Ultrasound guided injections of platelets rich plasma for muscle injury in professional athletes. Comparative study

Case series: effects of platelet-rich plasma (PRP) on the recovery of bilateral muscle injuries after removal of semitendinosus and gracilis grafts in bilateral anterior cruciate ligament (ACL) reconstruction

To assess the healing of acute bilateral muscle injury in cases of bilateral anterior cruciate ligament reconstruction using platelet-rich plasma (PRP) after tendon graft removal. The study included 12 cases of bilateral anterior cruciate ligament reconstruction using semitendinosus and gracilis (STG) grafts. In the right knee, the STG graft was removed, and saline solution was applied; in the left knee, the graft was removed, and PRP was applied. Patients were evaluated using the visual analog scale, pre and postoperative isokinetic tests (5 months), and muscle area analysis. A slight difference in results was observed at 15 and 30 days on the PRP-treated side, but there was no variation in circumference and muscle strength. Due to the small sample size, the study will be continued to increase the number of cases, aiming for the publication of results.

Platelet-Poor versus Platelet-Rich Plasma for the Treatment of Muscle Injuries

ABSTRACT

Muscle injury in sport results in significant lost time and potential for reinjury for athletes. Autologous blood product, namely, platelet-rich plasma (PRP), has been investigated for possible augmentation of the treatment timeline with prevention of reinjury; however, conflicting results have been identified. A growing body of basic science and clinical literature is forming that supports the use of platelet-poor plasma (PPP) for muscle injury. The purpose of this study was to provide a background of the basic science of PRP versus PPP for muscle injury and to identify and review the clinical evidence for both autologous blood products, including the author's clinical experience utilizing the blood products. At the tissue level, PRP causes myoblast proliferation while PPP has led to myoblast induction, potentially identifying improved native muscle healing. Conflicting studies have been identified for the use of PRP for muscle injury. A growing body of positive results for PPP was identified, but high-quality comparative studies are needed.

[Muscle injuries: the importance of high-resolution dynamic sonography in diagnostics, treatment and monitoring]

BACKGROUND

Muscle injuries are common in football. Imaging diagnostics have a major role in establishing a diagnosis. The main diagnostic procedures are MRI and ultrasound. Both diagnostics have advantages and disadvantages, which should be balanced against each other.

NEW ULTRASONIC TECHNIQUES

The role of MRI as the gold standard is increasingly being replaced by high-resolution ultrasound techniques, and MRI imaging is not always useful. To detect complications in the early stages it is advised to perform regular ultrasound-imaging check-ups. The healing process can be monitored, and it offers additional options for ultrasound-guided interventions such as hematoma punctures and targeted infiltrations.

ADVANTAGES AND DISADVANTAGES

However, ultrasound imaging is highly user dependent. Experienced operators can eliminate this disadvantage, which makes ultrasound a superior imaging system in many areas, especially for dynamic examinations. Nevertheless, MRI imaging remains a necessary imaging method in certain areas.

The Role of Platelet-Rich Plasma Injection for Muscle Strains in Athletes

Muscle tears/strains are among the most common musculoskeletal injuries, posing a serious challenge for sports medicine. Aiming to reduce the time to return to play and the rate of reinjuries, apart from the traditional conservative treatments and rehabilitation protocols, new and innovative therapeutic options have emerged, particularly platelet-rich plasma (PRP). This study aims to present the available evidence regarding PRP injection for the treatment of muscle strains in athletes. Two databases were searched for articles published between January 2012 and December 2022 in Portuguese or English. The query used for the PubMed database was ("Muscles/injuries"[Mesh]) AND ("Athletes"[Mesh] OR "Athletic Injuries"[Mesh]) AND "Platelet-Rich Plasma"[Mesh], while for the Web of Science database the search was performed for "Platelet-rich plasma" AND "Muscle injuries" AND ("Athletes" OR "Athletic injuries"). Eleven studies involving athletes diagnosed with muscle injuries who received treatment with PRP injection alone, or in combination with traditional conservative treatment, compared to a control group, were included. Four randomized controlled trials, four systematic reviews/meta-analyses, two retrospective studies, and one comparative study were included. Current evidence from the highest-quality studies does not support the hypothesis of reduction of time to return to play and the rate of reinjuries after PRP injection, even though some studies reported positive results. However, the available evidence suggests that PRP might have a beneficial effect on the pain perceived by athletes following an acute muscle strain. It is challenging to arrive at definitive conclusions and translate these findings into a clinical context for treating muscle strains in athletes. The existing trials present several inconsistencies and limitations, with a heterogeneous set of patients and injuries, as well as the use of different and inconsistent methods for preparing, administering, and measuring the effects of PRP. To achieve consistent outcomes, standardizing PRP administration procedures is essential.

[New treatment methods in competitive sports : What can we learn from the medical care of top athletes?]

BACKGROUND

As elite sport becomes more professional, the medical-psychological care of athletes is an important factor in providing them with the best possible support and thus optimising their performance. Our experience in the fields of prevention, conservative and surgical treatment, and rehabilitation also provides valuable insights for the treatment of our patients in daily practice.

PREVENTION

Designed to improve static and dynamic muscle strength, kinaesthetic sensitivity, and neuromuscular control, the FIFA 11+ injury prevention programme is a three-part warm-up programme that is widely used in coaching and recreational sports.

CONSERVATIVE TREATMENT

Platelet-rich plasma (PRP) is probably the most widely used orthobiologic treatment modality for the conservative management of tendon, muscle and cartilage injuries. Its effectiveness depends on the underlying pathology and the affected body region. The best evidence exists for the treatment of patellar tendinitis ("jumper's knee") and epicondylitis humeri radialis ("tennis elbow").

SURGICAL TREATMENT

The treatment of ACL injuries in competitive athletes is challenging due to the high physical demands. Prompt surgical intervention, anatomical reconstruction and additional extra-articular stabilisation are associated with improved surgical outcomes. Graft selection must be individualised, adapted to the needs of the athletes and our patients.

REHABILITATION

Electromyography (EMG) is a diagnostic tool to identify muscular imbalances in rehabilitation and, at the same time, to help reduce them through biofeedback training.

COGNITIVE TRAINING

Training for the development of basic cognitive skills helps to optimise performance through its potentially positive influence on the executive functions of athletes.

Efficacy of platelet-rich plasma injection in the treatment of frozen shoulder: A systematic review and meta-analysis

BACKGROUND

Frozen shoulder (FS) is characterized by progressive shoulder pain and a limited range of motion. Recently, platelet-rich plasma (PRP) injection is a newly developed treatment option for patients with FS and its efficacy needs to be examined.

