Platelet-Rich Plasma Injections in the Treatment of Chronic Rotator Cuff Tendinopathy: A Randomized Controlled Trial With 1-Year Follow-up.
Kesikburun S, Kenan Tan A, Yılmaz B, Yaşar E, Yazıcıoğlu K. Am J Sports Med July 26, 2013; published online before print July 26, 2013, doi:10.1177/0363546513496542
Take Home Message: Despite its popularity as a promising new treatment option, the use of PRP injection for rotator cuff tendinopathy did not result in improved pain or functional outcome when compared to placebo injection.
The treatment of rotator cuff tendinopathy without complete a rotator cuff tear – a common cause of shoulder pain – includes rest, avoidance of aggravating activities, physical therapy, anti-inflammatory medications, and corticosteroid injections. It is hypothesized that platelet-rich plasma (PRP) could help reverse the degenerative changes and regenerate normal tendon tissue, which is something current treatments (e.g., rehabilitation) can’t do. However, we have little evidence to support the clinical use of PRP for chronic rotator cuff tendinopathy. In this double-blinded randomized clinical trial, the authors compared a subacromial injection of PRP to an injection of saline placebo for the management of symptomatic rotator cuff tendinopathy. A patient with shoulder pain was assessed and included in the study if he/she had chronic pain in the shoulder exacerbated by overhead-throwing activities, tenderness to palpation of the rotator cuff insertion site at the proximal humerus, decreased shoulder range of motion, and tendinosis or partial tearing on magnetic resonance imaging, no other shoulder disorders that could be the source of shoulder pain, no history of corticosteroid injections within 6 weeks prior to enrollment, and no NSAID use within the week prior to the study. The authors randomly assigned 40 patients (18-70 years old) to one of 2 groups: 20 patients received a PRP injection and 20 patients received a placebo injection of normal saline. To keep the authors and patients blinded 5 mL solutions of either PRP or saline were placed in covered syringes. The same physician performed all of the ultrasound-guided injections in the subacromial space near the center of the rotator cuff tendinopathy and at 4 sites around it. Each patient began a formal 3-week rehabilitation program and then transitioned to a home program for an additional 3 weeks. The authors assessed shoulder symptoms, disability, pain, and passive range of motion at baseline, 3 weeks, 6 weeks, 12 weeks, 24 weeks, and 1 year after the injection. Both treatment groups improved over time and there was no difference between patients receiving PRP or placebo. The authors reported no adverse events with the exception of some temporary local inflammatory reactions to the injections.
PRP injections have been gaining popularity as a possible treatment for tendinopathy in various anatomic locations. Although it had some early positive outcomes in a few treatment studies for chronic elbow tendinopathy, patellar tendinosis, rotator cuff surgery, and acute Achilles tendon repair the results have been less clear since. Recent studies indicate that the therapeutic benefit of PRP may be related to the type of PRP preparation, the duration of symptoms, the anatomic location or loading on a tendon, and when the patient is evaluated after the injection (see related posts below). Therefore, it is hard to generalize this study’s results because they are based on a single injection of a specific PRP preparation among patients with chronic rotator cuff tendinopathy. Furthermore, in this study, it remains unclear if the improvement was from the injections or the exercises the patients were prescribed. When we advise our patients we may want to try therapeutic exercise and with PRP we should consider the evidence specific to the patient’s treatment (e.g., type of PRP preparation, anatomical location, duration of symptoms). In summary, a single injection of PRP for chronic rotator cuff tendinopathy is no better than using a placebo injection.
Questions for Discussion: Have you used PRP injections in practice? What were the results? Would you consider using PRP for chronic rotator cuff tendinopathy? If used in your practice, did it take more than one treatment to obtain satisfying results?
Written by: Michelle Noreski and Marc Harwood
Reviewed by: Jeffrey Driban
Kesikburun S, Tan AK, Yilmaz B, Yasar E, & Yazicioglu K (2013). Platelet-Rich Plasma Injections in the Treatment of Chronic Rotator Cuff Tendinopathy: A Randomized Controlled Trial With 1-Year Follow-up. The American journal of sports medicine PMID: 23893418