Rotator cuff tears and tendinopathy - Is platelet rich plasma (PRP) helpful? Read this important updated version.

A review of published randomized trials and meta-analyses indicates that non-operative treatment is effective for the majority of patients with conditions of the rotator cuff, including rotator cuff tears.

Local corticosteroid injections are sometimes used in non-operative treatment, however they apparently have no biologic effect in terms of regenerating or reversing the degenerative changes occurring in rotator cuff tendons and their clinical benefit usually wears off quickly.

It has been suggested that local injection of platelet-rich plasma (PRP) may promote stem and progenitor cell proliferation, modulate inflammatory responses, stimulate angiogenesis, enhance the proliferation of tenocytes, stimulate the production of extracellular matrix proteins, protect against oxidative stress, and inhibit inflammation (see Platelet-Rich Plasma in Orthopaedic Surgery: A Critical Analysis Review) and that these effects may benefit patients with rotator cuff tendinopathies before structural failure of the rotator cuff occurs. 

 The authors of Subacromial injection of platelet-rich plasma provides greater improvement in pain and functional outcomes compared to corticosteroids at 1-year follow-up: a double-blinded randomized controlled trial attempted to answer this question in a randomized clinical trial of patients between 18 and 50 years old (mean age 28 years) who had both a clinical and magnetic resonance imaging diagnosis of supraspinatus tendinopathy refractory to conservative treatment. 

A total of 50 patients received a single subacromial injection of PRP, whereas 50 patients received a single subacromial corticosteroid injection. All the patients completed 12 months of clinical follow-up. 

At 12 months, in comparison to the those receiving cortisone, patients in the PRP group showed a significantly greater improvement in 

the VAS score: 1.68 vs. 2.3

the American Shoulder and Elbow Surgeons (ASES) score, 89.8  vs. 78.0 

the Single Assessment Numeric Evaluation (SANE) score, 89.2 vs. 80.5 

and the the Pittsburgh Sleep Quality Index (PSQI) score, 2.72 vs. 4.02 

The overall failure rate was significantly higher in the corticosteroid group (30%) than in the PRP group (12%) (P < .01).

It was particularly interesting to note that the difference in the course of the two groups was not evident until 6 months after the injection. As Michael Pearl pointed out, it is possible that the PRP folks would have gotten better anyway (i.e. the PRP may not have had an effect). We'd need a saline injected control arm to examine that possibility.

It does seem that the corticosteroid injected group tended to do less well with time and their greater failure rate may be related to the adverse effects of cortisone on tendons. As Dr Pearl says "An alternative explanation could be that cortisone is deleterious and the PRP less interfered with the natural history.  " 

It is notable that the ASES score difference between 3 and 12 months (85 to 90) does not exceed the minimal clinically important difference for ASES of 15. 

Comment: This double blinded randomized clinical trial showed that young patients with rotator cuff tendinosis having subacromial injection of PRP did better than comparable patients having subacromial injection of cortisone. It does not show that patients having subacromial injection of PRP would do better than those with no treatment or with a placebo control. Keep in mind that these patients had an average age of 28, folks who have a lot of potential for recovery with time and rehab.

A possible benefit of PRP in cuff tendinosis cannot be extrapolated to the treatment of cuff tendons with structural failure, as demonstrated by the authors of Subacromial Platelet-Rich Plasma Injections Produce Significantly Worse Improvement in Functional Outcomes in Patients With Partial Supraspinatus Tears Than in Patients With Isolated Tendinopathy who found that  improvement in the ASES score was significantly greater in the group without tears than in the group with partial cuff tears (PTRCTs) at all follow-up times. 94% of the patients in the isolated tendinopathy group but less than half of patients in the PTRCTs group achieved a substantial clinical benefit at 12 months follow-up. 

Furthermore, a review of published randomized controlled trials and meta-analyses failed to demonstrate a clinically significant benefit to the patient of the use of PRP in conjunction with surgical repair of a torn rotator cuff.

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
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The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link). 

Platelet rich plasma (PRP) and the rotator cuff - what patients should know

While arthroscopic rotator cuff repair is one of the commonest of all shoulder procedures, the postoperative re-tear rate ranges between 9% and 94% despite intensive exploration of surgical techniques and adjunctive therapies. Investigators have explored the use of growth factors - in particular, platelet-rich plasma (PRP) - with the hope of inducing a faster and better healing of the repaired tendon tissue.