OBJECTIVE

By conducting a systematic review and meta-analysis, this study attempted to evaluate the efficacy of PRP injection in the treatment of patients with FS.

METHODS

PubMed, EMBASE, Web of Science, Elsevier, The Cochrane Library, WanFang Data and CNKI databases were searched up to May 31, 2020. This study included randomized controlled trials as well as prospective cohort studies. Two reviewers independently screened the title, abstract and full text in order to extract data from qualified studies. The main outcome was pain visual analogue score (VAS) while the secondary outcome was range of motion (ROM) of the shoulder joint that consists of four parts: internal rotation, flexion, external rotation and abduction.

RESULTES

Three randomized controlled trials and one prospective cohort study met the inclusion criteria. Accordingly, a total of 359 cases were analyzed and followed up to 3 months. The control group included corticosteroids (CS), ultrasound therapy, and stellate ganglion block. Compared to other groups, VAS was statistically significant after 1 month and 3 months of treatment (SMD: -0.46, 95% CI: -0.75 to -0.18, P= 0.002; I=2 43.2%), (SMD: -0.87, 95% CI: -1.23 to -0.50, P= 0.00, I=2 61.9%). Compared to the control group, only flexion of the patients treated with PRP demonstrated no significant improvement at 1 month, whereas internal rotation, flexion, external rotation and abduction of the shoulder were found to be improved following 3 months of treatment.

CONCLUSIONS

The corresponding findings illustrate that compared to other non-operative treatments, local injection of PRP can effectively improve pain and shoulder motion in patients with FS. However, due to the short follow-up time and limitations regarding the quantity and quality of studies, the above conclusions require further elucidation by performing additional high-quality studies.

Histological and biochemical evaluation of plasma rich in growth factors treatment for grade II muscle injuries in sheep

The purpose of this study was to perform a histological and biochemical evaluation of the influence of plasma rich in growth factors (PRGF) on muscle regeneration process after a surgically induced grade II muscle laceration. A randomized, single blind, controlled experimental research was conducted including twenty-one adult healthy sheep, randomly divided in three groups (n = 7). A grade II surgical section was performed in the biceps femoris muscle of both hindlimbs. After two days (basal time), intralesional infiltration of autologous PRGF or Saline solution was randomly administered in both hindlimbs. Treatment was repeated once a week. Animal groups were euthanized at 1 (T1), 2 (T2) or 4 (T4) weeks. Histological assessment showed that PRGF intralesional injection induced a significant decrease of inflammatory cells density, significant higher centrally nucleated fibers percentage and significantly smaller fibrotic areas compared to Saline-treated muscles at T1, T2 and T4. Also, lower vascular density, with lower capillaries cross-sectional area, in PRGF group compared to Saline was observed. Biochemical analysis revealed a significant higher expression level of MYOD1, MYF5 and MYOG genes in PRGF groups at T1 compared to Saline treated muscles. At ultrastructural level, PRGF groups presented scarce edema and loss of connective tissue structure, as well as higher mitochondrial density adequately associated to the sarcomere unit in contrast to the Saline group. In conclusion, histological, biochemical, and ultrastructural results showed that PRGF treatment improved muscle regeneration process leading to more mature histological aspect in newly formed muscle tissue after a surgically induced grade II muscle injury.

Concentrated Growth Factors Promote hBMSCs Osteogenic Differentiation in a Co-Culture System With HUVECs

Osteogenesis is a complex physiologic process that occurs during bone regeneration. This process requires several growth factors that act on bone marrow-derived mesenchymal stem cells (BMSCs). Concentrated growth factor (CGF) is a new-generation platelet-rich derivative that is an appealing autologous material for application in tissue repair and bone regenerative medicine because it contains a variety of fibrin and growth factors. In this study, the effects of CGF on the proliferation and osteogenic differentiation of hBMSCs and human umbilical vein endothelial cells (HUVECs) were explored with in vitro cell co-culture experiments. HBMSCs and HUVECs were directly co-cultured at the ratio of 1:2 under different concentrations (0, 2, 5, 10, 20%) of CGF for 7 days. Alkaline phosphatase (ALP) staining and quantitative reverse transcription polymerase chain reaction were used to detect the effects of CGF on the expression of osteogenic genes (ALP, osteocalcin [OCN], type I collagen [COL-1], Runt-related transcription factor 2 [RUNX2]) and connexin 43 (CX43). RNA sequencing was used to explore potential regulated genes and signaling pathways that affect the osteogenesis of co-cultured hBMSCs exposed to CGF. The results showed higher expressions of ALP, COL-1, RUNX2, OCN, and CX43 in the direct co-culture group containing 10% CGF compared to the direct co-culture group without CGF and the indirect co-culture group. In summary, 10% CGF can significantly promote osteogenesis in hBMSCs directly co-cultured with HUVECs. Intercellular communication between the direct co-culture of hBMSCs and HUVECs through CX43 may be one of the main regulatory mechanisms.

Galvanic current activates the NLRP3 inflammasome to promote type I collagen production in tendon

The NLRP3 inflammasome coordinates inflammation in response to different pathogen- and damage-associated molecular patterns, being implicated in different infectious, chronic inflammatory, metabolic and degenerative diseases. In chronic tendinopathic lesions, different non-resolving mechanisms produce a degenerative condition that impairs tissue healing and which therefore complicates their clinical management. Percutaneous needle electrolysis consists of the application of a galvanic current and is an emerging treatment for tendinopathies. In the present study, we found that galvanic current activates the NLRP3 inflammasome and induces an inflammatory response that promotes a collagen-mediated regeneration of the tendon in mice. This study establishes the molecular mechanism of percutaneous electrolysis that can be used to treat chronic lesions and describes the beneficial effects of an induced inflammasome-related response.

Ultrasound-guided Procedures Allow Delay of Definitive Treatment for Core Muscle Injuries

INTRODUCTION

Core muscle injuries (CMI) are common in every sport. To minimize lost playing time, providers apply various nonsurgical treatments, including platelet-rich plasma, corticosteroids, ultrasound (US)-guided percutaneous tenotomy, and prolotherapy. Limited data exist with regard to their effectiveness. We chose to review a cohort of consecutive professional and collegiate athletes who sustained CMI at various points within their seasons and underwent a combination of US-guided percutaneous needle "tenotomy" and corticosteroid injections to complete the remainder of their seasons.

