Tools for Practice


#244 Injecting Evidence into Platelet-Rich Plasma Injections


CLINICAL QUESTION
How effective is platelet-rich plasma 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 platelet-rich plasma, dry needling, or saline for patients with Achilles tendinopathy, lateral epicondylitis, or rotator cuff tendinopathy.


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EVIDENCE
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 ~$500, not normally covered by insurance.16 

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Author(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.