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).
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). 

Rotator Cuff 3 - Patterns of tearing

In partial thickness cuff tears loss of some of the tendon fibers reduces the ability of the attached muscle fibers to deliver force to the bone.  This disruption typically starts on the deep surface of the cuff.

, but may also occur within the tendon

or on the bursal side.  

Partial tears may be accompanied by avulsion of a piece of the greater tuberosity

 A thinned tendon contains fewer fibers than one of normal thickness; thus, a muscle with a thinned tendon has lost the optimal attachment of its contractile elements and increasing load is placed on the remaining fibers

Partial tendon tears can also prevent effective use of the muscle by producing pain on muscle contraction.  In this respect a partial thickness cuff tear resembles a tennis elbow, a condition in which the extensor carpi radialis brevis is partially torn from the latter epicondyle.  Contraction of the muscle produces pain at the tendon attachment to bone.  This condition is also similar to partial thickness tears at the insertion of the Achilles and patellar tendons.  While these conditions are often thought to be inflammatory (“tendonitis”), the problem is actually mechanical. When a tendon is partially torn, there is disproportionate load on the fibers at the edge of the tear – like when a zipper is pulled open, or like a nylon stocking developing a run in it, or like a piece of paper that is partially torn – the load is on the connection adjacent to the tear.  This force concentration is sometimes referred to as the ‘notch’ phenomenon – a mechanism by which partial tears can propagate progressively

This progressive tendon tearing is often progressive, each step in the progression may be interpreted as episodes of ‘tendonitis’ until it is recognized that the problem is a cuff tear.

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How you can support research in shoulder surgery Click on this link.

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).