METHODS

Twenty-five consecutive collegiate or professional athletes with CMI involving the rectus abdominis-adductor aponeurotic plate were included in this retrospective study. Athletes with concomitant symptomatic hip femoroacetabular impingement were included in the study. The primary outcome measure was whether athletes completed their seasons. Secondary measures were weeks played after the procedures (delay until surgery), need for repeat procedures, and outcomes after eventual surgery. Postoperative performance was assessed via interviews at 6 wk and 6 months postoperatively.

RESULTS

Twenty-one of 25 (84%) athletes completed their seasons. On average, athletes returned to play 3 d (range, 1-9 d) after the procedures. Surgical repair was delayed a mean of 18 wk (range, 2-44 wk). Seven athletes had concomitant symptomatic femoroacetabular impingement and six underwent combined hip arthroscopy and core muscle repairs. Among 17 patients who eventually had core muscle surgery alone (no hip surgery), 82% (14 of 17) reported performing at their preinjury level at 6 wk. At 6 months, 96% of postop athletes (22 of 23) reported performing at their preinjury level.

CONCLUSIONS

Temporizing CMI with US-guided percutaneous tenotomy and corticosteroid injections is effective in allowing continued sport participation among high-level athletes and does not negatively affect postoperative outcomes.

The Biological Use of Platelet-Rich Plasma in Skeletal Muscle Injury and Repair

Platelet-rich plasma (PRP) is a blood product that contains several growth factors and active proteins. PRP is thought to be used autologously to assist in the repair of injured tissues as well as to treat pain at the site of injury. The mechanism behind PRP in regenerative medicine has been well investigated and includes the identification and concentration of released growth factors and exosomes. The benefits of PRP have been highly recommended and are used widely in orthopaedics and sports medicine, including repair of injured skeletal muscle. This current report summarizes some of the more recent studies in the use of PRP as it relates to muscle healing, in both the in vitro and clinical arenas.

Ultrasound-Guided Percutaneous Needle Electrolysis and Rehab and Reconditioning Program for Rectus Femoris Muscle Injuries: A Cohort Study with Professional Soccer Players and a 20-Week Follow-Up

Rectus femoris muscle strains are one of the most common injuries occurring in sports such as soccer. The purpose of this study was to describe the safety and feasibility of a combination of percutaneous needle electrolysis (PNE) and a specific rehab and reconditioning program (RRP) following an injury to the rectus femoris in professional soccer players. Thirteen professional soccer players received PNE treatment 48 h after a grade II rectus femoris muscle injury, followed by a the RRP 24 h later. Assessment of recovery from injury was done by registering the days taken to return to train (RTT), return to play (RTP), and structural and functional progress of the injured muscle was registered through ultrasound imaging and match-GPS parameters. Also, adverse events and reinjuries were recorded in the follow up period of twenty weeks. The RTT registered was 15.62 ± 1.80 days and RTP was 20.15 ± 2.79 days. After fourteen days, the ultrasound image showed optimal repair. Match-GPS parameters were similar before and after injury. There were no relapses nor were any serious adverse effects reported during the 20-week follow-up after the RTP. A combination of PNE and a specific RRP facilitated a faster RTP in previously injured professional soccer players enabling them to sustain performance and avoid reinjuries.

Treatment of lateral ankle sprain with platelet-rich plasma: A randomized clinical study

BACKGROUND

We aimed to clinically evaluate the effect of platelet-rich plasma (PRP) therapy in patients with acute lateral ankle sprain treated with rigid immobilization.

METHODS

Patients with first-time grade II lateral ankle sprain clinically diagnosed were evaluated (n=21). A rigid immobilization was placed in all patients for ten days; previously, an application of PRP over the anterior talofibular ligament was performed in patients from the experimental group. The Visual Analogue Scale, the American Orthopedic Foot and Ankle Score, and the Foot and Ankle Disability Index were applied at 3, 5, 8 and 24 weeks of follow-up period.

RESULTS

The experimental group presented the highest reduction in pain and better functional scores than the control group at 8 weeks. At the end of follow-up period the results of both groups were similar.

CONCLUSIONS

A similar evolution was observed in patients treated with rigid immobilization with or without PRP after 24 weeks.

TRIAL REGISTRATION

Clinical Trials.gov with ID NCT02609308.

Sonodelivery in Skeletal Muscle: Current Approaches and Future Potential

There are currently multiple approaches to facilitate gene therapy via intramuscular gene delivery, such as electroporation, viral delivery, or direct DNA injection with or without polymeric carriers. Each of these methods has benefits, but each method also has shortcomings preventing it from being established as the ideal technique. A promising method, ultrasound-mediated gene delivery (or sonodelivery) is inexpensive, widely available, reusable, minimally invasive, and safe. Hurdles to utilizing sonodelivery include choosing from a large variety of conditions, which are often dependent on the equipment and/or research group, and moderate transfection efficiencies when compared to some other gene delivery methods. In this review, we provide a comprehensive look at the breadth of sonodelivery techniques for intramuscular gene delivery and suggest future directions for this continuously evolving field.

Injectable Ketorolac and Corticosteroid Use in Athletes: A Systematic Review

CONTEXT

The use of injectable medications to help athletes quickly return to the field of play after injury is common. Understanding the effects and risks of these medications will help providers make informed decisions regarding their use in this patient population.

OBJECTIVE

To evaluate the utilization, efficacy, and adverse effects of injectable ketorolac and corticosteroids in athletes.

DATA SOURCES

This systematic review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A systematic search of the literature was performed using multiple databases (PubMed, Embase, Cochrane, Web of Science, and ClinicalTrials.gov). Secondary references were appraised for relevant articles. No randomized controlled trials or other prospective studies were identified. Articles included retrospective database reviews and physician survey studies.

STUDY SELECTION

A total of 6 studies met the inclusion and exclusion criteria and were reviewed by 2 independent reviewers with a third consulted in the case of disagreement, which was not needed.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 5.

DATA EXTRACTION

Two reviewers recorded rate of use, effectiveness of treatment, and reported side effect data.

RESULTS

Most studies centered around the football athlete, either professional or collegiate. Professional football game day use of intramuscular ketorolac declined from 93.3% (28/30) in 2002 to 48% in 2016. Collegiate football game day use of intramuscular ketorolac declined from 62% in 2008 to 26% in 2016. Game day corticosteroid injection was far lower than ketorolac usage. Both medications were reported to be effective with few adverse events.

CONCLUSION

Use of injectable ketorolac is common but declining in professional and college football. Pain control efficacy is good, and risk of adverse events is low. The incidence of injectable corticosteroid use in athletes is unknown. Use of injectable corticosteroids in athletes allows for early return to sport activities with no reported complications.

