Dr. MELISSA BURMANMDMAY 2026
Creating the Right Environment for Healing
From My Clinic Notebook
Earlier this year I attended the Interventional Orthobiologics Foundation meeting, and as I listened to lectures over the conference I kept writing down variations of the same idea. Interestingly, it wasn’t tied to a particular procedure or technology — not PRP versus bone marrow aspirate, or whether one biologic was superior. The recurring theme was much simpler: healing doesn’t happen in isolation.
One presentation by Dr. John Ferrell put words to something I’ve gradually been realizing in my own practice. Orthobiologics provide a biologic signal, but the tissue environment largely determines how that signal is received. For years many of us asked, “Which injectate should I use? Is PRP better than corticosteroid? Should I add shockwave?” Those are important questions, but perhaps incomplete.
A better question may be: what creates the best environment for healing? Tendons don’t recover because of a single injection — they recover within a biologic system of loading, blood supply, inflammation, sleep, nutrition, metabolism, rehabilitation, and time. The more I learn, the less I see procedures as isolated treatments and the more I see them as one piece of a much larger ecosystem.
What We Know
Rather than comparing one treatment against another, it’s more useful to understand how each intervention contributes to the overall healing environment.
It may not be the most exciting statement in regenerative medicine, but it is probably the most important. Whether a patient receives PRP, ESWT, or no procedure at all, appropriately prescribed loading remains essential for tendon remodeling — it stimulates collagen organization, improves capacity, and lets biologic recovery translate into real strength and function. If biologics create an opportunity, rehabilitation teaches the tissue how to respond to it.
Often framed as an adjunct to orthobiologics, ESWT has earned its place as a stand-alone treatment. High-quality evidence supports it for plantar fasciitis, calcific rotator cuff tendinopathy, greater trochanteric pain syndrome, and selected Achilles tendinopathies, and guidelines recognize it as reasonable for knee osteoarthritis in selected patients. In other words, shockwave doesn’t need PRP to justify its role.
ESWT appears to influence mechanotransduction, angiogenesis, inflammatory signaling, and cellular activity. If PRP delivers growth factors, could modifying the local environment improve how those signals are used? Several small studies of PRP combined with ESWT report encouraging outcomes, but protocols vary and questions remain. Today the biologic rationale is stronger than the clinical evidence — an honest reflection of where we are.
Randomized trials remain the gold standard for whether a treatment works under controlled conditions. Registries answer a different question — how treatments perform across thousands of patients, many physicians, and diverse practices. They don’t prove causation; they reveal patterns that generate hypotheses and inspire the next generation of trials. Together, trials and registries help us understand what works, for whom, and when.
Question to Consider
If healing depends not only on the procedure we perform but also on the environment surrounding it, should we spend as much time optimizing rehabilitation, sleep, nutrition, loading, and metabolic health as we do deciding which injection to perform?
Medicine is constantly evolving. So are the questions worth asking. I’ll keep sharing what I’m learning — from research, from colleagues, and from the patients who continually remind me that good medicine begins with curiosity. If this perspective resonates with you, I’d be honored to have you join me for the next edition.