Research Review By Dr. Demetry Assimakopoulos©

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Date Posted:

October 2016

Study Title:

Does platelet-rich plasma deserve a role in the treatment of tendinopathy?

Authors:

Nourissant G, Ornetti P, Berenbaum F et al.

Author's Affiliations:

Department de chirurgie orthopedique, group Masussins, Paris; Inserm UMR-S938, universite de la Sorbonne, Paris; CIC-P Inserm 803, plateforme d’investigation technologique, hospital universitaire de Dijon; Department de rhumatologie, hospital universitaire de Dijon; Department de rheumatologie, hospital Lariboisiere, universite Paris; Department de rheumatologie, hospital Henri-Mondor, universite Paris, France.

Publication Information:

Joint Bone Spine 2015; 82: 230-234

Background Information:

Tendinopathy is a common condition often related to a multitude of factors, including microtrauma, excessive loading and aging. Platelet-rich plasma (PRP) is a popular and relatively new treatment modality for tendinopathy. However, the current evidence regarding its efficacy for pain, dysfunction or overall recovery from tendinopathy is inconclusive. With this in mind, the authors of this study performed a literature review to identify the potential benefits of PRP for tendinopathy.

Summary:

Background information on PRP

PRP therapy is derived from an increased concentration of platelets that have been obtained from the patient through phlebotomy (autologous platelets). Blood is drawn from the patient and spun until it is separated into 3 layers: platelet poor plasma, PRP and red blood cells. When spun, the PRP is deposited at the bottom of the tube, and a platelet gel is subsequently created. The process produces a 3-5x greater platelet concentration. The PRP solution is then injected into the patient’s injured tissue. A number of human tissue in vitro studies have demonstrated that platelets release various growth factors, such as platelet-derived growth factor (PDGF), vascular endothelial growth factor (VEGF), transforming growth factor beta (TFG-beta) and hepatocyte growth factor. These growth factors are thought to mediate PRP’s purported beneficial effects, and promote tendon matrix repair (1-7).

Use of PRP in Lateral Epicondylitis (“Tennis Elbow”)

Generally, the included studies were limited to the use of PRP in the treatment of lateral epicondylitis that is recalcitrant to physical and pharmacological treatment. The studies demonstrated a 25-60% decrease in visual analogue scale (VAS) score. One large, multi-centred RCT (8) of leucocyte-containing PRP (L-PRP) demonstrated significantly greater pain relief in the PRP group at multiple time intervals. In spite of these data, a 2014 meta-analysis concluded that there is no evidence that PRP is effective in the treatment of chronic lateral epicondylitis (9).

Use of PRP in Achilles Tendinopathy

The data for this condition is mixed, due to small sample sizes and treatment protocol heterogeneity. Recent RCT (10) and imaging (11) studies on patients with chronic, refractory, mid-portion Achilles tendinopathy showed no difference between PRP injected and saline control groups. Still, some additional studies have found PRP therapy to speed return to sporting competition when combined with surgical intervention (12). However, the current data is not robust enough to justify the use of PRP in patients suffering from recalcitrant Achilles tendinopathy.

Use of PRP in Patellar Tendinopathy (“Jumper’s Knee”)

A small study evaluated the use of ultrasound-guided PRP injections in athletes suffering from patellar tendinopathy, and demonstrated up to 80% improvement in SF-36, VAS and knee function scores (13). Similar findings were shown in studies comparing PRP to physical therapy (14) and extracorporeal shockwave therapy (15, 16). The above mentioned data supports the use of PRP to treat refractory, insertional patellar tendinopathy. However, the results require confirmation via higher quality studies.

Use of PRP in Rotator-Cuff Tendinopathy

Unfortunately, the majority of the studies on this topic have included heterogeneous patient populations and had several methodological weaknesses. The available data are not sufficient to conclude that PRP is effective in the treatment of recalcitrant rotator-cuff tendinopathy, either as a stand-alone treatment or in combination with surgery (17, 18).

Clinical Application & Conclusions:

The authors of this study reviewed the current literature on the use of PRP in lateral epicondylitis, and Achilles, patellar and rotator cuff tendinopathies. In summary, the available data do not support the use of PRP as a first-line treatment for chronic tendinopathy, regardless of lesion site or type. This is likely because of the vast heterogeneity of patient populations, tendinopathy sub-types, composition of PRP injection solutions, and injection protocols that comprise the current body of literature.

It is important to note that not all tendinopathies are created equal. Tendon lesions can exist in either the tendon body or insertion, whose regions embody different histological and biochemical qualities. It is unclear at this time if different tendinous regions might react differently to PRP injection therapy.

Drs. Jill Cook and Craig Purdum have previously discussed the spectrum and staging of tendinopathy (reviewed extensively on RRS). Might PRP be helpful in a specific stage of tendinopathy? To date, no studies have taken this variable into account.