Platelet-rich plasma (PRP) as therapy for cartilage, tendon and muscle damage - German working group position statement

Purpose

Platelet rich plasma (PRP) is widely used in orthopaedics, but is still heavily debated. Therefore, a survey among the German “Working Group for Clinical Tissue Regeneration” of the German Society of Orthopaedics and Traumatology was conducted to achieve a consensus about the current therapeutical potential of PRP.

Methods

A first survey (n = 65 experts, all orthopaedic/trauma surgeons) was conducted (n = 13 questions). Following, a second round (n = 40 experts) was conducted with 31 questions to achieve consensus in 5 categories: three most common indications, PRP application, future research areas.

Results

Therapeutic PRP application was regarded as useful (89%), possibly even more important in the future (90%). Most common indications were tendon pathologies (77%), osteoarthritis (OA) (68%), muscle injuries (57%) and cartilage damage (51%). Consensus was reached in 16/31 statements. The application of PRP for early knee OA (Kellgren-Lawrence grade II) was regarded as potentially useful, as well as for acute and chronic tendinopathies. For chronic lesions (cartilage, tendons), multiple injections (2–4) were seen preferable to singular injections. However, no sufficient data exists on the time interval between the injections. Standardization of PRP preparation, application, frequency, as well as determining the range of indication is strongly recommended.

Conclusions

There is a need of further standardization of the PRP preparation methods, indication and application protocols for knee OA and other indications, which must be further evaluated in basic science studies and randomized controlled clinical trials.

Level of evidence

Consensus of expert opinion, Level V.

The Clinical Use of Platelet-Rich Plasma in Knee Disorders and Surgery-A Systematic Review and Meta-Analysis

In recent years, the interest in biological treatment of knee lesions has increased, especially the application of platelet-rich plasma is of particular note. The number of articles evaluating platelet-rich plasma (PRP) efficacy in the recovery of knee disorders and during knee surgery has exponentially increased over the last decade. A systematic review with meta-analyses was performed by assessing selected studies of local PRP injections to the knee joint. The study was completed in accordance with 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A multistep search of PubMed, Embase, Cochrane Database of Systematic Reviews, and Clinicaltrials.gov was performed to identify studies on knee surgery and knee lesion treatment with PRP. Of the 4004 articles initially identified, 357 articles focusing on knee lesions were selected and, consequently, only 83 clinical trials were analyzed using the revised Cochrane risk-of-bias tool to evaluate risk. In total, seven areas of meta-analysis reported a positive effect of PRP. Among them, 10 sub-analyses demonstrated significant differences in favor of PRP when compared to the control groups (p < 0.05). This study showed the positive effects of PRP, both on the recovery of knee disorders and during knee surgery; however further prospective and randomized studies with a higher number of subjects and with lower biases are needed.

Platelet Concentrates in Musculoskeletal Medicine

Platelet concentrates (PCs), mostly represented by platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) are autologous biological blood-derived products that may combine plasma/platelet-derived bioactive components, together with fibrin-forming protein able to create a natural three-dimensional scaffold. These types of products are safely used in clinical applications due to the autologous-derived source and the minimally invasive application procedure. In this narrative review, we focus on three main topics concerning the use of platelet concentrate for treating musculoskeletal conditions: (a) the different procedures to prepare PCs, (b) the composition of PCs that is related to the type of methodological procedure adopted and (c) the clinical application in musculoskeletal medicine, efficacy and main limits of the different studies.

Platelet Rich Plasma for Treatment of Rheumatoid Arthritis: Case Series and Review of Literature

Platelet-rich plasma (PRP) is an autologous blood product with platelets above circulating levels and releases several growth factors after activation. PRP may help to decrease joint inflammation by modulating synovial cell proliferation and differentiation and inhibition of catabolic pathways in various articular conditions. Though PRP has shown good efficacy in osteoarthritis and other musculoskeletal conditions such as synovitis, epicondylitis, skeletal muscle injuries, and tendinopathy, there is limited experience for the use of PRP in patients with rheumatoid arthritis. Precise mechanisms of action of PRP are not known. We present clinical experience for treatment with PRP (2–4 ml) in four patients with rheumatoid arthritis who had inadequate response and persistent pain and inflammation with intra-articular steroids. Irrespective of past and ongoing treatments and duration of disease, all patients showed improvement in the visual analog scale and disease activity score of 28 joints at 4 and 8 weeks after injection. There was an improvement in joint inflammation on ultrasound imaging in some patients. These effects were sustained for up to 1 year. No adverse effects were reported in any patient. PRP may be a safe and useful therapy in patients with rheumatoid arthritis who fail to respond to one or more established treatment options.

Rectus femoris myotendinous lesion treated with PRP: a case report

BACKGROUND AND AIM OF WORK

Musculoskeletal injuries are the most common cause of severe, chronic pain and physical disability for the majority of all sport-related injuries. Platelet-rich plasma is being used more frequently to promote healing of muscle injuries. We report a case of 39 years old non professional soccer player who came to our attention for a quadriceps muscle pain onset after kicking the ball during a match.

METHODS

Clinical and instrumental evaluation revealed a myotendinous junction rupture of the rectus femoris with retraction of 1.5 cm from the anterior inferior iliac spine. We decided to treat the patient with PRP ultrasound guided injections and a specific rehabilitation protocol.

RESULTS

Clinical evaluation 45 days following the end of the treatment showed the resolution of the pain and the full recovery of strength and range of motion. Muscle healing was documented by magnetic resonance imaging.

CONCLUSIONS

Even if the role of PRP in muscle injury is not still clear, the result observed confirms that it could be used in the treatment of muscle lesions.

PRP and BMAC for Musculoskeletal Conditions via Biomaterial Carriers

Platelet-rich plasma (PRP) and bone marrow aspirate concentrate (BMAC) are orthobiologic therapies considered as an alternative to the current therapies for muscle, bone and cartilage. Different formulations of biomaterials have been used as carriers for PRP and BMAC in order to increase regenerative processes. The most common biomaterials utilized in conjunction with PRP and BMAC clinical trials are organic scaffolds and natural or synthetic polymers. This review will cover the combinatorial strategies of biomaterial carriers with PRP and BMAC for musculoskeletal conditions (MsCs) repair and regeneration in clinical trials. The main objective is to review the therapeutic use of PRP and BMAC as a treatment option for muscle, bone and cartilage injuries.

Impact of Platelet-Rich Plasma Use on Pain in Orthopaedic Surgery: A Systematic Review and Meta-analysis

CONTEXT

Amid extensive debate, evidence surrounding the use of platelet-rich plasma (PRP) for musculoskeletal injuries has rapidly proliferated, and an overall assessment of efficacy of PRP across orthopaedic indications is required.

