PRP for the Treatment of Rotator Cuff Tendinopathy
Platelet rich plasma (PRP) injections have been studied in their role in treating rotator cuff pathology. Rotator cuff pathology can range from tendinopathy to partial thickness tears. Patients with rotator cuff tendonitis typically complain of pain with overhead arm motion, nocturnal pain, and pain that limits their activities of daily living (3). Rotator cuff tendinopathy (RCT) is typically treated first line with physical therapy, NSAIDs, and corticosteroid injection (1). Corticosteroid injections have been shown to release metalloproteinase, which are associated with tendon degeneration (7). The aim of this review is to see if there is evidence for the use of a PRP injection for the treatment of RTC.
The platelets found in PRP will release growth factor that are responsible for cell recruitment, angiogenesis, and possible immunomodulatory effects (2). In recent years, we have aimed at personalizing PRP by controlling the amount of leukocytes that are present and increasing the platelet concentration (1). An issue with studies looking at PRP and RCT is that many do not include platelet counts, so it is hard to generalize the findings (4). It is also important to note that none of the studies reviewed pulled the same amount of blood. In a study in Skeletal Radiology, they pulled 10mL of blood, which led to a doubling in platelet concentration (10). This study did find a statistically significant improvement in pain at one year, but it is uncertain if the response would have been more robust with a higher platelet concentration (10).
A study published in Arthroscopy looked at the role of a subacromial bursa injection with PRP in the treatment of RCT (3). They found at 12 months there were improvements in visual analogue pain score in the PRP group (3). They also found that in patients who had nocturnal pain, it had resolved in 86% after PRP injection (3).
A follow-up study published in Arthroscopy looked at the injection of leukocyte rich PRP into the subacromial bursa in the treatment of RCT and partial thickness rotator cuff tears (2). They found that at 12 months, the group with RCT had statistically significant improvements in pain (2). However, the response to PRP based on the American Shoulder and Elbow Surgeons score was more robust in the RCT group than the partial thickness tear group (2).
Another study published in the Journal of Sports Medicine looked at intra-tendinous injections of PRP or saline for the treatment of RCT and partial thickness rotator cuff tears (6). The injections were performed under ultrasound guidance and the PRP injections were placed within the partial thickness tear and the tendinopathy injection was placed within the center point of the thickened tendon (6). The results of this study did not find a statistically significant effect on pain between PRP and saline (6). This study did not discriminate between tendinosis and partial thickness tearing, which may have led to not finding a statistically significant effect.
In a study published in Sports Medicine, they compared a subacromial corticosteroid injection verse an intra-lesional PRP injection (9). They found that partial thickness rotator cuff tears decreased in size in the PRP group (9). The steroid injection did not lead to an increase or decrease in cuff tear size (9).
To summarize, the data on PRP injections for RCT appears to be positive, but more studies are needed for partial thickness rotator cuff tears. There is also no homogeneity in the studies, as there was variability amongst studies regarding leukocyte count and total platelet concentration. Future studies should compare different platelet concentrations against a placebo.
By Gregory Rubin, DO
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