The authors of Platelet-Rich Plasma in Arthroscopic Rotator Cuff Repair: Clinical and Radiological Results of a Prospective Randomized Controlled Trial Study at 10-Year Follow-Up sought to compare, at 10-year follow-up, the clinical and radiological outcomes of arthroscopic rotator cuff repair with or without the addition of platelet-rich plasma (PRP) over the tendon-bone interface at the end of
the surgical procedure.

Patients were randomly divided into 2 groups: 26 received PRP and 27 served as controls. 38 (71%) patients (median age 71 years) were re-evaluated at least 10 years after the index procedure performed by an individual highly experienced surgeon. The patients in the two groups were similar.

The clinical outcomes were not better for the shoulders receiving PRP



While the mean ASES score was higher for the PRP group (100) than for the non-PRP group (93), the difference did not approach clinical significance (see Establishing clinically significant outcome after arthroscopic rotator cuff repair).

On average, 37% of the operated patients had a re-rupture on ultrasound examination, regardless of whether PRP was used or not (PRP group: 35%; control group: 38%; P . 1.0000).

Interestingly, the clinical outcomes were essentially the same whether the repair remained intact or not.


While the average Constant score was higher for patients with intact cuffs in comparison to those with re-tears, the difference failed to reach clinical significance (see Investigating minimal clinically important difference for Constant score in patients undergoing rotator cuff surgery).

The authors concluded that in comparison to patients not receiving PRP, patients treated with PRP did not have better clinical outcomes and did not have lower re-tear rates of the repaired tendons. These finding are similar to those reported by the authors of The clinical efficacy of leukocyte-poor platelet-rich plasma in arthroscopic rotator cuff repair: a meta-analysis of randomized controlled trials in which the clinical effects of PRP failed to reach clinical significance.

Comment: PRP can be an expensive adjunct to rotator cuff repair and the expense may not be covered by the patient's insurance. Further evidence is needed to support the value (benefit/cost) of PRP as an adjunct to rotator cuff repair. 

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

Does platelet rich plasma significantly improve patient outcomes for rotator cuff repair?

The clinical efficacy of leukocyte-poor platelet-rich plasma in arthroscopic rotator cuff repair: a meta-analysis of randomized controlled trials

These authors performed a meta-analysis of 10 randomized controlled trials (RCTs) involving 742 patients to evaluate whether leucocyte-poor PRP significantly affects the outcomes of arthroscopic rotator cuff repair.

The meta-analysis showed that in comparison to controls, treatment with leukocyte-poor PRP was associated with 

(1) statistically significantly less postoperative pain than the control in the short-term and long-term, however, the changes in

the VAS were below the MCID. 

(2) statistically significantly higher patient reported outcomes, however, the changes in the Constant and UCLA scores were below the MCID.

(3) statistically lower rates of retears 

The authors concluded that "leukocyte-poor PRP is associated with lower retear rates in the medium and long term regardless of the tear size and methods used for rotator cuff repair. However, the use of leukocyte-poor PRP in terms of postoperative pain and patient reported outcomes failed to show clinically meaningful effects."

Comment: We should consider how to best assess the value (benefit to the patient/cost) of leukocyte-poor PRP. 

This quote from a PRP vendor (see this link) is of interest:

"We make no bones about promoting platelet-rich plasma (PRP) therapy as a way of increasing revenues and expanding a medical practice. Both PRP and stem cell therapies are gaining wider acceptance along with a growing body of evidence proving their effectiveness. But there is an elephant in the room that, unfortunately, is hindering the growth of PRP therapy in this country. That elephant is disguised as America’s insurance companies.

It is no secret that health insurance providers are not convinced of the efficacy or usefulness of PRP therapy. That, despite growing demand for PRP therapy training among doctors looking to meet increasing demand among patients. It is also no secret that the vast majority of patients who inquire about PRP therapy never go through with it after they find out they have to pay out of pocket."

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Are injections good for arthritis?

Injectable Biological Treatments for Osteoarthritis of the Knee

These authors reviewed the highly controversial topic of injectable biologic treatments for arthritis. 

Here are their conclusions:

 (1) platelet-rich plasma may provide symptomatic relief on a short-term basis, but long-term data are lacking on the effectiveness of PRP in changing the course of arthritis.

(2) stem cell therapy may provide symptomatic relief on a short-term basis, however it is unclear how to direct these cells to form useful new cartilage in an arthritic joint. 

See related post: Is there such a thing as injection arthropathy? which includes theAAOS recommendations on the use of injections.

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Is platelet-rich plasma (PRP) good for rotator cuff tendons?