OBJECTIVES

(1) Does PRP improve patient-reported pain in musculoskeletal conditions? and (2) Do PRP characteristics influence its treatment effect?

DATA SOURCES

MEDLINE, EMBASE, Cochrane, CINAHL, SPORTDiscus, and Web of Science libraries were searched through February 8, 2017. Additional studies were identified from reviews, trial registries, and recent conferences.

STUDY SELECTION

All English-language randomized trials comparing platelet-rich therapy with a control in patients 18 years or older with musculoskeletal bone, cartilage, or soft tissue injuries treated either conservatively or surgically were included. Substudies of previously reported trials or abstracts and conference proceedings that lacked sufficient information to generate estimates of effect for the primary outcome were excluded.

STUDY DESIGN

Systematic review and meta-analysis.

LEVEL OF EVIDENCE

Level 1.

DATA EXTRACTION

All data were reviewed and extracted independently by 3 reviewers. Agreement was high between reviewers with regard to included studies.

RESULTS

A total of 78 randomized controlled trials (5308 patients) were included. A standardized mean difference (SMD) of 0.5 was established as the minimum for a clinically significant reduction in pain. A reduction in pain was associated with PRP at 3 months (SMD, -0.34; 95% CI, -0.48 to -0.20) and sustained until 1 year (SMD, -0.60; 95% CI, -0.81 to -0.39). Low- to moderate-quality evidence supports a reduction in pain for lateral epicondylitis (SMD, -0.69; 95% CI, -1.15 to -0.23) and knee osteoarthritis (SMD, -0.91; 95% CI, -1.41 to -0.41) at 1 year. PRP characteristics did not influence results.

CONCLUSION

PRP leads to a reduction in pain; however, evidence for clinically significant efficacy is limited. Available evidence supports the use of PRP in the management of lateral epicondylitis as well as knee osteoarthritis.

Influence of Platelet-Rich and Platelet-Poor Plasma on Endogenous Mechanisms of Skeletal Muscle Repair/Regeneration

The morpho-functional recovery of injured skeletal muscle still represents an unmet need. None of the therapeutic options so far adopted have proved to be resolutive. A current scientific challenge remains the identification of effective strategies improving the endogenous skeletal muscle regenerative program. Indeed, skeletal muscle tissue possesses an intrinsic remarkable regenerative capacity in response to injury, mainly thanks to the activity of a population of resident muscle progenitors called satellite cells, largely influenced by the dynamic interplay established with different molecular and cellular components of the surrounding niche/microenvironment. Other myogenic non-satellite cells, residing within muscle or recruited via circulation may contribute to post-natal muscle regeneration. Unfortunately, in the case of extended damage the tissue repair may become aberrant, giving rise to a maladaptive fibrotic scar or adipose tissue infiltration, mainly due to dysregulated activity of different muscle interstitial cells. In this context, plasma preparations, including Platelet-Rich Plasma (PRP) and more recently Platelet-Poor Plasma (PPP), have shown advantages and promising therapeutic perspectives. This review focuses on the contribution of these blood-derived products on repair/regeneration of damaged skeletal muscle, paying particular attention to the potential cellular targets and molecular mechanisms through which these products may exert their beneficial effects.

Is Platelet-Rich Plasma (PRP) Effective in the Treatment of Acute Muscle Injuries? A Systematic Review and Meta-Analysis

BACKGROUND

Muscle lesions account for one-third of sport-related injuries, thus representing a substantial problem for both players and their teams. The use of platelet-rich plasma (PRP) injections is rapidly growing in clinical practice, prompted by an unmet clinical need with a large commercial market. However, after early reports of positive preliminary experience, higher quality studies recently questioned the real benefit provided by PRP injections to promote muscle healing and return to sport.

OBJECTIVE

To evaluate the effect of platelet-rich plasma (PRP) injections on outcomes following acute muscle injuries.

DESIGN

Meta-analysis of randomized, controlled trials (RCTs), Level I.

DATA SOURCES

PubMed (MEDLINE), Cochrane (CENTRAL), Web of Science, clinicaltrials.gov, who.int, isrctn.com, greylit.org, opengrey.eu.

ELIGIBILITY CRITERIA

RCTs investigating the effect of PRP for the treatment of acute muscle injuries against at least one control group including patients treated with placebo injection or physical therapy. The outcomes evaluated were time to return to sport, re-injuries, complications, pain, muscle strength, range of motion (ROM)/flexibility, muscle function, and imaging.

RESULTS

Six studies, involving 374 patients, were included in the meta-analysis. The time to return to sport evaluated in all six studies was significantly shorter in patients treated with PRP (mean difference = - 7.17 days). However, if only the double-blind studies (n = 2) or studies including only hamstring injuries (n = 3) were considered, non-significant differences were found. Re-injuries (relative risk = - 0.03) and complications (relative risk = 0.01) were also similar between the two groups (p > 0.05), nor were any substantial differences found regarding pain, muscle strength, ROM/flexibility, muscle function, and imaging. The performance bias was high risk due to the lack of patient blinding in four studies. The quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) was therefore low or very low.

CONCLUSIONS

The promising biological rationale, the positive preclinical findings, and the successful early clinical experience of PRP injections are not confirmed by the recent high-level RCTs. Therefore any benefit in terms of pain, function, return to sport, and recurrence using PRP injections for the treatment of acute muscle injuries is not supported. Due to the bias in the studies, the heterogeneity of the findings, and the limited sample size, the evidence should be considered to be of low or very low quality.

Treatment of Muscle Injuries with Platelet-Rich Plasma: a Review of the Literature

PURPOSE OF REVIEW

This review discusses the current literature regarding the use of platelet-rich plasma (PRP) in the treatment of muscle strain injuries. Case series as well as experimental trials for both human and animal models are covered.

RECENT FINDINGS

Multiple studies have examined outcomes for the use of PRP in the treatment of muscle strain injuries. PRP has been shown to promote muscle recovery via anabolic growth factors released from activated platelets, and in doing so, potentially reduces pain, swelling, and time for return to play. In vitro studies support the regenerative potential of PRP for acute soft tissue injuries. Multiple clinical case series for PRP injections in the setting of muscle strains demonstrate imaging evidence for faster healing, less swelling, which can decrease time for return to play. These studies, however, are retrospective in nature, and few randomized controlled studies exist to demonstrate a clear clinical benefit. Additionally, there is tremendous heterogeneity regarding the injectant preparation, optimum platelet concentration, presence of leukocytes, and volume of PRP which should be administered as well as number of and timing of treatments.

