Why PRP Should Always Be Leukocyte-Rich

APEX Biologix
10 min read

Platelet-rich plasma (PRP) continues to evolve as clinicians seek more precise, biologically informed approaches to musculoskeletal care. In a recent educational webinar hosted by APEX Biologix, Thomas Buchheit, MD and Ariana DeMers, DO, RMSK explored the growing evidence supporting leukocyte-rich PRP (LR-PRP) and challenged traditional assumptions surrounding inflammation and osteoarthritis.

Throughout the discussion, both physicians emphasized a central theme: chronic musculoskeletal pain may not simply be a condition of “too much inflammation,” but rather a failure of tissue repair and healing resolution.

Osteoarthritis as a Chronic Wound

Early in the presentation, Dr. Buchheit reframed osteoarthritis through a different biologic lens.

He reviewed multiple studies evaluating corticosteroids, NSAIDs, and immune-suppressing therapies, highlighting evidence suggesting that suppression of the inflammatory cascade may not improve long-term joint health and, in some cases, may accelerate degeneration.

According to Dr. Buchheit, tissue healing depends on a coordinated immune response involving platelets, neutrophils, monocytes, macrophages, and inflammation-resolving cytokines.


Why Leukocytes Matter in PRP

The webinar focused heavily on the biologic role of leukocytes within PRP formulations. While leukocyte-poor PRP has often been promoted for intra-articular applications, Dr. Buchheit reviewed several studies suggesting there is limited evidence that leukocyte-poor preparations are superior.

Instead, he emphasized that leukocytes may contribute to:

  • Cellular recruitment
  • Growth factor signaling
  • Inflammation resolution
  • Tissue remodeling
  • Healing cascade activation

“Leukocytes play a really critical role. Platelet dosing is critical, but part of the healing cascade are leukocytes, and I think it’s misguided to assume that if we remove them, we’re doing the patient good.”

Inflammation Is a Signal, Not the Enemy

One of the most significant themes throughout the webinar was the idea that inflammation itself should not automatically be viewed as harmful. Acute inflammation, when properly regulated, is part of the body’s natural repair mechanism.

Dr. Buchheit compared the healing response to exercise physiology, where temporary inflammation and immune activation help stimulate tissue adaptation and rebuilding.

Patients Are Looking for More Than Symptom Suppression

Dr. DeMers emphasized that many patients today are seeking alternatives to repetitive cycles of temporary symptom management.

She explained that many patients experience repeated cycles of:

  • Corticosteroid injections
  • Anti-inflammatory medications
  • Physical therapy
  • Temporary relief followed by recurrent symptoms

Rather than presenting leukocyte-rich PRP as simply another injectable therapy, Dr. DeMers framed it as a fundamentally different approach focused on biologic restoration and tissue signaling.

The Importance of Patient Clarity

A major focus of Dr. DeMers’ presentation involved patient education and communication. She explained that many patients are willing to pursue regenerative therapies when they clearly understand:

  • Why previous treatments may have failed
  • The biologic rationale behind regenerative medicine
  • The importance of healing-focused interventions
  • The role of inflammation in tissue repair

Looking Ahead: Personalized Regenerative Medicine

During the Q&A portion of the webinar, both presenters acknowledged that regenerative medicine will likely continue evolving beyond simplistic “leukocyte-rich versus leukocyte-poor” classifications. Future therapies may become increasingly personalized based on:

  • Immune responsiveness
  • Cellular phenotypes
  • Platelet functionality
  • Patient-specific biologic characteristics

Watch the Full Educational Session and Explore Additional Regenerative Medicine Resources

Watch the full webinar, Why PRP Should Always Be Leukocyte Rich, along with additional regenerative medicine webinars, procedural education, clinical resources, and biologic therapy insights through the APEX Resource Library.

