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19 Sep

Platelet-Rich Plasma Therapy: A Safe and Effective Treatment for Tendon and Ligament Injury

Posted at 19:36h in Platelet-Rich Plasma by
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What is PRP Therapy?

Patients often ask about how platelet-rich plasma (PRP) therapy works and what conditions it can treat. The goal of this regenerative intervention is to jumpstart your body’s own healing capacities in order to facilitate the repair and strengthening of damaged tissues. PRP is safe and effective for treating tendon and ligament injuries, which we will cover in this blog, and also for managing arthritic joints which will be an upcoming topic in our series. 

PRP injections are made from a concentrated solution of the patient’s own blood plasma with platelets isolated from a blood sample drawn in the office. Platelets are the primary source of multiple growth factors and chemokines that induce the healing process and also express chemokine receptors that regulate the inflammatory response (1). Many of the cytokines found in PRP are involved in the signaling pathways that occur naturally during the healing stages of inflammation, cellular proliferation, and subsequent tissue remodeling (3).

 

How is PRP Made?

First, a small sample of your blood is taken and concentrated in a centrifuge machine in a two-step process that eliminates red blood cells and neutrophils. The remaining plasma portion contains a high concentration (8 times that of whole blood) of platelets, rich in growth factors, which is then injected directly into an injured area using ultrasound guidance or fluoroscopic (x-ray) guidance. If you have more questions on what PRP therapy is or what to expect during your first PRP injection, be sure to contact our Board-Certified Physical Medicine and Rehabilitation providers.

 

Tendon and Ligament Pain and Injury

Tendon and ligament injuries commonly occur in athletes and non-athletes alike and across the entire age spectrum. The natural course of these injuries is followed by a typical three-phase healing process: acute inflammation, matrix and cellular proliferation, and, finally, remodeling and maturation of the tissue. (2) During this process, tendons and ligaments can form scars and adhesions that impair the function of the normal structure, which can cause prolonged pain and make the tissue susceptible to re-injury. 

The main cell types in tendons and ligaments are fibroblasts and tenocytes (or tendon fibroblasts), while the main extracellular component is type I collagen. At the cellular level, the repair phase can result in the production of a disorganized matrix of collagen fibers with the production of type III fibers leading to a weaker structure. (1) Additionally, tendons and ligaments tend to have poor vascularization. It is for these reasons that recovery from injuries to these soft tissue structures can make treatment difficult and result in a prolonged and frustrating course for patients.

 

The Role of PRP in the Management of Tendon and Ligament Injury

Multiple studies have shown that PRP stimulates fibroblast and tenocyte proliferation at the site of injury and upregulates type I collagen gene expression, which leads to healing of the tissue with improved biomechanical strength (2). Tendons also include tendon stem cells, which have the ability to regenerate and differentiate into tenocytes. PRP therapy induces the differentiation of these cell populations into tenocytes that produce collagen. Finally, through platelet-derived growth factors and cytokines, PRP stimulates angiogenesis (growth of blood vessels) which brings blood flow to injured tissue and helps mitigate the poor vascularity. 

 

How Safe and Effective Is PRP?

This blog post focuses on PRP’s role in treating acute or chronic tendon and ligament injuries that have resulted in functionally limiting pain unresponsive to other conservative treatments. Many studies have demonstrated a good safety profile for this treatment. A systematic review and meta-analysis assessing PRP for tendon and ligament injuries showed no significant adverse events in the 1937 patients treated with PRP. (12) In addition, a growing body of literature supports the efficacy of PRP for treating tendon and ligament injuries.

 

PRP for Musculoskeletal Conditions – What Do The Studies Show?

Gluteus Medius and Minimus Tendinopathy (aka “hip bursitis”)

A double-blinded, randomized control trial (RCT) including 80 patients showed a single intratendinous PRP injection was superior to corticosteroid injection in regards to improvement of pain and function. This treatment effect was maintained at the final two-year follow-up mark included in the study. (8) 

Lateral Epicondylitis

The efficacy of treatment of this diagnosis has been shown in multiple clinical trials including a large systematic review and meta-analysis that showed a statistically significant improvement in pain, disability scores, and pressure pain threshold when compared to corticosteroid injection. (5) One of the higher-powered studies, a double-blinded study from Mishra et al., shows significant improvement in pain and residual elbow soreness at 24 weeks compared to patients treated with an active control injection of local anesthetic. (4) 

Rotator Cuff Tendinopathy

A recent systematic review and meta-analysis evaluating eight RCTs showed that PRP significantly improved pain outcomes compared to control (saline injection +/- physical therapy) for medium (6 months) and long-term (12 months) pain symptom control. (5) 

Plantar Fasciitis

Multiple prospective case series and RCTs show clinically and statistically significant improvements in heel pain (measured via the visual analogue scale (VAS)), functional outcome scores, and restoration of plantar fascia thickness with a single dose PRP injection compared to steroid injection. Additionally, PRP has few associated serious side effects compared to side effects associated with steroids (rupture or tear of plantar fascia, nerve and muscle injury, and heel fat pad atrophy). (7)

Achilles Tendinopathy

A systematic review including eight RCTs and 526 patients showed a substantial and statistically significant improvement in pain as measured by the VAS at 12 weeks compared to placebo. The study also showed that the PRP treatment group had a higher return to exercise rate and increased thickness of the Achilles tendon at 12 weeks when compared to placebo, however, these trends were not statistically significant. (9)