Platelet-rich plasma: myth or reality?

Platelet-rich plasma (PRP) is a preparation for therapeutic purposes that is increasingly accepted for various musculoskeletal disorders, due to its theoretical potential to repair tissues with poor healing capacity. Several randomised clinical trials have investigated the capacity of PRP to repair tendons, ligaments, muscles and cartilage, and to date there is level 1a evidence to support its use for lateral epicondylitis, osteoarthritis of the knee, plantar fasciitis and rotator cuff tendinopathy; and level 1b for patellar tendinopathy and osteoarthritis of the hip. Retrospective cohort studies and case series describe promising results with PRP for treating other musculoskeletal disorders. Since its side effects are fewer than those of the control groups, the treatment is considered practically harmless and is being increasingly used. Further randomised clinical trials are necessary to establish future indications, and to confirm effectiveness and safety.

The use of platelet-rich plasma (PRP) in the treatment of gastrocnemius strains: a retrospective observational study

The aim of the present retrospective observational study was to evaluate the time of functional recovery following a specific combined therapeutic approach characterized by an active exercise therapy carried out immediately after Platelet-rich plasma (PRP) injections for the treatment of the muscular lesion of the distal musculotendinous junction of the gastrocnemius medial head.Medical records of 31 subjects treated with three PRP intra-lesional ultrasound guided injections and 30 patients treated with the standard therapeutic approach (control group) were analyzed. Both groups followed the same rehabilitation therapy. Patients in the control group were able to start active exercise with a significant delay when compared to the PRP treated subjects: 17 ± 7.2 days and 9 ± 3.8 days (p = 0.0001), respectively. This delay was mainly due to the persistence of pain in the subjects in the control group. The time necessary to return to walk without pain was significantly shorter in the PRP treated group: 24.27 ± 12.36 days versus 52.4 ± 20.03 days in the control group (p < 0.001) as well as the time needed to fully return to practice the previous sport activity: 53.33 ± 27.74 days versus 119.3 ± 43.87 days in the control group (p < 0.001).The present study showed that ultrasound guided delivery of PRP into the site of muscle injury has to be considered a valid therapeutic approach with the potentiality of significantly reduce time and costs for reaching a complete functional recovery.

Effectiveness of PRP Injection in Reducing Recovery Time of Acute Hamstring Injury: A Critically Appraised Topic

Clinical Scenario: Hamstring strains are common athletic injuries, with a high-recurrence rate (34%). Recently, platelet-rich plasma (PRP) injections have gained popularity as a potential treatment option to accelerate healing of hamstring injury. Focused Clinical Question: Does the combination of PRP injection and rehabilitation decrease recovery time of acute hamstring injury as compared to rehabilitation alone in college athletes? Summary of Key Findings: A literature search resulted in 3 randomized controlled trials. One study showed benefits in various outcome measures with PRP, compared to rehabilitation alone, while 2 showed no benefits. One study reported improved pain, ultrasonography regenerative indications, and recovery time with PRP injection following acute hamstring injury; however, larger studies have shown no benefits. The literature demonstrates conflicting evidence regarding benefits of PRP injections in hamstring injuries. Clinical Bottom Line: At this time, PRP injections cannot be recommended as having value for hamstring injuries, compared to rehabilitation alone. Strength of Recommendation: Due to inconsistent or limited quality patient-oriented evidence in existing literature, the strength of this recommendation is grade B, based on the strength of recommendation taxonomy.

Platelet biology in regenerative medicine of skeletal muscle

Platelet-based applications such as platelet-rich plasma (PRP) and platelet releasate have gained unprecedented attention in regenerative medicine across a variety of tissues as of late. The rationale behind utilizing PRP originates in the delivery of key cytokines and growth factors from α-granules to the targeted area, which in turn act as cell cycle regulators and promote the healing process across a variety of tissues. The aim of the present review is to assimilate current experimental evidence on the role of platelets as biomaterials in tissue regeneration, particularly in skeletal muscle, by integrating findings from human, animal and cell studies. This review is composed of 3 parts: firstly, we review key aspects of platelet biology that precede the preparation and use of platelet-related applications for tissue regeneration. Secondly, we critically discuss relevant evidence on platelet-mediated regeneration in skeletal muscle focusing on findings from (i) clinical trials, (ii) experimental animal studies and (iii) cell culture studies; and thirdly, we discuss the application of platelets in the regeneration of several other tissues including tendon, bone, liver, vessels and nerve. Finally, we review key technical variations in platelet preparation that may account for the large discrepancy in outcomes from different studies. This review provides an up-to-date reference tool for biomedical and clinical scientists involved in platelet-mediated tissue regenerative applications.

High regenerative capacity of the liver and irreversible injury of male reproductive system in carbon tetrachloride-induced liver fibrosis rat model

BACKGROUND

Liver fibrosis (LF) is a chronic disease, associated with many collateral diseases including reproductive dysfunction. Although the normal liver has a large regenerative capacity the complications of LF could be severe and irreversible. Hormone and sex-related issues of LF development and interactions with male reproductive have not been finally studied. The aim was to study the reproductive function of male rats in experimental CCl4-induced liver fibrosis rat model, and the capability for restoration of both the liver and male reproduction system.

MATERIALS

Studies were conducted on 20 3-month old Wistar male rats. The experimental animals were injected with freshly prepared 50% olive oil solution of carbohydrate tetrachloride (CCl4). On the 8th week after injection we noted the manifestations of liver fibrosis. The rats were left to self-healing of the liver for 8 weeks. All male rats underwent ultrasound and biopsy of the liver and testes on the 8th and 16th weeks. The male rats were mated with healthy females before CCl4 injection, after modeling LF on the 8th week, and after self-healing of the liver. Pregnancy was monitored on ultrasound.

RESULTS

On the 8th week of experiment we observed ultrasound manifestation of advanced liver fibrosis, including hepatosplenomegaly, portal hypertension. Ultrasound exam of the rat testes showed testicular degeneration, hydrocele, fibrosis, scarring, petrifications, size reduction, and restriction of testicular descent; testes size decreased from 1.24 ± 0.62 ml to 0.61 ± 0.13, p < 0.01. Liver histology showed granular dystrophy of hepatocytes, necrotic areas, lipid inclusions in parenchyma. Rats with liver fibrosis demonstrated severe injury of the reproductive system and altering of fertility: the offspring of male rats with advanced LF was 4.71 ± 0.53 born alive vs 9.55 ± 0.47 born from mating with healthy males, p < 0.001. Eight weeks after last CCl4 injection, we revealed signs of liver regeneration, significant recovery of its structure. The ALT and AST levels significantly decreased and reached background measurements. As a result of the second interbreeding after liver self-healing no significant difference was found vs previous mating.