The APEX Resource Library provides healthcare professionals with access to:

  • Educational webinars and expert discussions

  • Clinical and procedural insights

  • Product processing tutorials

  • Research and evidence-based resources

  • Practice development education

  • Additional physician-focused regenerative medicine content

References
  1. McAlindon, T., et al. Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: a randomized clinical trial. JAMA. 2017;317(19):1967-1975. doi:10.1001/jama.2017.5283
  2. Bharadwaj, U., et al. Intra-articular knee injections and progression of knee osteoarthritis: data from the osteoarthritis initiative. Radiology. 2025;315(2):e233081. doi:10.1148/radiol.233081
  3. Aitken, D., et al. A randomised double-blind placebo-controlled crossover trial of HUMira (adalimumab) for erosive hand osteoarthritis: the HUMOR trial. Osteoarthritis Cartilage. 2018;26(7):880-887. doi:10.1016/j.joca.2018.02.899
  4. Kloppenburg, M., et al. Etanercept in patients with inflammatory hand osteoarthritis (EHOA): a multicentre, randomised, double-blind, placebo-controlled trial. Ann Rheum Dis. 2018;77(12):1757-1764. doi:10.1136/annrheumdis-2018-213202
  5. Chevalier, X., et al. Intraarticular injection of anakinra in osteoarthritis of the knee: a multicenter, randomized, double-blind, placebo-controlled study. Arthritis Rheum. 2009;61(3):344-352. doi:10.1002/art.24096
  6. Salis, Z. & Sainsbury, A. Association of long-term use of non-steroidal anti-inflammatory drugs with knee osteoarthritis: a prospective multi-cohort study over 4-to-5 years. Sci Rep. 2024;14(1):6593. doi:10.1038/s41598-024-56665-3
  7. Luitjens, J., et al. NSAIDs may worsen arthritis inflammation. Radiological Society of North America. Published November 21, 2022. Accessed May 12, 2026. https://www.rsna.org/media/press/i/2379
  8. Parisien, M., et al. Acute inflammatory response via neutrophil activation protects against the development of chronic pain. Sci Transl Med. 2022;14(644):eabj9954. doi:10.1126/scitranslmed.abj9954
  9. Buchheit, T. Healing Joints and Nerves: Immune Stimulation and the New Science of Regenerative Therapies. Bull Publishing Company; 2026.
  10. Knighton, D., et al. Classification and treatment of chronic nonhealing wounds: successful treatment with autologous platelet-derived wound healing factors. Ann Surg. 1986;204(3):322-330. doi:10.1097/00000658-198609000-00011
  11. Bennell, K., et al. Effect of intra-articular platelet-rich plasma vs placebo injection on pain and medial tibial cartilage volume in patients with knee osteoarthritis: the RESTORE randomized clinical trial. JAMA. 2021;326(20):2021-2030. doi:10.1001/jama.2021.19415
  12. Cole, B., et al. Hyaluronic acid versus platelet-rich plasma: a prospective, double-blind randomized controlled trial comparing clinical outcomes and effects on intra-articular biology for the treatment of knee osteoarthritis. Am J Sports Med. 2017;45(2):339-346. doi:10.1177/0363546516665809
  13. Paget, L., et al. Effect of platelet-rich plasma injections vs placebo on ankle symptoms and function in patients with ankle osteoarthritis: a randomized clinical trial. JAMA. 2021;326(16):1595-1605. doi:10.1001/jama.2021.16602
  14. Lewis, E., et al. The effectiveness of leucocyte-poor platelet-rich plasma injections on symptomatic early osteoarthritis of the knee: the PEAK randomized controlled trial. Bone Joint J. 2022;104-B(6):663-671. doi:10.1302/0301-620X.104B6.BJJ-2021-1109.R2
  15. Bansal, H., et al. Platelet-rich plasma (PRP) in osteoarthritis (OA) knee: correct dose critical for long term clinical efficacy. Sci Rep. 2021;11(1):3971. doi:10.1038/s41598-021-83025-2
