Frequently Asked Questions
Answers about regenerative medicine procedures, aftercare, pain control, and recovery — from Sean Mulvaney, MD.
Preparing for Your Procedure
1.How can I optimize conditions before my procedure?+
For many regenerative procedures — especially PRP, BMAC, or Lipogems — there is reasonable supporting evidence that a short fasting window in the 24–36 hours immediately beforehand (roughly 800 calories per day, with minimal animal protein) improves cell mobilization and treatment quality. This is separate from the general nutrition guidelines in our Optimizing Recovery section, which is still worth following for the 2–3 days before your procedure. Click here for your Optimizing Recovery Guide. Exercise you can comfortably tolerate is fine right up until your procedure, and minimizing tobacco, alcohol, and other toxins along with getting good sleep in the days leading up to your appointment will help. If you tend to feel very anxious before any kind of medical treatment, please talk to Dr. Mulvaney — we can discuss ways to make the experience easier for you.
2.What if I am taking anticoagulation therapy or blood-thinning drugs?+
Please talk to Dr. Mulvaney directly if you're on anticoagulant (blood-thinning) therapy. He will let you know whether it's necessary to come off of it for your particular treatment or medical condition — some procedures require it, and some do not. The same goes for corticosteroids such as prednisone: let him know if you're taking one for an existing condition. If you do need to stay on a blood thinner, NSAID, or corticosteroid, your treatment will still work — it just won't work quite as well as it would if you were able to safely pause it.
3.Are there medications that I should hold before my procedure, or that may interfere with my procedure?+
If you have any questions, please talk to Dr. Mulvaney about any decisions to hold a medication around the time of your procedure.
A literature review was conducted to identify which medications have compelling, evidence-based reasons to be held before regenerative medicine procedures, versus those commonly assumed to interfere but lacking supporting data. Several agents often held out of caution — statins, biologic DMARDs, and methotrexate — do not clear the evidentiary bar for a routine hold recommendation.
| Medication / Class | Recommendation | Basis / Level of Evidence |
|---|---|---|
| NSAIDs / other anti-inflammatories | HOLD | Well-established suppression of the early inflammatory phase required for platelet/growth-factor signaling; standard peri-procedural practice. |
| Aspirin (peri-PRP) | HOLD | Established interference with platelet activation central to PRP's mechanism of action. |
| Therapeutic anticoagulants | HOLD (case-by-case) | Established bleeding risk. Not all agents equal: LMWH (tinzaparin) also directly impairs MSC proliferation in vitro; fondaparinux appears MSC-neutral — a reasonable substitution if anticoagulation cannot be paused. |
| Fluoroquinolones | HOLD / AVOID | Direct tenocyte and collagen toxicity via MMP upregulation; ~4x increased tendinopathy risk and ~2.5x rupture risk, compounded by concurrent corticosteroid use. Rarely first-line antibiotics regardless. |
| Nicotine / smoking | HOLD (cessation) | Vasoconstriction, blunted VEGF-driven angiogenesis, and direct impairment of platelet growth-factor release — hits PRP's mechanism directly. 2–4 week cessation window best supported, though not RCT-defined. |
| Statins (HMG-CoA reductase inhibitors) | NO ROUTINE HOLD | Evidence is genuinely mixed: theoretical antiplatelet effect and a tendon MMP/tendinopathy signal exist, but counterbalanced by pro-angiogenic (EPC/eNOS) effects and known harms of stopping in cardiac-risk patients. No procedure-specific outcome data. Consider individualizing only for a patient with active tendinopathy or prior statin-associated tendon injury. |
| Biologic DMARDs (TNF inhibitors, IL-targeted agents) | NO ROUTINE HOLD | Orthopedic surgery literature shows discontinuation raises flare risk without clearly improving outcomes. The infection-risk rationale for holding applies far more to open/implant surgery than to a needle-based injection procedure. |
| Methotrexate | NO ROUTINE HOLD | In vitro data shows dose-dependent inhibition of MSC osteogenesis/chondrogenesis, but this is contradicted by stronger clinical evidence: an RCT in RA surgical patients found no difference in complications between continuing and suspending MTX, and continuing significantly reduced flare rates. Two systematic reviews concur. |
| Non-fluoroquinolone antibiotics | NO ROUTINE HOLD | No compelling data supporting withholding standard antibiotic classes before an orthobiologic procedure. |
Key Takeaway
Of the medications frequently questioned in this context, only four have compelling evidence supporting a hold: NSAIDs, aspirin/antiplatelet-anticoagulant agents, fluoroquinolones, and nicotine. Statins, biologic DMARDs, methotrexate, and non-fluoroquinolone antibiotics do not have evidence supporting routine discontinuation.