CONCLUSION

Carbohydrate tetrachloride induces injury of liver parenchyma evoking fast and severe liver fibrosis, and is associated with irreversible structural and functional changes in testes, reducing fertility, decreasing potential pregnancy rate, and affecting its development. Liver showed high potential to regenerate, however the self-restoring after liver fibrosis was not accompanied with recovery of the reproductive system.

Does Platelet-Rich Plasma Lead to Earlier Return to Sport When Compared With Conservative Treatment in Acute Muscle Injuries? A Systematic Review and Meta-analysis

PURPOSE

To compare the time to return to sport and reinjury rate after platelet-rich plasma (PRP) injection versus control therapy (i.e., physiotherapy or placebo injection) in patients with acute grade I or II muscle strains.

METHODS

All eligible studies comparing PRP against a control in the treatment of acute (≤7 days) grade I or II muscle strains were identified. The primary outcome was time to return to play. The secondary outcome was the rate of reinjury at a minimum of 6 months of follow-up. Subgroup analysis was performed to examine the efficacy of PRP in hamstring muscle strains alone. The checklist to evaluate a report of a nonpharmacologic trial (CLEAR-NPT) was used to assess the quality of studies.

RESULTS

Five randomized controlled trials including a total of 268 patients with grade I and II acute muscle injuries were eligible for review. The pooled results revealed a significantly earlier return to sport for the PRP group when compared with the control group (mean difference, -5.57 days [95% confidence interval, -9.57 to -1.58]; P = .006). Subgroup analysis showed no difference in time to return to sport when comparing PRP and control therapy in grade I and II hamstring muscle strains alone (P = .19). No significant difference was noted in the rate of reinjury between the 2 groups (P = .50) at a minimum of 6 months of follow-up.

CONCLUSIONS

Evidence from the current literature, although limited, suggests that the use of PRP may result in an earlier return to sport among patients with acute grade I or II muscle strains without significantly increasing the risk of reinjury at 6 months of follow-up. However, no difference in time to return to sport was revealed when specifically evaluating those with a grade I or II hamstring muscle strain.

LEVEL OF EVIDENCE

Level II, meta-analysis of level I and II studies.

A Call for Standardization in Platelet-Rich Plasma Preparation Protocols and Composition Reporting: A Systematic Review of the Clinical Orthopaedic Literature

BACKGROUND

Platelet-rich plasma (PRP) is a blood-derived preparation whose use has grown exponentially in orthopaedic practice. However, there remains an unclear understanding of the biological properties and effects of PRP on musculoskeletal healing. Heterogeneous processing methods, unstandardized nomenclature, and ambiguous classifications make comparison among studies challenging. A comprehensive assessment of orthopaedic clinical PRP trials is key to unraveling the biological complexity of PRP, while improving standardized communication. Toward this goal, we performed a systematic review of the PRP preparation protocols and PRP composition utilized in clinical trials for the treatment of musculoskeletal diseases.

METHODS

A systematic review of the literature was performed from 2006 to 2016. Inclusion criteria were human clinical trials, English-language literature, and manuscripts that reported on the use of PRP in musculoskeletal/orthopaedic conditions. Basic-science articles, editorials, surveys, special topics, letters to the editor, personal correspondence, and nonorthopaedic applications (including cosmetic use or dental application studies) were excluded.

RESULTS

A total of 105 studies (in 104 articles) met the inclusion criteria for analysis. Of these studies, only 11 (10%) provided comprehensive reporting that included a clear description of the preparation protocol that could be used by subsequent investigators to repeat the method. Only 17 studies (16%) provided quantitative metrics on the composition of the final PRP product.

CONCLUSIONS

Reporting of PRP preparation protocols in clinical studies is highly inconsistent, and the majority of studies did not provide sufficient information to allow the protocol to be reproduced. Furthermore, the current reporting of PRP preparation and composition does not enable comparison of the PRP products being delivered to patients. A detailed, precise, and stepwise description of the PRP preparation protocol is required to allow comparison among studies and provide reproducibility.

Postinjury Exercise and Platelet-Rich Plasma Therapies Improve Skeletal Muscle Healing in Rats But Are Not Synergistic When Combined

BACKGROUND

Skeletal muscle injuries are the most common sports-related injury and a major concern in sports medicine. The effect of platelet-rich plasma (PRP) injections on muscle healing is still poorly understood, and current data are inconclusive.

PURPOSE

To evaluate the effects of an ultrasound-guided intramuscular PRP injection, administered 24 hours after injury, and/or posttraumatic daily exercise training for 2 weeks on skeletal muscle healing in a recently established rat model of skeletal muscle injury that highly mimics the muscle trauma seen in human athletes.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 40 rats were assigned to 5 groups. Injured rats (medial gastrocnemius injury) received a single PRP injection (PRP group), daily exercise training (Exer group), or a combination of a single PRP injection and daily exercise training (PRP-Exer group). Untreated and intramuscular saline-injected animals were used as controls. Muscle force was determined 2 weeks after muscle injury, and muscles were harvested and evaluated by means of histological assessment and immunofluorescence microscopy.

RESULTS

Both PRP (exhibiting 4.8-fold higher platelet concentration than whole blood) and exercise training improved muscle strength (maximum tetanus force, TetF) in approximately 18%, 20%, and 30% of rats in the PRP, PRP-Exer, and Exer groups, respectively. Specific markers of muscle regeneration (developmental myosin heavy chain, dMHC) and scar formation (collagen I) demonstrated the beneficial effect of the tested therapies in accelerating the muscle healing process in rats. PRP and exercise treatments stimulated the growth of newly formed regenerating muscle fibers (1.5-, 2-, and 2.5-fold increase in myofiber cross-sectional area in PRP, PRP-Exer, and Exer groups, respectively) and reduced scar formation in injured skeletal muscle (20%, 34%, and 41% of reduction in PRP, PRP-Exer, and Exer groups, respectively). Exercise-treated muscles (PRP-Exer and Exer groups) had significantly reduced percentage of dMHC-positive regenerating fibers (35% and 47% decrease in dMHC expression, respectively), indicating that exercise therapies accelerated the muscle healing process witnessed by the more rapid replacement of the embryonic-developmental myosin isoform by mature muscle myosin isoforms.

CONCLUSION

Intramuscular PRP injection and, especially, treadmill exercise improve histological outcome and force recovery of the injured skeletal muscle in a rat injury model that imitates sports-related muscle injuries in athletes. However, there was not a synergistic effect when both treatments were combined, suggesting that PRP does not add any beneficial effect to exercise-based therapy in the treatment of injured skeletal muscle.

