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#244 Injecting Evidence into Platelet-Rich Plasma Injections


CLINICAL QUESTION
QUESTION CLINIQUE
How effective is platelet-rich plasma for treating Achilles tendinopathy, lateral epicondylitis, and rotator cuff tendinopathy?


BOTTOM LINE
RÉSULTAT FINAL
The best quality evidence shows no difference in pain, function, or return to sport between platelet-rich plasma, dry needling, or saline for patients with Achilles tendinopathy, lateral epicondylitis, or rotator cuff tendinopathy.



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EVIDENCE
DONNÉES PROBANTES
Only patient-important outcomes from randomized, placebo-controlled trials (RCTs) were included.
  • Chronic Achilles Tendinopathy: 
    • 3 RCTs of platelet-rich plasma (PRP) injections versus saline.1-3 
      • Highest quality, double-blind, RCT: 54 patients randomized to one injection of PRP or saline.1 
        • Outcomes at 6, 12, and 24 weeks: No significant differences in pain, function, return to sport, or patient satisfaction.  
    • 2 smaller, unblinded RCTs (24-38 patients) had inconsistent results. 
      • Single injection of PRP versus saline (24 patients):2 
        • No difference in pain at 12 weeks. 
      • Four injections (one every 2 weeks) of PRP or saline (38 patients):3 
        • PRP statistically significantly improved pain on 100-point scale: 
          • At 6 weeks: PRP (37 points), saline (23 points). 
          • At 12 weeks: PRP (41 points), saline (30 points).  
          • At 24 weeks: PRP (37 points), saline (18 points). 
    • Systematic review found similar.4 
  • Chronic Lateral Epicondylitis:   
    • 2 RCTs:5,6  
      • PRP versus saline (60 patients, one injection).5 At 12 weeks:  
        • Pain or function: no difference.  
      • PRP plus dry needle insertion versus dry needle alone (28 patients, two injections 1 month apart).6 At 24 weeks: 
        • Pain: no difference.  
    • Limitations: Treating physician not blinded5, high dropout rate5, small numbers6. 
  • Rotator Cuff Tendinopathy (at least 3 months of symptoms), 2 RCTs7,8 compared to saline (40 patients) or dry needling (39 patients):  
    • No difference in pain or disability scores.  
  • Adverse events (including tendon rupture): none reported.
  • Other systematic reviews included observational studies or other types of tendinopathy.9-11 
Context: 
  • Up to 90% of lateral epicondylitis heal within a year with conservative management.12 
  • Other evidence-based options include:  
    • Corticosteroid injections for lateral epicondylitis or rotator cuff tendinopathy show only short-term benefit.12,13  
    • Physiotherapy and topical nitrates.14  
  • PRP injections require specialized equipment and training.15 
    • Each injection costs ~$500not normally covered by insurance.16 


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Author(s)
Auteur(s)
  • Danielle Perry BScN RN
  • Joey Ton PharmD
  • Michael R Kolber MD CCFP MSc

1. de Vos RJ, Weir A, van Schie HT, et al. JAMA. 2010 Jan; 303(2):144-9.

2. Krogh TP, Ellingsen T, Christensen R, et al. Am J Sports Med. 2016 Aug; 44(8):1990-7.

3. Boesen AP, Hansen R, Boesen MI, et al. Am J Sports Med. 2017 Jul; 45(9):2034-43.

4. Zhang YJ, Xu SZ, Gu PC, et al. Clin Orthop Relat Res. 2018 Aug; 476(8):1633-41.

5. Krogh TP, Fredberg U, Stegaard-Pedersen K, et al. Am J Sports Med. 2013; 41(3):625-35.

6. Stenhouse G, Sookur P, Watson M. Skeletal Radiol. 2013; 42(11):1515-20.

7. Kesikburun S, Tan AK, Yilmaz B, et al. Am J Sports Med. 2013; 41(11):2609-16.

8. Rha DW, Park GY, Kim KY, et al. Clin Rehabil. 2013; 27(2):113-22.

9. Balasubramaniam U, Dissanayake R, Annabell L. Phys Sportsmed. 2015 Jul; 43(3):253-61.

10. Di Matteo B, Filardo G, Kon E, et al. Musculoskelet Surg. 2015 Apr; 99(1):1-9.

11. Fitzpatrick J, Bulsara M, Zheng MH. Am J Sports Med. 2017 Jan; 45(1):226-33.

12. Korownyk C, Allan M. Tools for Practice. Available at: https://gomainpro.ca/wp-content/uploads/tools-for-practice/1432830714_updatedtfp48elbowsteroid.pdf Last accessed: September 6, 2019.

13. Mohamadi A, Chan JJ, Claessen FM, et al. Clin Orthop Relat Res. 2017; 475(1):232-43.

14. Challoumas D, Kirwan PD, Borysov D, et al. Br J Sports Med. 2019 Feb; 53(4):251-262.

15. Kaux JF, Emonds-Alt T. Platelets. 2018 May; 29(3):213-27.

16. Personal communication with administrative staff, Glen Sather Sports Medicine Clinic, May 2019.

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.