Treatment of Subacromial Impingement Syndrome: Platelet-Rich Plasma or Exercise Therapy? A Randomized Controlled Trial

Clinical Effects of Additional Platelet-Rich Plasma Application to Exercise Therapy in Patients with Subacromial Impingement Syndrome: A Double-Blind Randomized Controlled Trial

Background

Exercise therapy (ET) is the main and initial treatment modality for treating subacromial impingement syndrome (SIS). The isolated or combined use of platelet-rich plasma (PRP) applications in treating SIS is increasing and promising. A comparison was made on the effectiveness of ET alone and in combination with PRP on pain, functionality, and quality of life (QoL) in patients with SIS.

Purposes/Hypothesis

The purposes of this study were to (1) investigate the possible positive effects of PRP injections combined with ET in treating SIS on pain, functionality, and QoL and (2) propose an alternative treatment protocol. It was hypothesized that the group receiving PRP applications in addition to ET would have a better QoL due to less pain and higher functionality 6 months after treatment.

Study Design

Randomized controlled trial; Level of evidence, 2.

Methods

Volunteer patients diagnosed with SIS were included based on history and physical examination findings. All participants underwent magnetic resonance imaging to confirm the diagnosis and exclude possible accompanying pathologies. The patients were randomly divided into 2 groups. The first group underwent ET at home for 8 weeks (ET group), and the second group received the same ET program and an additional 2 PRP injections, at the beginning of the study and the end of the fourth week (PRP group). Patients were evaluated initially and 6 months after the treatment using the visual analog scale (VAS) for pain score, Constant-Murley Score (CMS), and the 36-Item Short Form Health Survey (SF-36). The Kolmogorov-Smirnov test determined the conformity of the data to a normal distribution, chi-square analysis was used to compare categorical variables between groups, and the Mann-Whitney U test was used to compare continuous and intergroup variables. Intragroup changes before and after treatment were evaluated with the Wilcoxon signed-rank test. P < .05 was considered statistically significant.

Results

A total of 67 patients were initially enrolled; 5 were excluded and 6 were lost to follow-up (1 because of a COVID diagnosis). Thus, 56 patients (56 shoulders) were included for analysis. There were 28 patients in the ET group and 28 patients in the PRP group. There were no statistical differences between groups regarding participant characteristics and clinical evaluations before treatment. A statistically significant improvement was observed in pain (VAS subgroups), functionality (CMS subgroups), and QoL (SF-36 subgroups) evaluations of patients in both the ET and the PRP groups compared with before the treatment and 6 months after treatment (P < .05). At the 6-month posttreatment evaluation, the PRP group was statistically significantly superior to isolated ET in terms of VAS rest (P = .001) and night (P = .004) scores. This superiority was also in favor of the PRP group in flexion strength (P = .001), abduction strength (P = .046), and abduction degree (P = .041) measurements. There was no significant difference between ET and PRP groups regarding VAS activity, CMS, and SF-36 scores (P > .05) at 6 months.

Conclusion

Our study showed that both isolated ET and additional PRP application to ET are effective methods in SIS treatment regarding pain, function, and QoL. Combining ET with PRP was superior in reducing pain and improving abduction degree and strength.

Evidence-Based Clinical Practice Guidelines on Regenerative Medicine Treatment for Chronic Pain: A Consensus Report from a Multispecialty Working Group

Purpose

Injectable biologics have not only been described and developed to treat dermal wounds, cardiovascular disease, and cancer, but have also been reported to treat chronic pain conditions. Despite emerging evidence supporting regenerative medicine therapy for pain, many aspects remain controversial.

Methods

The American Society of Pain and Neuroscience (ASPN) identified the educational need for an evidence-based guideline on regenerative medicine therapy for chronic pain. The executive board nominated experts spanning multiple specialties including anesthesiology, physical medicine and rehabilitation, and sports medicine based on expertise, publications, research, and clinical practice. A steering committee selected preliminary questions, which were reviewed and refined. Evidence was appraised using the United States Preventive Services Task Force (USPSTF) criteria for evidence level and degree of recommendation. Using a modified Delphi approach, consensus points were distributed to all collaborators and each collaborator voted on each point. If collaborators provided a decision of "disagree" or "abstain", they were invited to provide a rationale in a non-blinded fashion to the committee chair, who incorporated the respective comments and distributed revised versions to the committee until consensus was achieved.