CLINICAL RELEVANCE

This study demonstrates the efficacy of an early active rehabilitation protocol or single intramuscular PRP injection on muscle recovery. The data also reveal that the outcome of the early active rehabilitation is adversely affected by the PRP injection when the two therapies are combined, and this could explain why PRP therapies have failed in randomized clinical trials where the athletes have adhered to postinjection rehabilitation protocols based on the principle of early, active mobilization.

The biology of rotator cuff healing

Despite advances in surgical reconstruction of chronic rotator cuff (RC) tears leading to improved clinical outcomes, failure rates of 13-94% have been reported. Reasons for this rather high failure rate include compromised healing at the bone-tendon interface, as well as the musculo-tendinous changes that occur after RC tears, namely retraction and muscle atrophy, as well as fatty infiltration. Significant research efforts have focused on gaining a better understanding of these pathological changes in order to design effective therapeutic solutions. Biological augmentation, including the application of different growth factors, platelet concentrates, cells, scaffolds and various drugs, or a combination of the above have been studied. It is important to note that instead of a physiological enthesis, an abundance of scar tissue is formed. Even though cytokines have demonstrated the potential to improve rotator cuff healing in animal models, there is little information about the correct concentration and timing of the more than 1500 cytokines that interact during the healing process. There is only minimal evidence that platelet concentrates may lead to improvement in radiographic, but not clinical outcome. Using stem cells to biologically augment the reconstruction of the tears might have a great potential since these cells can differentiate into various cell types that are integral for healing. However, further studies are necessary to understand how to enhance the potential of these stem cells in a safe and efficient way. This article intends to give an overview of the biological augmentation options found in the literature.

Update in Musculoskeletal Ultrasound Research

CONTEXT

Musculoskeletal ultrasound (US) research is expanding due to increased clinical utility of sonography.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Ultrasound is widely applied in musculoskeletal imaging and sports medicine. The real-time capabilities and favorable cost profile of US make it ideal for use in diagnosis of musculoskeletal conditions. The enthusiasm for the use of US in musculoskeletal imaging has led to an increase in US research to broaden its applications.

CONCLUSION

Several recent advances have been made in conventional and novel US imaging techniques, quantitative US imaging, and US-guided interventions.

STRENGTH OF RECOMMENDATIONS TAXONOMY SORT

C.

Platelet-rich plasma in the treatment of acute hamstring injuries in professional football players

PURPOSE

muscle injuries have a high incidence in professional football and are responsible for the largest number of days lost from competition. Several in vitro studies have confirmed the positive role of platelet-rich plasma (PRP) in accelerating recovery and in promoting muscle regeneration, and not fibrosis, in the healing process. This study examines the results of intralesional administration of PRP in the treatment of primary hamstring injuries sustained by players belonging to a major league football club.

METHODS

twenty-five hamstring injuries (grade 2 according to MRI classification) sustained by professional football players during a 31-months observation period were treated with PRP and analyzed. Sport participation absence (SPA), in days, was considered to correspond to the healing time, and we also considered the re-injury rate, and tissue healing on MRI. The mean follow-up was 36.6 months (range 22-42).

RESULTS

there were no adverse events. The mean SPA for the treated muscle injuries was 36.76±19.02 days. The re-injury rate was 12%. Tissue healing, evaluated on MRI, was characterized by the presence of excellent repair tissue and a small scar.

CONCLUSIONS

this study confirmed the safety of PRP in treating hamstring lesions in a large series of professional football players. PRP-treated lesions did not heal more quickly than untreated lesions described in the literature, but they showed a smaller scar and excellent repair tissue.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

A systematic review and meta-analysis of the application of platelet rich plasma in sports medicine

Introduction

In recent years, platelet rich plasma (PRP) has been receiving increasing attention for the treatment of soft tissue injuries. These numerous applications have raised a great deal of questions and debate about the effectiveness of this method. This study aimed to determine the efficacy of PRP in improving sports injuries and subsequently throw some light on these controversies.

Methods

A systematic review of the literature and meta-analysis of results were undertaken. All related databases, such as PubMed, Cochrane Database of Systematic Reviews, DARE, and EMBASE, were searched on the use of PRP on athletes and in sports medicine. The search was conducted from June 2013 to February 2014.

Results

Our search retrieved 905 studies, of which 13 randomized control trials (RCT) met our inclusion criteria for systematic review and meta-analysis. All articles were appraised by Critical Appraisal Skills Program (CASP) checklist for RCT studies. The analysis of the results of pain scores and physical activity/functions did not show any superiority for PRP as opposed to the other options.

Conclusions

The meta-analysis showed no more effectiveness for PRP application in sports-related injuries in terms of physical function improvement and pain relief. Therefore, the extensive use of PRP for such injuries should be limited. Well-designed RCTs are needed to support the findings.

Plasma rich in growth factors (PRGF) as a treatment for high ankle sprain in elite athletes: a randomized control trial

PURPOSE

Syndesmotic sprains are uncommon injuries that require prolonged recovery. The influence of ultrasound-guided injections of platelet-rich plasma (PRP) into the injured antero-inferior tibio-fibular ligaments (AITFL) in athletes on return to play (RTP) and dynamic stability was studied.

METHODS

Sixteen elite athletes with AITFL tears were randomized to a treatment group receiving injections of PRP or to a control group. All patients followed an identical rehabilitation protocol and RTP criteria. Patients were prospectively evaluated for clinical ability to return to full activity and residual pain. Dynamic ultrasound examinations were performed at initial examination and at 6 weeks post-injury to demonstrate re-stabilization of the syndesmosis joint and correlation with subjective outcome.

RESULTS

All patients presented with a tear to the AITFL with dynamic syndesmosis instability in dorsiflexion-external rotation, and larger neutral tibia-fibula distance on ultrasound. Early diagnosis and treatment lead to shorter RTP, with 40.8 (±8.9) and 59.6 (±12.0) days for the PRP and control groups, respectively (p = 0.006). Significantly less residual pain upon return to activity was found in the PRP group; five patients (62.5 %) in the control group returned to play with minor discomfort versus one patient in the treatment group (12.5 %). One patient in the control group had continuous pain and disability and subsequently underwent syndesmosis reconstruction.

CONCLUSIONS

Athletes suffering from high ankle sprains benefit from ultrasound-guided PRP injections with a shorter RTP, re-stabilization of the syndesmosis joint and less long-term residual pain.

LEVEL OF EVIDENCE

II.