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OtherPractice

Platelet-rich plasma injections

Danielle Perry, Joey Ton and Michael R. Kolber
Canadian Family Physician May 2020, 66 (5) 337;
Danielle Perry
Knowledge Translation Expert with the PEER Group in the Department of Family Medicine at the University of Alberta in Edmonton.
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Joey Ton
Knowledge Translation Expert with the PEER Group in the Department of Family Medicine at the University of Alberta in Edmonton.
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Michael R. Kolber
Professor with the PEER Group in the Department of Family Medicine at the University of Alberta in Edmonton.
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Clinical question

How effective is platelet-rich plasma (PRP) for treating Achilles tendinopathy, lateral epicondylitis, and rotator cuff tendinopathy?

Bottom line

The best-quality evidence shows no difference in pain, function, or return to sport between PRP, dry needling, and saline for patients with Achilles tendinopathy, lateral epicondylitis, or rotator cuff tendinopathy.

Evidence

The following are patient-important outcomes from placebo-controlled RCTs.

  • For chronic Achilles tendinopathy, 3 RCTs compared PRP injections with saline.1–3

    • - In the highest-quality double-blind RCT, 54 patients were randomized to 1 injection of PRP or saline.1 There were no significant differences in pain, function, return to sport, or patient satisfaction at 6, 12, and 24 weeks.

    • - In 2 smaller, unblinded RCTs (24 to 38 patients), there were inconsistent results. One compared a single injection of PRP with saline (24 patients)2 and found no difference in pain at 12 weeks. Another compared 4 injections (1 every 2 weeks) of PRP or saline (38 patients)3 and found PRP statistically significantly improved pain on a 100-point scale at 6 weeks (PRP 37 points, saline 23 points), 12 weeks (PRP 41 points, saline 30 points), and 24 weeks (PRP 37 points, saline 18 points).

    • - A systematic review found similar results to the above.4

  • For chronic lateral epicondylitis, there were 2 RCTs.5,6

    • - In a study comparing PRP with saline (60 patients, 1 injection),5 there was no difference in pain or function at 12 weeks.

    • - In a study comparing PRP plus dry needle insertion with dry needle alone (28 patients, 2 injections 1 month apart),6 there was no difference in pain at 24 weeks.

    • - Limitations: The treating physician was not blinded,5 there was a high dropout rate,5 and studies had small numbers of participants.6

  • For rotator cuff tendinopathy (at least 3 months of symptoms), 2 RCTs7,8 compared PRP with saline (40 patients) or dry needling (39 patients) and found no difference in pain or disability scores.

  • No adverse events (including tendon rupture) were reported.

Context

  • Platelet-rich plasma injections require specialized equipment and training.9

  • Each injection costs about $500 and is not normally covered by insurance (telephone communication with administrative staff, Glen Sather Sports Medicine Clinic, Edmonton, Alta, May 2019).

Implementation

Up to 90% of those with lateral epicondylitis heal within a year without any intervention.10 Corticosteroid injections might be effective in the short term; however, they could result in worse outcomes than no treatment at 1 year.10 Physiotherapy-led exercises have been found to improve pain in 39% to 100% of patients.10 Topical nitrates have shown inconsistent benefit for tendinopathies. For example, in lateral epicondylitis, topical nitrates showed a pain reduction of 4 points (out of 10) over placebo at 6 months in one trial but did not show benefit over placebo at 8 weeks in another trial.11 Patient handouts might be helpful in explaining treatment options and exercises.12,13

Acknowledgments

Ms Perry is supported by the Alberta College of Family Physicians and Dr Ton is supported by the College of Family Physicians of Canada.

Notes

Tools for Practice articles in Canadian Family Physician are adapted from articles published on the Alberta College of Family Physicians (ACFP) website, summarizing medical evidence with a focus on topical issues and practice-modifying information. The ACFP summaries and the series in Canadian Family Physician are coordinated by Dr G. Michael Allan, and the summaries are co-authored by at least 1 practising family physician and are peer reviewed. Feedback is welcome and can be sent to toolsforpractice{at}cfpc.ca. Archived articles are available on the ACFP website: www.acfp.ca.

Footnotes

  • Competing interests

    None declared

  • The opinions expressed in Tools for Practice articles are those of the authors and do not necessarily mirror the perspective and policy of the Alberta College of Family Physicians.