  16. Berrigan, W., et al. A greater platelet dose may yield better clinical outcomes for platelet-rich plasma in the treatment of knee osteoarthritis: a systematic review. Arthroscopy. 2025;41(3):809-817.e2. doi:10.1016/j.arthro.2024.03.018
  17. Chu, J., et al. Intra-articular injections of platelet-rich plasma decrease pain and improve functional outcomes than sham saline in patients with knee osteoarthritis. Knee Surg Sports Traumatol Arthrosc. 2022;30(12):4063-4071. doi:10.1007/s00167-022-06887-7
  18. Park, Y., et al. Clinical efficacy of platelet-rich plasma injection and its association with growth factors in the treatment of mild to moderate knee osteoarthritis: a randomized double-blind controlled clinical trial as compared with hyaluronic acid. Am J Sports Med. 2021;49(2):487-496. doi:10.1177/0363546520986867
  19. Boffa, A., et al. Influence of platelet concentration on the clinical outcome of platelet-rich plasma injections in knee osteoarthritis. Am J Sports Med. 2024;52(13):3223-3231. doi:10.1177/03635465241283463
  20. Belk, J., et al. Platelet-rich plasma versus hyaluronic acid for knee osteoarthritis: a systematic review and meta-analysis of randomized controlled trials. Am J Sports Med. 2021;49(1):249-260. doi:10.1177/0363546520909397
  21. Filardo, G., et al. Platelet-rich plasma intra-articular injections for cartilage degeneration and osteoarthritis: single- versus double-spinning approach. Knee Surg Sports Traumatol Arthrosc. 2012;20(10):2082-2091. doi:10.1007/s00167-011-1837-x
  22. Di Martino, A., et al. Leukocyte-rich versus leukocyte-poor platelet-rich plasma for the treatment of knee osteoarthritis: a double-blind randomized trial. Am J Sports Med. 2022;50(3):609-617. doi:10.1177/03635465211064303
  23. Lim, A., et al. The use of intra-articular platelet-rich plasma as a therapeutic intervention for hip osteoarthritis: a systematic review and meta-analysis. Am J Sports Med. 2023;51(9):2487-2497. doi:10.1177/03635465221095563
  24. Parrish, W., et al. Normal platelet function in platelet concentrates requires non-platelet cells: a comparative in vitro evaluation of leucocyte-rich (type 1a) and leucocyte-poor (type 3b) platelet concentrates. BMJ Open Sport Exerc Med. 2016;2(1):e000071. doi:10.1136/bmjsem-2015-000071
  25. Lin, K., et al. Leukocyte-rich platelet-rich plasma has better stimulating effects on tenocyte proliferation compared with leukocyte-poor platelet-rich plasma. Orthop J Sports Med. 2022;10(3):23259671221084706. doi:10.1177/23259671221084706
  26. Jayaram, P., et al. Leukocyte-rich platelet-rich plasma is predominantly anti-inflammatory compared with leukocyte-poor platelet-rich plasma in patients with mild-moderate knee osteoarthritis: a prospective, descriptive laboratory study. Am J Sports Med. 2023;51(8):2133-2140. doi:10.1177/03635465231170394
  27. Jayaram, P., et al. Leukocyte-dependent effects of platelet-rich plasma on cartilage loss and thermal hyperalgesia in a mouse model of post-traumatic osteoarthritis. Osteoarthritis Cartilage. 2020;28(10):1385-1393. doi:10.1016/j.joca.2020.06.004

This blog post is a summary of an educational session and is provided for informational purposes for healthcare professionals. The perspectives shared reflect the clinical experience and opinions of the speaker(s) and do not necessarily represent the views of APEX Biologix. This content is not medical advice and is not intended to establish a standard of care, diagnose, or recommend treatment for any individual patient. Clinicians should evaluate all therapies using their independent clinical judgment, applicable regulations, and the most current evidence.