References
- Grennan DM, et al. Methotrexate and early postoperative complications in patients with rheumatoid arthritis undergoing elective orthopaedic surgery. Ann Rheum Dis. 2001;60:214-217.
- Effect of methotrexate in post-operative wound healing in rheumatoid patients undergoing foot and ankle surgery. ISRCTN86123456.
- Assessment and Comparison of the Efficacy of Methotrexate, Prednisolone, Adalimumab, and Tocilizumab on Multipotency of Mesenchymal Stem Cells. PMC7348038.
- Stopping Biologics Before Surgery May Raise Flare Risk in RA. Rheumatology Advisor, citing Arthritis Research & Therapy (2026).
- Perioperative Management of Biologic and Targeted Synthetic DMARDs in Orthopedic Surgery: Balancing Infection Risk and Disease Control. Microorganisms 2026;14:398.
- To stop or not to stop: what should we be doing with biologic DMARDs when patients undergo orthopaedic surgery? PMC8493102.
- Dose Tapering and Discontinuation of Biologic DMARDs in Axial Spondyloarthritis: A Narrative Review. Curr Rheumatol Rep. 2024. DOI: 10.1007/s11926-024-01137-w.
- Is Fluoroquinolone Exposure after Primary Tendon Repair Associated with Higher Rates of Reoperations? A Matched Cohort Study. Orthopedic Reviews, 2025.
- Short-Term Exposure to Ciprofloxacin Reduces Proteoglycan Loss in Tendon Explants. PMC9777606.
- Ciprofloxacin reduces tenocyte viability and proteoglycan synthesis in short-term explant cultures of equine tendon. PMC8411937.
- Positive Association Between Fluoroquinolone Exposure and Tendon Disorders: A Nationwide Population-Based Cohort Study in Taiwan. PMC8978711.
- Statin treatment increases the clinical risk of tendinopathy through matrix metalloproteinase release. Scientific Reports. 2019;9:17958.
- Effects of Statin Treatment on the Development of Tendinopathy: A Nationwide Population-Based Cohort Study. PMC10350772.
- Statins: bitter enemies of tendons or not? A systematic review of clinical evidence. PubMed PMID: 41182304.
- Tobert JA. Tendinopathy and Tendon Rupture Associated with Statins. PubMed PMID: 27490216.
- HMG-CoA reductase inhibitors (statins) increase endothelial progenitor cells via the PI3-kinase/Akt pathway. PMC209365.
- Statins, HMG-CoA Reductase Inhibitors, Improve Neovascularization by Increasing the Expression Density of CXCR4 in Endothelial Progenitor Cells. PMC4550447.
- HMG-CoA reductase inhibitor protects against in vivo arterial thrombosis by augmenting platelet-derived nitric oxide release in rats. PubMed PMID: 15772528.
- Effects of Antithrombotic Drugs Fondaparinux and Tinzaparin on In Vitro Proliferation and Osteogenic and Chondrogenic Differentiation of Bone-Derived Mesenchymal Stem Cells. J Orthop Res. 2011;29:1327-1335.
- Why You Should Stop Smoking Before Your PRP Treatment. Ubie Doctor's Note, 2026.
- Orthopedic Surgery Complication Risk Associated with Smoking Cessation and Use of Nicotine Replacement Therapies: A Systematic Review. NCBI Bookshelf NBK595265.
- The influence of smoking and alcohol on bone healing: Systematic review and meta-analysis of non-pathological fractures. PMC8571530.
4.Does Dr. Mulvaney treat teenagers?+
Dr. Mulvaney will treat teenagers under a firm policy: we do something for the patient, not to the patient. The teenager being treated must understand the treatment and want it done, and the parent must understand that their wishes for their child will not override the desires of the patient — if the teenager doesn't want the procedure, it will not be done.