  • Copyright© the College of Family Physicians of Canada

References

  1. 1.↵
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    3. van Schie HT,
    4. Bierma-Zeinstra SM,
    5. Verhaar JA,
    6. Weinans H,
    7. et al
    . Platelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial. JAMA 2010;303(2):144-9.
    OpenUrlCrossRefPubMed
  2. 2.↵
    1. Krogh TP,
    2. Ellingsen T,
    3. Christensen R,
    4. Jensen P,
    5. Fredberg U
    . Ultrasound-guided injection therapy of Achilles tendinopathy with platelet-rich plasma or saline: a randomized, blinded, placebo-controlled trial. Am J Sports Med 2016;44(8):1990-7.
    OpenUrlCrossRefPubMed
  3. 3.↵
    1. Boesen AP,
    2. Hansen R,
    3. Boesen MI,
    4. Malliaras P,
    5. Langberg H
    . Effect of high-volume injection, platelet-rich plasma, and sham treatment in chronic midportion Achilles tendinopathy: a randomized double-blinded prospective study. Am J Sports Med 2017;45(9):2034-43.
    OpenUrl
  4. 4.↵
    1. Zhang YJ,
    2. Xu SZ,
    3. Gu PC,
    4. Du JY,
    5. Cai YZ,
    6. Zhang C,
    7. et al
    . Is platelet-rich plasma injection effective for chronic Achilles tendinopathy? A meta-analysis. Clin Orthop Relat Res 2018;476(8):1633-41.
    OpenUrl
  5. 5.↵
    1. Krogh TP,
    2. Fredberg U,
    3. Stengaard-Pedersen K,
    4. Christensen R,
    5. Jensen P,
    6. Ellingsen T
    . Treatment of lateral epicondylitis with platelet-rich plasma, glucocorticoid, or saline: a randomized, double-blind, placebo-controlled trial. Am J Sports Med 2013;41(3):625-35.
    OpenUrlCrossRefPubMed
  6. 6.↵
    1. Stenhouse G,
    2. Sookur P,
    3. Watson M
    . Do blood growth factors offer additional benefit in refractory lateral epicondylitis? A prospective, randomized pilot trial of dry needling as a stand-alone procedure versus dry needling and autologous conditioned plasma. Skeletal Radiol 2013;42(11):1515-20.
    OpenUrlCrossRefPubMed
  7. 7.↵
    1. Kesikburun S,
    2. Tan AK,
    3. Yilmaz B,
    4. Yaşar E,
    5. Yazicioğlu K
    . Platelet-rich plasma injections in the treatment of chronic rotator cuff tendinopathy: a randomized controlled trial with 1-year follow-up. Am J Sports Med 2013;41(11):2609-16.
    OpenUrlCrossRefPubMed
  8. 8.↵
    1. Rha DW,
    2. Park GY,
    3. Kim KY,
    4. Kim MT,
    5. Lee SC
    . Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease: a randomized controlled trial. Clin Rehabil 2013;27(2):113-22.
    OpenUrlCrossRefPubMed
  9. 9.↵
    1. Kaux JF,
    2. Emonds-Alt T
    . The use of platelet-rich plasma to treat chronic tendinopathies: a technical analysis. Platelets 2018;29(3):213-27.
    OpenUrl
  10. 10.↵
    1. Korownyk C,
    2. Allan GM
    . Steroid injections and lateral epicondylitis (tennis elbow). What is the evidence? Tools for Practice #48. Edmonton, AB: Alberta College of Family Physicians; 2015.
  11. 11.↵
    1. Challoumas D,
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    4. Clifford C,
    5. McLean M,
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    . Topical glyceryl trinitrate for the treatment of tendinopathies: a systematic review. Br J Sports Med 2019;53(4):251-62.
    OpenUrlAbstract/FREE Full Text
  12. 12.↵
    1. Scott-Demster C
    . Tennis elbow. Advice and exercises. Information for patients. Oxford, UK: National Health Service Foundation Trust; 2019. Available from: https://www.ouh.nhs.uk/patient-guide/leaflets/files/43963Ptenniselbow.pdf. Accessed 2020 Mar 2.
  13. 13.↵
    1. Healthwise Staff
    . Rotator cuff problems: exercises you can do at home. Health Link BC; 2018. Available from: https://www.healthlinkbc.ca/health-topics/ue4829. Accessed 2020 Mar 3.
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Canadian Family Physician: 66 (5)
Canadian Family Physician
Vol. 66, Issue 5
1 May 2020
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Platelet-rich plasma injections
Danielle Perry, Joey Ton, Michael R. Kolber
Canadian Family Physician May 2020, 66 (5) 337;

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