The Use of Platelet-rich Plasma in Sports Injuries

Vikram Chatrath, MS, MCh
Orthopaedic Fellow, Halifax Infirmary

Ivan Wong, M.D., FRCSC, Dip. Sports Medicine
Assistant Professor, Dalhousie University
Halifax, NS

Platelet-rich plasma (PRP) is an exciting and relatively new technique, which has gained a lot of interest recently for the treatment of sports injuries. PRP  is obtained by centrifuging a sample of the patient's own blood to obtain a concentrate of platelets in a small volume of plasma. This preparation can then be administered locally with the objective of allowing the growth factors released by the platelets to assist tissue healing.

The application of PRP works by a dual action. The activated platelets and associated growth factors amplify the release of various chemical mediators. This helps promote neovascularization, fibroblast and tenocyte proliferation1,2 resembling an inflammatory response1,3. The second role involves suppression of IL-1 (released from activated macrophages and inhibitory to early stages of healing)4 and a possible antibacterial action5. This property of accelerating tissue healing, especially for relatively avascular tissues like tendons and ligaments, offers a plethora of applications in sports medicine.

The preparation methods vary greatly usually involving 1-2 cycles of centrifugation. This may be followed by platelet activation prior to application6. The various commercially available preparations7 differ in their method of isolation, function and type of collecting tube and centrifuge speed which result in varying overall volume, platelet numbers, residual white and red blood cells and quantities of growth factors8. There is strong in-vitro evidence to support the positive effect of PRP in tendon and cartilage9 healing and repair. It is imperative to choose and further refine the ideal preparation and delivery method so that we are able to maximize the benefits of PRP in-vivo as well.

Marx10 has defined clinically-active PRP as having at least four times the normal platelet concentration; however, efficacy of PRP has been demonstrated with less concentrated preparations11. A recent meta-analysis concluded12 that there is a marked variability among different platelet preparations, dosages, outcome measures and even indications for use. This makes it very difficult to draw conclusions from the available literature. Some analyses13,14 report that the use of PRP did not make any difference to clinical outcomes for a variety of orthopaedic conditions. This again highlights that poor results can be an outcome of different PRP formulations and application procedures.

Studies have demonstrated the successful use of PRP as an adjunct in the treatment of rotator cuff pathology15,16,17, elbow tendinosis18,19, patellar tendinosis20 and surgical repair of Achilles tendon injuries21,22,23. Of these, the most compelling evidence is available about the beneficial role of PRP in treating elbow tendinosis18,19,24,25. These studies have demonstrated faster recovery with less pain medication requirement, greater range of motion, and greater ability to perform activities of daily living. Corticosteroid injections have been commonly used to treat these pathologies, but their action tends to be short-lived and relapse is frequent26. PRP can potentially be an ideal autologous alternative for these as their "tendon-healing" properties observed in basic science studies27,28 may be very helpful for tendon-related pathologies. Halpern et al.29 have postulated that PRP may rebalance the "healing" equation by promoting formation of the stronger type I collagen rather than type III collagen. Even in the absence of structural or functional improvements, PRP is often associated with a reduced need for narcotics, better sleep, and reduced perception of pain29. A recent randomized single-blinded trial17 demonstrated a decreased re-tear rate and increased cross sectional area of the supraspinatus with PRP gel application [Table 1]. Other areas where PRP has been used include30: improving bone-tendon healing after ACL reconstruction, healing of osetochondral defects31, plantar fasciitis32, knee osteoarthritis33, 34 and muscle injuries24. The aforementioned reports suggest the various possible ways in which PRP may be helpful in sports medicine. An interesting comment in the 2010 International Olympic Committee consensus paper35 notes, that although more studies are needed to prove the "beneficence" (doing good) of PRP, the principle of non-maleficence (do no harm) is upheld with its use. It has been suggested that the efficacy of PRP can be enhanced by ultrasound-guided injection of the lesion36.

Table 1

wong_table

KJOC: Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow
VAS: Visual Analogue Scale
UCLA: University of California at Los Angeles
AOFAS: American Orthopaedic Foot and Ankle Society
VISA-A: Victorian Institute of Sports Assessment-Achilles
PDUS: Power Doppler ultrasonography
Dash: Disabilities of the Arm, Shoulder and Hand

With the introduction of every new technology, it's natural for safety concerns to be expressed before its widespread acceptance. To date, no adverse events or deleterious effects on recovery or functional outcome have been documented6. No systemic effects on the level of circulating cytokines or GFs have been demonstrated so far37; this is helpful to reduce the fear of carcinogenic effects of GHs. Nevertheless, further studies are needed to demonstrate safety of PRP for human use.