Results

Sixteen questions were selected for guideline development. Questions that were addressed included type of injectable biologics and mechanism, evidence in treating chronic pain indications (eg, tendinopathy, muscular pathology, osteoarthritis, intervertebral disc disease, neuropathic pain), role in surgical augmentation, dosing, comparative efficacy between injectable biologics, peri-procedural practices to optimize therapeutic response and quality of injectate, federal regulations, and complications with mitigating strategies.

Conclusion

In well-selected individuals with certain chronic pain indications, use of injectable biologics may provide superior analgesia, functionality, and/or quality of life compared to conventional medical management or placebo. Future high-quality randomized clinical trials are warranted with implementation of minimum reporting standards, standardization of preparation protocols, investigation of dose-response associations, and comparative analysis between different injectable biologics.

Studies with Direct Industry Affiliation are More Likely to Report Positive Results in Randomized Controlled Trials for Platelet-Rich Plasma Use in Rotator Cuff Pathology: A Systematic Review

PURPOSE

To perform a systematic review to evaluate the effect of industry affiliation on the outcomes of randomized controlled trials (RCTs) for platelet-rich plasma (PRP) injections in rotator cuff tears.

METHODS

PubMed, SPORTdiscus, and Scopus databases were searched from 2010 to the present for terms "rotator cuff" and "platelet-rich plasma." Inclusion criteria were RCTs comparing PRP to controls for treatment of rotator cuff tears and exclusion criteria were systematic reviews, meta-analyses, case reports, cohort studies, basic science studies, other level 3 and below studies, and studies not in English. Degree of industry affiliation was categorized into three groups: direct, indirect, and not affiliated. Direct affiliation required the study or its authors to receive financial support from the company manufacturing the devices used in the study to prepare or administer PRP. Indirect affiliation required financial association with a different company that produces or administers PRP than the one used in the study. Studies were classified as favorable if study outcomes achieved significance (p < 0.05) of PRP over the control, or analogous if there was no statistical significance between PRP and control. Data was analyzed using chi-squared and fisher's exact tests.

RESULTS

Of the 47 studies selected for analysis, 8 (17.0%) had no direct industry affiliation, 9 (19.1%) indirect affiliation and 30 (63.8%) no industry affiliation. 22 (46.8%) studies reported favorable results with PRP compared to the control and 25 (53.2%) showed analogous results between PRP and control. Degree of industry affiliation was significantly associated with increased likelihood of reporting favorable study outcomes (p = 0.041). Directly affiliated studies had a significantly increased likelihood of reporting favorable results (p = 0.024) compared to indirectly affiliated.

CONCLUSIONS

Studies that used PRP produced by companies that directly fund the study or were financially affiliated with the authors were significantly more likely to report favorable results.

LEVEL OF EVIDENCE

Systematic review of Level I and II studies.

Is exercise therapy the right treatment for rotator cuff-related shoulder pain? Uncertainties, theory, and practice

BACKGROUND

Exercise therapy is a popular non-surgical treatment to help manage individuals with rotator cuff-related shoulder pain (RCRSP) and is recommended in all clinical practice guidelines. Due to modest effect sizes, low quality evidence, uncertainty relating to efficacy, and mechanism(s) of benefit, exercise as a therapeutic intervention has been the subject of increasing scrutiny.

AIMS

The aim of this critical review is to lay out where the purported uncertainties of exercise for RCRSP exist by exploring the relevant quantitative and qualitative literature. We conclude by offering theoretical and practical considerations to help reduce the uncertainty of delivering exercise therapy in a clinical environment.

RESULTS AND DISCUSSION

Uncertainty underpins much of the theory and practice of delivering exercise therapy for individuals with RCRSP. Nonetheless, exercise is an often-valued treatment by individuals with RCRSP, when provided within an appropriate clinical context. We encourage clinicians to use a shared decision-making paradigm and embrace a pluralistic model when prescribing therapeutic exercise. This may take the form of using exercise experiments to trial different exercise approaches, adjusting, and adapting the exercise type, load, and context based on the individual's symptom irritability, preferences, and goals.

CONCLUSION

We contend that providing exercise therapy should remain a principal treatment option for helping individuals with RCRSP. Limitations notwithstanding, exercise therapy is relatively low cost, accessible, and often valued by individuals with RCRSP. The uncertainty surrounding exercise therapy requires ongoing research and emphasis could be directed towards investigating causal mechanisms to better understand how exercise may benefit an individual with RCRSP.