Patellar Tendonopathy

Meta-analysis including 22 studies and 591 patients demonstrated that PRP injections offer better results after six months of follow-up compared to a control, which was upheld at long-term follow-up. (10)

 

Take Home Point

In summary, the studies consistently show that PRP is a safe and effective treatment for pain and functional limitation related to tendon and ligament injuries. Contact us at Desert Spine and Sports Physicians if you are interested in learning more about this innovative treatment that heals and strengthens musculoskeletal tissue. Our Board-Certified Physical Medicine and Rehabilitation and Fellowship-Trained Interventional Spine and Musculoskeletal Medicine Physicians are the leading experts in the non-operative pain management of tendon and ligament injuries in Arizona, and we look forward to helping you manage your pain and get back in the game. 

Additional Reading

 

 

  1. Yuan T, Zhang CQ, Wang JH. Augmenting tendon and ligament repair with platelet-rich plasma (PRP). Muscles Ligaments Tendons J. 2013 Aug 11;3(3):139-49. PMID: 24367773; PMCID: PMC3838322.
  2. Chalidis B, Givissis P, Papadopoulos P, Pitsilos C. Molecular and Biologic Effects of Platelet-Rich Plasma (PRP) in Ligament and Tendon Healing and Regeneration: A Systematic Review. International Journal of Molecular Sciences. 2023; 24(3):2744. https://doi.org/10.3390/ijms24032744
  3. Le, A.D.K., Enweze, L., DeBaun, M.R. et al. Current Clinical Recommendations for Use of Platelet-Rich Plasma. Curr Rev Musculoskelet Med 11, 624–634 (2018). https://doi.org/10.1007/s12178-018-9527-7
  4. Mishra AK, Skrepnik NV, Edwards SG, Jones GL, Sampson S, Vermillion DA, et al. Efficacy of platelet-rich plasma for chronic tennis elbow: a double-blind, prospective, multicenter, randomized controlled trial of 230 patients. Am J Sports Med. 2014;42:463–71. Large multicenter double-blind randomized controlled trial for PRP and lateral epicondylitis, demonstrating significant symptomatic and functional benefit of PRP injection.
  5. Arirachakaran, A., Sukthuayat, A., Sisayanarane, T. et al. Platelet-rich plasma versus autologous blood versus steroid injection in lateral epicondylitis: systematic review and network meta-analysis. J Orthopaed Traumatol 17, 101–112 (2016). https://doi.org/10.1007/s10195-015-0376-5
  6. A. Hamid MS, Sazlina SG (2021) Platelet-rich plasma for rotator cuff tendinopathy: A systematic review and meta-analysis. PLoS ONE 16(5): e0251111. https://doi.org/10.1371/journal.pone.0251111
  7. Kalia RB, Singh V, Chowdhury N, Jain A, Singh SK, Das L. Role of Platelet Rich Plasma in Chronic Plantar Fasciitis: A Prospective Study. Indian J Orthop. 2020;55(Suppl 1):142-148. Published 2020 Oct 6. doi:10.1007/s43465-020-00261-w
  8. Fitzpatrick J, Bulsara MK, O’Donnell J, Zheng MH. Leucocyte-Rich Platelet-Rich Plasma Treatment of Gluteus Medius and Minimus Tendinopathy: A Double-Blind Randomized Controlled Trial With 2-Year Follow-up. Am J Sports Med. 2019;47(5):1130-1137. doi:10.1177/0363546519826969
  9. Arthur Vithran DT, Xie W, Opoku M, Essien AE, He M, Li Y. The Efficacy of Platelet-Rich Plasma Injection Therapy in the Treatment of Patients with Achilles Tendinopathy: A Systematic Review and Meta-Analysis. Journal of Clinical Medicine. 2023; 12(3):995. https://doi.org/10.3390/jcm12030995
  10. Andriolo L, Altamura SA, Reale D, Candrian C, Zaffagnini S, Filardo G. Nonsurgical Treatments of Patellar Tendinopathy: Multiple Injections of Platelet-Rich Plasma Are a Suitable Option: A Systematic Review and Meta-analysis. The American Journal of Sports Medicine. 2019;47(4):1001-1018. doi:10.1177/0363546518759674
  11. Migliorini F, Driessen A, Quack V, et al. Comparison between intra-articular infiltrations of placebo, steroids, hyaluronic and PRP for knee osteoarthritis: a Bayesian network meta-analysis. Arch Orthop Trauma Surg. 2021;141(9):1473-1490. doi:10.1007/s00402-020-03551-y
  12. Chen X, Jones IA, Park C, Vangsness CT Jr. The Efficacy of Platelet-Rich Plasma on Tendon and Ligament Healing: A Systematic Review and Meta-analysis With Bias Assessment. Am J Sports Med. 2018;46(8):2020-2032. doi:10.1177/0363546517743746
  13. Lim A, Zhu JB, Khanduja V. The Use of Intra-articular Platelet-Rich Plasma as a Therapeutic Intervention for Hip Osteoarthritis: A Systematic Review and Meta-analysis [published online ahead of print, 2022 Jun 7]. Am J Sports Med. 2022;51(9):3635465221095563. doi:10.1177/03635465221095563