The current literature is comprised of different kinds of studies and is not necessarily Level 1 evidence. This, although not conclusive, suggests that PRP may have a role in faster recovery, better functional outcomes and early return to sports from the patient's perspective15-25. For the orthopaedic surgeon, the use of PRP is a relatively straightforward procedure to learn and perform. It adds to our armamentarium in treating rotator cuffs, elbow and patellar tendinitis and Achilles ruptures. These common pathologies are not only treated by the sports surgeon but by general orthopaedic surgeons as well. Further ongoing research will help clarify the ideal indications and method of preparation for this exciting technology.

References

  1. Pietrzak W.S., Eppley B.L. Platelet rich plasma: biology and new technology. J Craniofac Surg. 2005;16:1043-1054.
  2. Sharma P., Maffulli N. Tendon injury and tendinopathy: healing and repair. J Bone Joint Surg Am. 2005;87:187-202.
  3. Woodell-May J., Pietrzak W. Platelet-rich plasma in orthopaedics. In: Pietrzak W., ed. Musculoskeletal Tissue Regeneration. Totowa, NJ: Humana Press; 2008:547-568.
  4. Woodall J. Jr, Tucci M., Mishra A., et al. Cellular effects of platelet rich plasma interleukin1 release from PRP treated macrophages. Biomed SciInstrum. 2008;44:489-494.
  5. Bielecki T.M., Gazdzik T.S., Arendt J., Szczepanski T., Król W., Wielkoszynski T.: Antibacterial effect of autologous platelet gel enriched with growth factors and other active substances: An in vitro study. J Bone Joint Surg Br 2007;89:417-420.
  6. Taylor D.W., Petrera M., Hendry M., Theodoropoulos J.S. A systematic review of the use of platelet-rich plasma in sports medicine as a new treatment for tendon and ligament injuries. Clin J Sport Med. 2011 Jul;21(4):344-52.
  7. Castillo T.N., Pouliot M.A., Kim H.J., Dragoo J.L. Comparison of growth factor and platelet concentration from commercial platelet-rich plasma separation systems. Am J Sports Med. 2011;39:266-71.
  8. Mazzocca A.D., McCarthy M.B., Chowaniec D.M., Cote M.P., Romeo A.A., Bradley J.P., Arciero J.P., Arciero R.A., Beitzel K. Platelet-rich plasma differs according to preparation method and human variability. J Bone Joint Surg Am. 2012 Feb 15;94(4):308-16.
  9. Smyth N.A., Murawski C.D., Fortier L.A., Cole B.J., Kennedy J.G.. Platelet-rich plasma in the pathologic processes of cartilage: review of basic science evidence. Arthroscopy. 2013 Aug;29(8):1399-409.
  10. Marx R.E.: Platelet-rich plasma: Evidence to support its use. J Oral Maxillofac Surg 2004;62:489-496.
  11. Eppley B.L., Woodell J.E., Higgins J.: Platelet quantification and growth factor analysis from platelet-rich plasma: Implications for wound healing. Plast Reconstr Surg 2004;114:1502-1508.
  12. Sheth U., Simunovic N., Klein G., Fu F., Einhorn T.A., Schemitsch E., Ayeni O.R., Bhandari M. Efficacy of autologous platelet-rich plasma use for orthopaedic indications: a meta-analysis. J Bone Joint Surg Am. 2012 Feb 15;94(4):298-307.
  13. Chahal J., Van Thiel G.S., Mall N., Heard W., Bach B.R., Cole B.J., Nicholson G.P., Verma N.N., Whelan D.B., Romeo A.A. The role of platelet-rich plasma in arthroscopic rotator cuff repair: a systematic review with quantitative synthesis. Arthroscopy. 2012 Nov;28(11):1718-27.
  14. Redler L.H., Thompson S.A., Hsu S.H., Ahmad C.S., Levine W.N. Platelet-rich plasma therapy: a systematic literature review and evidence for clinical use. Phys Sportsmed. 2011 Feb;39(1):42-51.
  15. Maniscalco P., Gambera D., Lunati A., et al. The ‘‘Cascade'' membrane: a new PRP device for tendon ruptures. Description and case report on rotator cuff tendon. Acta Biomed. 2008;79:223-226.
  16. Randelli P.S., Arrigoni P., Cabitza P., et al. Autologous platelet rich plasma for arthroscopic rotator cuff repair. A pilot study. Disabil Rehabil. 2008; 30:1584-1589.
