000 injection instead. It's really much cheaper than that. One thing I wanted to get into, I'm kind of lost my train of thought with it a little bit. But the. Again, back when you, when you talk about why do they have to cover again, there would be much bigger market for everybody getting it done versus a few people getting it done. I want to talk about young people having this done. I think I lost my train of thought. I had. I should have made a note. Oh, one other question on my list of things to ask you. After somebody has stem cell treatment with bone marrow aspirator or stem cells from the fat, what are you telling them to do? What's the recovery period? What are we recommending they do afterwards in terms of activity, mobility, that sort of thing?

It depends on what we do. So we actually do osteoplasties with bone marrow aspirate. So you actually can inject it into the bone. Oftentimes when you have some of those more severe arthritic joints, the bone where it's, you know, talk about, you were talking about the deformity. The bone on the side of the, of the, of the, of the deformity will have a lot of inflammation. If you get an mri, you can see inflammation in the bone. Well, that's microscopically fracture. And so we can actually heal that and reduce that pain very significantly by injecting directly into the bone in those areas. That's something that's done really frequently in those patients. We slow them down a little bit more. It could be four to six weeks before they go back to their full activities. But they can put in as much weight on it as they want. Starting the day we do the procedure. In, in, in the case of bone marrow aspirate or prp, if I have a really active person, I want their joint to sort of calm down, right. Because part of our problem is inflammation. And so we ask them to refrain, like to, to do an exercise program with mobility for about four to six weeks before they go back to their more normal activities. I have a whole protocol that we use and it's, you know, it can be up up to three months before they go back to their full activities. But the, but the benefit is they have no, no downtime. Right.

But they can go walk in afterwards.

Oh, absolutely. And, and you know, walking. You can jump in your hot tub. Hot tub is actually excellent for bone maraspirate prp. Any regenerative therapies is going to respond better to heat than cold. So there's a lot less, there's a lot more safety involved with, with the regenerative therapies that we do. There's a lot less, you know, complication risk, lifestyle risk with these types of treatments versus a major joint replacement or major surgery. And honestly I do, I did 15 years of orthopedic surgery and I found myself spending a lot of time in the OR sort of looking critically at something that I was doing and I'm like, am I really making a difference for this person? I've, I've, I've, I've put this patient on the table. I've induced an anesthetic which has a risk of death. Right. I mean it's really safe to do surgery in the United States, but like it's a non zero risk. Right, right. And then I'm doing this surgery on somebody who, you know, either habits, lifestyle conservative management could have made a huge difference in, in, in them and they, and they wouldn't have had to be here having this torture that I'm going to do to them. And now they're going to be tortured in a sling for six weeks. And I've got, you know, and I've got, it's, it's two years before their joints as good as it's going to get, it's just on and on. Then that's if they don't have a complication. So it's my life's work to get regenerative therapies and a combination of regenerative therapies and this sort of metabolic approach to musculoskeletal care into the consciousness. I want more people doing Karen, more about the patient's whole health. You know, we get into the, you said it. You know, there's a lot of regenerative doctors out there who don't really do much focus on whole health. The, the, you know, the maximum sophistication I've seen of a couple of the guys down in Dallas are they give them a supplement that's actually says stem cell supplement. Well, it's got resveratrol in it and, and yeah, omega 3s and NMN, which doesn't absorb through oral means usually anyway, so that's not a really great supplement. But. And then it's got Like, I don't know, a probiotic, lactobacillus. So.

I was at a men's event, men's of our hospital back when we were allowed to have, you know, men's events. It was like a smoking thing with the, with the guys. And I was working in the hospital at the time and I was telling, telling them I had my shoulder done with, with PRP and a heel back and I was interested in stem cells. And this is 10 years ago. And I was sitting with some orthopedic buddies of mine. They're like, I just hope this doesn't catch on before I retire. And I was thinking, yeah, right.

Well, yeah, I'm trying to get it to catch on early. Let's. Yeah.

But they were thinking, like, I hope this doesn't happen because I make a living on replacing joints and not worry about their wellness and not worrying about their health and not worrying about their obesity. I can send them somewhere else. Get medically. I mean, the classic story is the orthopedic doctor sees them. Okay, I remember what I was going to talk to you about. Here's my favorite line at all. Line of all. Well, I've seen my doctor five times. He's giving me five steroid shots. He says, it's just getting worse. What the hell did you expect? You're injecting a joint with something that prevents healing. Absolutely. Gonna get worse. And really, if you do two or three steroid injections, wasted all it does, it hastens when you need a joint replacement. And that's been a modus operation. I think it's even considered not appropriate to do more than a couple times. But we hear that all the time. They get a steroid injection every few months. You know, they do these ha injections that have some benefit, but not much long term. But it's sort of like the orthopedic doctor gets a patient, they do a couple steroid injections failing. So now they've never talked about their weight or lifestyle. They send them to a family doctor to get medical clearance. They do it. See they're obese. Maybe do a. See them to a cardiologist, get a stress test. It's normal. So now nobody's talking about what they're doing, about inflammation, about their lifestyle. They decide, you're not having a heart attack, you're gonna have surgery, you get the surgery done. Maybe nutritionist sees them and they feed him crap at the hospital.

That's awful.

So I sent them home and they're right back in the same lifestyle. And then the other knee goes bad.