5.Are you put to sleep or sedated for the procedures?+
No — the medical literature is clear that these procedures are safer when performed on an unsedated patient. We use local anesthetic to minimize discomfort. If you're especially needle-phobic, you can call ahead to request medication to reduce anxiety before your procedure, and we have other options available during treatment for patients who are especially sensitive to discomfort, including nitrous oxide and other pain-reducing methods.
6.What should I wear for this treatment?+
For an upper body procedure, a button-down garment is helpful. For a lower extremity procedure, easily removable pants or shorts work well. We can also provide exam shorts or a gown as needed.
7.Can someone be in the room with me?+
If a teenager is being treated, a parent may be in the room. Otherwise, depending on the type of procedure, we may be able to accommodate an additional person in the room on a case-by-case basis.
8.How long does a treatment usually take?+
Prolotherapy and PRP cases typically take around 30 minutes, though for PRP you'll need to arrive 45 minutes before your appointment time for a blood draw. Most stem cell cases take about 1.5 to 2 hours.
9.Can I drink alcohol the night before a procedure? How about after?+
Alcohol strongly interferes with the cellular migration needed for repair — even one or two drinks can significantly impair cells' ability to migrate to the repair site. For patients wanting optimal outcomes, Dr. Mulvaney strongly recommends avoiding alcohol starting the day before your procedure and continuing for at least 10 days afterward.
10.Can I get a stellate ganglion block and a musculoskeletal treatment on the same day?+
Dr. Mulvaney does not recommend having a stellate ganglion block and a musculoskeletal treatment on the same day under any circumstances. There may be rare exceptions, which Dr. Mulvaney can determine on a case-by-case basis.
Recovery & Aftercare
11.When can I shower after a procedure?+
For most procedures using a hypodermic needle, there is no restriction on showering afterward. If you had a larger procedure — bone marrow aspirate concentrate (BMAC), adipose-derived, or micro-fragmented adipose — it is prudent to wait 48 hours before showering or bathing.
12.Should I use ice or heat after my treatment?+
Up to 10 minutes of ice or heat every hour or two can be safely used for comfort and will not interfere with the healing process. Other than for your own comfort, there is no reason you need to use ice or heat — the natural healing process is proceeding just as it should.
13.What can I use for pain control after a regenerative medicine procedure?+
Please avoid non-steroidal anti-inflammatory drugs such as ibuprofen, naproxen, or Celebrex if possible. Inflammation is a critical part of the healing process — it's what allows your body's cells to travel to the injury site and facilitate repair, and NSAIDs blunt that response. After many procedures, such as prolotherapy or neuroplasty, no pain medication is usually needed at all. After PRP or other regenerative treatments, if pain control is needed, we will write a short prescription for a narcotic to control your pain. Please let Dr. Mulvaney know if you have a history of narcotic abuse, or feel free to politely decline narcotic pain medicine if it's offered — we'll come up with other strategies, and in no way want that to impair your recovery.
14.How should I control the inflammation after a regenerative medicine procedure?+
Inflammation is the vital first phase of healing for the musculoskeletal system — without it, the healing process never initiates. It leads into the proliferative phase, when the cells needed to repair damaged tissue accumulate at the injury site, which in turn leads to the remodeling phase that produces stronger, more durable repair. Although inflammation can be uncomfortable, we do not want to interfere with it after these procedures, since it is precisely what drives the healing. Think of it like a hard workout: the soreness you feel afterward is inflammation, and that inflammation is what leads to stronger muscles and tissue. If you are having pain and need pain control, call Dr. Mulvaney and we will discuss treatment options.
15.Do I need a driver after my procedure?+
For some procedures, such as prolotherapy and shock wave treatments, most people can safely drive themselves to and from the appointment. Some procedures leave you more sore — such as platelet-rich plasma, bone marrow aspirate concentrate, or micro-fragmented adipose — and for those, you should have a driver accompany you to the appointment or use a driving service such as Lyft or Uber.
16.Will I be on crutches or in a sling after my procedure?+
If you are having a lower extremity procedure (other than prolotherapy), you will usually be on crutches for around two days. If you are having an upper extremity procedure other than prolotherapy, you will usually be in a sling for two to three days.
17.How can I optimize my healing response?+
See our Optimizing Recovery guide for evidence-based nutrition and lifestyle strategies — covering protein and key supplements, toxins that slow healing, and lifestyle factors like sleep, movement, and stress management, everything you need to give your procedure the best chance of success.