  17. Jo C.H., Shin J.S., Lee Y.G., Shin W.H., Kim H., Lee S.Y., Yoon K.S., Shin S. Platelet-Rich Plasma for Arthroscopic Repair of Large to Massive Rotator Cuff Tears: A Randomized, Single-Blind, Parallel-Group Trial. Am J Sports Med. 2013 Aug 6
  18. Mishra A., Pavelko T. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Am J Sports Med. 2006;34:1774-1778.
  19. Peerbooms J.C., Sluimer J., Bruijn D.J., et al. Platelet-rich plasma versus corticosteroid injection with a 1-year follow-up. Am J Sports Med. 2010; 38:255-262.
  20. 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.
  21. Sanchez M., Anitua E., Azofra J., et al. Comparison of surgically repaired Achilles tendon tears using platelet-rich fibrin matrices. Am J Sports Med. 2007;35:245-251.
  22. Sanchez M., Anitua E., Cole A., et al. Management of post-surgical Achilles tendon complications with a preparation rich in growth factors: a study of two-cases. Injury Extra. 2009;40:11-15.
  23. Gaweda K., Tarczynska M., Krzyzanowski W. Treatment of Achilles tendinopathy with platelet-rich plasma. Int J Sports Med. 2010;31:577-583.
  24. Mishra A., Woodall J. Jr, Vieira A.: Treatment of tendon and muscle using platelet-rich plasma. Clin Sports Med 2009;28:113-125.
  25. Podesta L., Crow S.A., Volkmer D., Bert T., Yocum L.A. Treatment of partial ulnar collateral ligament tears in the elbow with platelet-rich plasma.. Am J Sports Med. 2013 Jul;41(7):1689-94.
  26. Smidt N., van der Windt D.A., Assendelft W.J., Deville´ W.L., Korthals-de Bos I.B., Bouter L.M. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet. 2002;359:657-662.
  27. Majewski M., Ochsner P.E., Liu F.J., Fluckiger R. and Evans C.H. Accelerated Healing of the Rat Achilles Tendon in Response to Autologous Conditioned Serum. Am J Sports Med. 2009; 37: 2117-2125
  28. Zhang J.Y. and Wang J.H.C. Platelet-Rich Plasma Releasate Promotes Differentiation of Tendon Stem Cells Into Active Tenocytes. Am J Sports Med. 2010; 38: 2477-2486.
  29. Halpern B.C., Chaudhury S., Rodeo S.A. The role of platelet-rich plasma in inducing musculoskeletal tissue healing. HSS J. 2012 Jul;8(2):137-45
  30. Hall M.P., Band P.A., Meislin R.J., Jazrawi L.M., Cardone D.A. Platelet-rich plasma: current concepts and application in sports medicine. J Am Acad Orthop Surg. 2009 Oct;17(10):602-8
  31. Van Pham P., Bui K.H., Ngo D.Q., Vu N.B., Truong N.H., Phan N.L., Le D.M., Duong T.D., Nguyen T.D., Le V.T., Phan N.K. Activated platelet-rich plasma improves adipose-derived stem cell transplantation efficiency in injured articular cartilage. Stem Cell Res Ther. 2013 Aug 1;4(4):91.
  32. Kumar V., Millar T., Murphy P.N., Clough T. The treatment of intractable plantar fasciitis with platelet-rich plasma injection. Foot (Edinb). 2013 Jul 29
  33. Hart R., Safi A., Komzák M., Jajtner P., Puskeiler M., Hartová P. Platelet-rich plasma in patients with tibiofemoral cartilage degeneration. Arch Orthop Trauma Surg. 2013 Jun 5.
  34. Patel S., Dhillon M.S., Aggarwal S., Marwaha N., Jain A.. Treatment with platelet-rich plasma is more effective than placebo for knee osteoarthritis: a prospective, double-blind, randomized trial. Am J Sports Med. 2013 Feb;41(2):356-64. Epub 2013 Jan 8.
  35. Engebretsen L. et al. IOC consensus paper on the use of platelet-rich plasma in sports medicine. Br J Sports Med. 2010; 44: 1072-1081.
  36. Bernuzzi G., Petraglia F., Pedrini M.F., De Filippo M., Pogliacomi F., Verdano M.A., Costantino C. Use of platelet-rich plasma in the care of sports injuries: our experience with ultrasound-guided injection. Blood Transfus. 2013 Jul 3:1-6. [Epub ahead of print].
  37. Banfi G., Corsi M.M., Volpi P. Could platelet rich plasma have effects on systemic circulating growth factors and cytokine release in orthopaedic applications? Br J Sports Med. 2006;40:816.

Submit Community Content

If you have orthopedic information that you would like to share with the Orthogate Community, please register/login and submit your news, event, job, article, case or workshop from the Submit Content menu under the My Account area. Learn more!