It is difficult to know if a PRP treatment or series of treatments will produce benefits across a variety of tendinopathy sub-types (19). The state of the current evidence is largely inconclusive. PRP might have therapeutic potential in chronic tendinopathies that have not responded to standard non-operative treatment, particularly in the case of chronic patellar tendinopathy. Like many interventions however, PRP might be beneficial in the right patient at the right time.

Study Methods:

This paper was an evidence-based clinical commentary. As such, no description of study selection or statistics was included.

Study Strengths / Weaknesses:

Strengths:
  1. This balanced review included a variety of studies both for and against the use of PRP for tendinopathy.
  2. The authors reviewed the basic cellular mechanisms responsible for the proposed benefits of PRP.
Weaknesses:
  1. There was no discussion of pain neuroscience in this paper. Including this aspect of tendinopathy would have enhanced the discussion.

Additional References:

  1. de Mos M, Koevoet W, van Schie HT, et al. In vitro model to study chondrogenic differentiation in tendinopathy. Am J Sports Med 2009; 37: 1214–22.
  2. de Mos M, van der Windt AE, Jahr H, et al. Can platelet-rich plasma enhance tendon repair? A cell culture study. Am J Sports Med 2008; 36: 1171–8.
  3. Anitua E, Sánchez M, Zalduendo MM, et al. Fibroblastic response to treatment with different preparations rich in growth factors. Cell Prolif 2009; 42: 162–70.
  4. Zargar Baboldashti N, Poulsen RC, Franklin SL, et al. Platelet-rich plasma protects tenocytes from adverse side effects of dexamethasone and ciprofloxacin. Am J Sports Med 2011; 39: 1929–35.
  5. Zhai W, Wang N, Qi Z, et al. Platelet-rich plasma reverses the inhibition of tenocytes and osteoblasts in tendon-bone healing. Orthopedics 2012; 35: e520–5.
  6. Jo CH, Kim JE, Yoon KS, et al. Platelet-rich plasma stimulates cell proliferation and enhances matrix gene expression and synthesis in tenocytes from human rotator cuff tendons with degenerative tears. Am J Sports Med 2012; 40: 1035–45.
  7. Carofino B, Chowaniec DM,McCarthy MB, et al. Corticosteroids and local anesthetics decrease positive effects of platelet-rich plasma: an in vitro study on human tendon cells. Arthroscopy 2012; 28: 711–9.
  8. Creaney L, Wallace A, Curtis M, et al. Growth factor-based therapies provide additional benefit beyond physical therapy in resistant elbow tendinopathy: a prospective, single-blind, randomised trial of autologous blood injections versus platelet-rich plasma injections. Br J Sports Med 2011; 45: 966–71.
  9. de Vos RJ1, Windt J, Weir A. Strong evidence against platelet-rich plasma injections for chronic lateral epicondylar tendinopathy: a systematic review. Br J Sports Med 2014; 48: 952–6.
  10. de Vos RJ, Weir A, van Schie HT, et al. Platelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial. JAMA 2010; 303: 144–9.
  11. de Vos RJ, Weir A, Tol JL, et al. No effects of PRP on ultrasonographic tendon structure and neovascularisation in chronic midportion Achilles tendinopathy. Br J Sports Med 2011; 45: 387–92.
  12. Gaweda K, Tarczynska M, Krzyzanowski W. Treatment of Achilles tendinopathy with platelet-rich plasma. Int J Sport Med 2010; 31: 577–83.
  13. Kon E, Filardo G, Delcogliano M, et al. Platelet-rich plasma: new clinical application: a pilot study for treatment of jumper’s knee. Injury 2009; 40: 598–603.
  14. Filardo G, Kon E, Della Villa S, et al. Use of platelet-rich plasma for the treatment of refractory jumper’s knee. Int Orthop 2010; 34: 909–15.
  15. Vetrano M, Castorina A, Vulpiani MC, et al. Platelet-rich plasma versus focused shock waves in the treatment of jumper’s knee in athletes. Am J Sports Med 2013; 41: 795–803.
  16. Smith J, Sellon JL. Comparing PRP injections with ESWT for athletes with chronic patellar tendinopathy. Clin J Sport Med 2014; 24: 88–9.
  17. Randelli P, Arrigoni P, Ragone V, et al. Platelet rich plasma in arthroscopic rota- tor cuff repair: a prospective RCT study, 2-year follow-up. J Shoulder Elbow Surg 2011; 20: 518–28.
  18. Castricini R, Longo UG, De Benedetto M, et al. Platelet-rich plasma augmentation for arthroscopic rotator cuff repair: a randomized controlled trial. Am J Sport Med 2011; 39: 258–65.
  19. Molloy T,WangY, Murrell G. The roles of growth factors in tendon and ligament healing. Sports Med 2003; 33: 381–94.