Right, right. It's a, it's a never ending, I mean, it's a never ending sort of recurring problem if we don't get to what we call the root cause. Right. So if, if you're going to spend your whole life working against your body's metabolism, then what do you expect? Of course you're going to have, of course you're gonna have problems with, with any, any type of thing that you're going to regenerate from. Surgery is, is surgery is an intense regenerative procedure. Like if you're going to have a surgery, you want your body optimized so that that sucker can heal, otherwise you're going to have a huge problem. And if you have a problem from a joint replacement, it is not a short term problem. Yeah, there are no short term problems with joint replacement that I can think of offhand. It's like you break around it, you're hosed, get stiff at may, stiff, stay stiff forever. If you get an infection, oh, that's really bad, you know, oh, if you just get tendinitis, it doesn't go away because it doesn't heal around a joint replacement. There are, and our lack of, in this compartmentalization. Right. I'm an orthopedic surgeon. I don't want to talk to patients about their health. That's irresponsible. It's created by a system that rewards us for doing high value, high volume, not high value. Right. High volume. Surgery is what we're going for when we're in the surgical specialties. We want to do as much as we can for as long as we can. And to your friend's point, I hope that doesn't happen before I retire because I make a living replacing joints. So what do I do in my, in my office as an orthopedic surgeon? I see you, I give you a steroid injection. You made an excellent point. Steroid injections are the devil as far as I'm concerned. We are injecting your joint with a toxic substance that can help you with inflammation but immediately starts damaging your joint. It immediately starts damaging the tissues around your joint and it immediately starts damaging your metabolism.

Right.

Because it gets out into, I mean, it has systemic effects. Ask a diabetic if we do more than two or three steroid injections in a calendar year. That's considered irresponsible. And yet we are doing it all the time.

All the time.

All the time. I, I, I have, I've seen patients that are like, yeah, I get My monthly steroid injection from my ex.

Yeah.

From my doctor, from my nurse practitioner. Such a bad idea. So basically, you're just dissolving your joint in crap, like, the whole time.

They're getting cataracts now they're getting vascular necrosis to their hip. I mean, there's all these other complications. Weight on, they're getting fat. They're retaining water.

It's horrible. And you take. And that's typically done in a person who is less than optimally healthy anyway. So you're taking a person that. That's already compromised, and you're. And you're. And you're giving them a medicine into the joint that not only damages the joint, but damages the rest of their health. I mean, what the hell? We've known since 1951 that joints. When we inject a steroid into a joint, that it damages the joint. Right. We started doing them in 1948. We're still doing them. And it's because it's cheap. And I think because we, as physicians like that feeling of, I helped you with your problem, at least for today.

They definitely get better.

For weeks, week or two, they feel better. And that makes me, as a doctor feel really good. All right. I did this thing. You feel better, you know. Okay. Well, it's. It's typical of human nature to sort of kick it down the curb, but kick that can down the curb. But the problem is we're getting you feeling better for a short amount of time, and it gets shorter every time. And it's damaging the joint.

Yep.

And it also increases the risk of complications. So that when you go to have a knee replacement, if you've had a lot of steroid injections, your risks of complications patients are much higher statistically.

I didn't think about that.

We don't even do joint replacement. It is not recommended to do a joint replacement within three to six months of a steroid injection because of the increased risk of infection. Now, when we do a steroid injection into the shoulder, which is the second most common joint that we do steroid injections for, we damage the tissues there because we're putting it into soft tissues, typically. And if you've ever had a painful steroid injection into your shoulder, it's not supposed to be painful. They probably injected your rotator cuff. So they injected your rotator cuff directly with a substance that's damaging. Yeah. And it's eating it. So that's. I mean, it's turned into mush in there. So that's so bad. So the, you know, in the shoulder. If we go and do a rotator cuff repair within six months of a steroid injection, it's been shown to have a much higher risk statistically of failure.

You know, this is way before your time, but when I was in medical school in the 80s, it was common that some of the older old timer family doctors would put their patients on oral steroids chronically.

Oh, we still have it, I still have it here.

They wind up just dying 10 years early. I mean it was, it was just, just amazing how ravaged their body and they couldn't come off of them.

No, because your steroids, your body becomes addictive. You stop making the substances that steroids suppress. Yep.

You can actually die stopping it.

Yeah, yeah, yeah. It's, it's such a bad idea. It's such a short, it's such a sacrifice of people's health for this short term gain, long term loss idea. It's like American politics. You know, we, we can't do anything in the long term because every four years we're changing what we do. It's, it's even worse in medicine because we're, it's a six week window. So I got to do something that's going to help you feel better for six weeks. Weeks. Right. Because then you come back to the office, I can give you another one or I can do this other BS thing. That, that, that just masks your problem. And I think that's, that's the power and the, and the, and the wonder of regenerative therapy. Especially when we combine it with actually changing the way a person looks at their health. It can make a, it, it's actually sustainable. It's long term, it looks down the road, it improves the patient's health outcome. Right. Our goal is to have that, that, that golden decade, the last 10 years of your life. 80% of Americans spend most of the last 10 years of their life in the hospital. That's bananas. You know, if we, if we can follow some very simple principles, if we can make some changes, if we can start that now and it's never too late, then we can make that last decade of life like it is in Sardinia where, you know, people are in their hundreds still hiking up those mountains. It's, it's not a mystery how that's done. It's just really hard to do it in America.

So this was a great talk. I really enjoyed it and I look forward to seeing you next week. I'm stopped by your office.

Awesome. Yeah, absolutely.