Platelet-Rich Plasma Injection With Arthroscopic Acromioplasty for Chronic Rotator Cuff Tendinopathy

These authors conducted a Level 1 randomized controlled trial to investigate the effects of platelet-rich plasma (PRP) injection in patients with chronic rotator cuff tendinopathy.

60 patients (55% women) aged between 35 and 75 years with cuff tendinopathy but without full thickness cuff tears were randomized to arthroscopic acromioplasty alone or acromioplasty in combination with an injection of autologous PRP into the subacromial bursa. The autologous leucocyte-rich PRP and thrombin were prepared with the Magellan Autologous Platelet Separator System. From 50 mL of whole venous blood, approximately 5 mL of PRP and 1 mL of thrombin were collected. The PRP injection needle was placed into the subacromial space (bursa) under arthroscopic
guidance to confirm correct location. The PRP was injected into the subacromial space with dual syringes after the acromioplasty had been performed and the arthroscopic portals had been closed to prevent escape of the PRP injection.

Tendon biopsy specimens were taken for histology from approximately 5 to 10 mm posterior to the anterior edge of the supraspinatus tendon  at baseline during the surgical procedure and at the 3-month follow-up visit under ultrasound guidance.

There was no significant difference in the Oxford Shoulder Score between the two groups at any time point in the study. 

The number of blood vessels and tendon cellularity were significantly decreased in tissue biopsy specimens taken from PRP-treated patients. The expression of p53-positive apoptotic cells increased in shoulders having PRP but decreased in the controls. The authors concluded that PRP significantly altered the tissue characteristics in tendons after surgery with reduced cellularity and vascularity and increased levels of apoptosis.

Comment: This high level study did not show a clinical benefit of PRP and appears to demonstrate a biological effect of PRP that may be detrimental to the quality of the cuff tendon. Other posts on PRP and the rotator cuff can be found here and here and here, none of which shows a benefit.

In New York, single PRP injection has been estimated to cost $1000 and is often not covered by insurance. If we divide the benefit by the cost, the value of this treatment so far seems vanishingly small.

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Rotator cuff repair - effect of platelet rich plasma

Efficacy of platelet-rich plasma in arthroscopic repair of full-thickness rotator cuff tears: a meta-analysis.

These authors used a systematic review to compare the clinical improvement and tendon-to-bone healing with and without platelet-rich plasma (PRP)* therapy in arthroscopic rotator cuff repair. They reviewed clinical scores such as the Constant score, the American Shoulder and Elbow Surgeons score, the University of California at Los Angeles (UCLA) Shoulder Rating Scale, the Simple Shoulder Test, and the failure-to-heal rate by magnetic resonance imaging between PRP+ and PRP- groups. The five included studies were randomized controlled trials with a high level of methodologic quality in which 303 patients were enrolled.

Their analysis of the five Level I studies found no statistically significant differences between PRP+ and PRP- groups for overall outcome scores (P > .05). However, the PRP+ group exhibited better healing rates postoperatively than the PRP- group (P = .03) in small/moderate full-thickness tears  but there was no difference in severe-to-massive tears.

* a sample of autologous blood with concentrations of platelets above baseline values

Comment: There continues to be major interest in the use of platelet-rich plasma to augment the healing of soft tissue repairs. This is a carefully done study of five high-quality randomized trials. As we've seen before, the results suggest that cuff integrity after repair does not correlate well with the clinical course after attempted cuff repair.

The manuscript does not present data on the incremental cost of PRP treatment.

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Platelet-Rich Plasma (PRP): failure to make a difference

Platelet-Rich Plasma Injections in the Treatment of Chronic Rotator Cuff Tendinopathy A Randomized Controlled Trial With 1-Year Follow-up

There is a lot of interest in platelet-rich plasma (PRP) as a treatment of rotator cuff tear pathologies.

Even our own Academy states "Treatment with platelet-rich plasma holds great promise. Currently, however, the research studies to back up the claims in the media are lacking. Although PRP does appear to be effective in the treatment of chronic tendon injuries about the elbow, the medical community needs more scientific evidence before it can determine whether PRP therapy is truly effective in other conditions.   Even though the success of PRP therapy is still questionable,...."

These authors conducted a Level 1 randomized controlled trial of 40 patients, 18 to 70 years of age, with (1) a history of shoulder pain for >3 months during overhead-throwing activities, (2) MRI findings of RCT or partial tendon ruptures, and (3) a minimum 50% reduction in shoulder pain with subacromial injections of an anesthetic. Patients were randomized into a PRP group (n = 20) or placebo group (n = 20). Patients received an ultrasound-guided injection into the subacromial space that contained either 5 mL of PRP prepared from autologous venous blood or 5 mL of saline solution. All patients underwent a 6-week standard exercise program. 