18.When will I follow up?+
We follow up after every procedure, usually about eight weeks afterward — though depending on the specific procedure or situation, your follow-up period may be shorter.
19.What happens if I do not get the results I hoped for after a procedure?+
At your follow-up, we'll determine whether additional imaging or additional treatment is needed. Either way, you'll be given clear treatment options for what comes next.
20.Can I go swimming or do water aerobics after a treatment?+
For treatments using only a hypodermic needle, there's no restriction on getting into the water within a few hours of treatment, as long as those movements weren't painful for you beforehand. For stem cell treatments, wait 48 hours before immersing the treated area in a pool or tub.
Returning to Movement
21.Will I do physical therapy after my procedure? If so, when?+
After most of our procedures, we recommend a period of physical therapy, usually starting four to six weeks afterward. In each case, we'll let you know when — and if — you should start.
22.I'm almost feeling better — when can I return to my sport or activity?+
This is a critical time in your recovery. It's very important to return to activity gradually and allow your body to re-adapt. Even if the treated area is feeling better, the repair may initially be tenuous — able to tolerate some activity, but not yet ready for full-acceleration movements. For example, you may be able to walk, but not run; or gently move a golf swing through its full range of motion, but not yet swing hard and take a full divot, since that kind of impulse load risks undoing the repair. Returning to activity using elastic resistance bands is almost always a good first step, since the load builds very gradually through the range of motion — this is where working with a physical therapist can be especially valuable. A key goal before returning to activity is restoring full range of motion, or as close to it as possible, in the area treated.
23.How do I start returning to running?+
Returning to running works best as a criteria-based, gradual progression rather than jumping straight back into your old routine. Before starting, you should be able to walk briskly for 30 minutes pain-free with normal gait mechanics, have full pain-free range of motion in the treated area, and tolerate light hopping or impact without pain or swelling.
A standard walk-run progression:
| Phase | Walk | Jog | Repeats | Days/Week |
|---|---|---|---|---|
| 1 | 4 min | 1 min | 3–6 | 2–3 |
| 2 | 3 min | 2 min | 3–6 | 2–3 |
| 3 | 2 min | 3 min | 3–6 | 2–3 |
| 4 | 1 min | 4 min | 3–6 | 2–3 |
| 5 | — | 30 min continuous | 1 | 3 |
- Do a 5–10 minute dynamic warm-up before each session, and take at least one rest day between running days.
- Run at a comfortable, easy effort — this isn't the phase for pace work.
- Only advance to the next phase once you can complete a full session pain-free, with no increased soreness or swelling afterward.
- Stop and back off if you get sharp pain, pain that worsens as you run, or pain significant enough to change your gait — talk to Dr. Mulvaney or your physical therapist before continuing.
- Once you complete Phase 5, increase weekly mileage by roughly 10% per week rather than jumping back to your prior volume all at once.
- Save speed work and hills for once you're back to 50–60% of your pre-injury weekly mileage; normal training can typically resume around 75–80%.
This is a general, evidence-informed framework — a physical therapist can tailor the pace of progression to your specific injury, running mechanics, and prior training level. Based on established graduated-return-to-running research, including Buist et al., Am J Sports Med. 2008;36:33-39, and Bredeweg et al., Br J Sports Med. 2012;46:865-870.
Payment
24.What form of payment does the ROSM Annapolis office take?+
ROSM Annapolis accepts credit cards, debit cards, and CareCredit. We do not accept cash or checks.
25.Are regenerative treatments covered by most medical insurance companies?+
Unfortunately, no. Although there is large-scale, high-quality medical evidence supporting the use of prolotherapy, PRP, bone marrow aspirate concentrate, and micro-fragmented adipose to heal musculoskeletal injuries, most insurance carriers do not currently cover them, and treatment involves an out-of-pocket expense.
26.Can I use my FSA or HSA account to pay for regenerative medicine treatments?+
Yes. We will provide you with either medical notes or an invoice to help with filing your claim.
27.Do you offer CareCredit or any other form of payment plan?+
We do offer CareCredit. We do not offer any other form of payment plan. Our front desk can help you apply.
Still Have Questions?
Call our Annapolis office Monday through Friday, 8 AM to 5 PM.