While both the treatment and control groups showed significant improvements compared with baseline at all time points, comparison of the patients revealed no significant difference between the treatment and control groups in WORC, SPADI, and VAS scores at 1-year follow-up. The authors concluded that at 1-year follow-up, a PRP injection was found to be no more effective in improving quality of life, pain, disability, and shoulder range of motion than placebo in patients with chronic RCT who were treated with an exercise program.

Comment: the key finding here is that the placebo group improved as much as the PRP group, so claims that 'the patient got better after PRP, does not prove that PRP was effective.

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platelet-rich plasma - is this evidence?

Clinical and MRI Outcomes After Platelet-Rich Plasma Treatment for Knee Osteoarthritis


The stated purpose of this study was to investigate whether  platelet-rich plasma therapy for early knee osteoarthritis is associated with good clinical outcomes and a change in magnetic resonance imaging (MRI) structural appearances. 22 patients were treated with platelet-rich plasma for early osteoarthritis, confirmed with a baseline MRI. All the patients received a platelet-rich plasma injection.

At 1 year, 12 of the 15 knees available did not show MRI progression. Functional scores improved over baseline.

As the authors point out, this study is limited by the absence of a control group and the number of patients lost to followup. These limitations are important because of the high degree of variability in the clinical management of knee arthritis. It is also not clear what other treatments (medication, physical therapy, etc) these patients may have received. 

Blinding is often difficult in orthopaedic clinical research, for example when comparing operative and non-operative management. However, with a study on injection therapy, a standard randomized control trial with blinding of the observers of the outcome to the method of treatment is straightforward.

We don't find that this study provides evidence supporting the use of PRP in the management of arthritis.

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Platelet-rich plasma - does it help healing?

Patellar tendon healing with platelet-rich plasma: a prospective randomized controlled trial.

The authors proposed to test the hypothesis that adding PRP to the patellar tendon harvest site would improve donor site healing and improve clinical outcome at 6 months after anterior cruciate ligament reconstruction with a patellar tendon graft. They randomly divided 27 patients to receive or not receive PRP in the patellar tendon harvest site during ACL reconstruction. The primary outcome was magnetic resonance imaging assessment of 'patellar tendon healing' (gap area) after 6 months. Secondary outcomes were questionnaires and isokinetic testing of ACL reconstruction with a patellar tendon graft comparing both groups.

They found that patellar tendon gap area was smaller in the PRP group (4.9 ± 5.3 mm(2);  than in the control group (9.4 ± 4.4 mm(2);  P = .046).  There were no differences after 6 months in questionnaire and isokinetic testing results comparing both groups.

The authors concluded that PRP had a positive effect on patellar tendon harvest site healing on MRI after 6 months.

Comment: There is much interest in “PRP” as an agent to accelerate and enhance healing. There is also great commercial interest in this “biologic” therapy. In this study the authors randomized the harvest site of bone-patellar-bone graft taken for ACL reconstruction into one group receiving 20-40 mL of PRP gel and the other group receiving nothing. The MRI’s showed a marginally significant decrease in ‘gap area’ by MRI but no difference in cross sectional area. The authors concluded that “the addition of platelet-rich plasma to the patellar tendon harvest site improved tissue-healing at the patellar tendon donor site.” There was no difference in knee function scores or in the isokinetic testing results. 

Taken as presented, there was no apparent functional benefit of the PRP. Furthermore, it is unclear that the reduced ‘gap area’ represented improved healing, or instead a filling in of the MRI defect with non-functional reactive tissue in response to the gel: the controls did not include a gel without PRP.

Once again, we have the value question: from the data presented, it is not clear that the cost of PRP is justified by the benefit.

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Efficacy of Autologous Platelet-Rich Plasma Use for Orthopaedic Indications JBJS

Two recent JBJS publications, Efficacy of Autologous Platelet-Rich Plasma Use for Orthopaedic Indications: A Meta-Analysis and Platelet-Rich Plasma Differs According to Preparation Method and Human Variability are relevant to the rapidly increasing interest in PRP for the management of musculoskeletal disorders. In short, the first article reports that in spite of 33 high quality studies, there remains uncertainty about the effectiveness of PRP in the management of disorders such as rotator cuff injuries - basically, the results were just too variable to determine if there was or was not a beneficial effect.

The second article indicates that the different preparations of PRP are quite variable.

We'll have to continue to observe this evolving area to see what sorts out as more high quality studies with the different preparations become available. 

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