Shoulder specific exercise therapy is effective in reducing chronic shoulder pain: A network meta-analysis

BACKGROUND

Exercise therapy (ET) is frequently an early treatment of choice when managing shoulder pain, yet evidence on its efficacy to expedite recovery is inconsistent. Moreover, the value of adding adjunct therapies (i.e. injections, manual therapy, electrotherapy) to ET is currently unclear. This study combined both direct and indirect evidence across studies on the effectiveness of ET with/without adjunct therapies compared to usual medical care for adults with chronic shoulder pain.

METHODS AND FINDINGS

Using a network meta-analysis, randomized control trials comparing ET along with adjunct therapies were identified in MEDLINE, Embase, CINAHL, Sportdiscus, CENTRAL, Conference Proceedings Citation Index-Science, clinicaltrials.gov, and association websites. Outcomes included pain, range of motion (ROM), and health-related quality of life (HRQL) measures in adult patients with chronic shoulder pain. Data analysis used a Frequentist hierarchical model. CINeMA tool assessed the confidence in the results and Cochrane Risk of Bias tool assessed quality of studies. 54 studies primarily from Europe (40.38%) included 3,893 participants who were followed up to 52 weeks. Shoulder-specific ET (Mean difference (MD) = -2.1; 95% confidence interval (CI) = -3.5 to -0.7) or in combination with electro-physical agents (MD = -2.5; 95% CI = -4.2 to -0.7), injections (MD = -2.4; 95% CI = -3.9 to-1.04) or manual therapy (MD = -2.3; 95% CI = -3.7 to -0.8) decreased pain compared to usual medical care. Trends with ROM and HRQL scores were seen; however, only Manual Therapy (MD = -12.7 and 95% CI = -24.4 to -1.0) achieved meaningfully important changes. Sensitivity analysis excluding studies with high risk of bias showed similar results, with exception of injections that did not reach significance (MD = -1.3; 95% CI = -4.3 to 1.7).

CONCLUSION(S)

Shoulder-specific ET provided pain relief up to 52 weeks. Adjunct therapies to shoulder-specific ET added little value in reducing pain. The quality of evidence varied between moderate and very low.

Most Orthopaedic Platelet-Rich Plasma Investigations Don't Report Protocols and Composition: An Updated Systematic Review

PURPOSE

To systematically review the literature to assess the heterogeneity of platelet-rich plasma (PRP) preparation and composition reporting for the treatment of musculoskeletal/orthopaedic pathologies.

METHODS

A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify Level I and Level II studies from 2016 to 2022 that evaluated the use of PRP therapy for musculoskeletal pathologies. The search phrase used was "platelet-rich plasma clinical studies." Studies were assessed based on their reporting of the PRP preparation methods and reporting of PRP composition.

RESULTS

One hundred twenty-four studies (in 120 articles) met inclusion criteria for analysis. Of these studies, 15 (12.1%) provided comprehensive reporting, including a clear, well-described, and reproducible preparation protocol that future investigators can follow. Thirty-three studies (26.6%) quantitatively reported the final PRP product composition.

CONCLUSIONS

Among the studies using PRP for the treatment of musculoskeletal/orthopaedic pathologies, less than 20% provided a clear, well-described, and reproducible PRP preparation protocol, and only one-fourth of studies reported on the final PRP product composition.

CLINICAL RELEVANCE

A diverse current reporting of PRP composition between studies provides a high heterogeneity of the term "PRP," which becomes a limitation for a comparison of studies using PRP.

"Restoring That Faith in My Shoulder": A Qualitative Investigation of How and Why Exercise Therapy Influenced the Clinical Outcomes of Individuals With Rotator Cuff-Related Shoulder Pain

OBJECTIVE

Rotator cuff-related shoulder pain (RCRSP) is the most common form of shoulder pain. Exercise therapy is a first-line recommended treatment for RCRSP. However, the causal mechanisms underpinning the benefits of exercise for RCRSP are not well understood. Moreover, how individuals with lived experience of RCRSP believe exercise helped or did not help them is unknown. This study aimed to gain insights into how individuals with RCRSP believe exercise influenced their shoulder pain and identify the clinical conditions that promoted or inhibited their beliefs.

METHODS

This qualitative study was underpinned by a critical realist approach to thematic analysis. Participants were recruited using hybrid purposive and convenience sampling techniques. Each participant attended an online semi-structured interview. The data were coded by 2 members of the research team (J.K.P. and N.C.) and verified by a third (B.S.). Recruitment continued until theoretical sufficiency was achieved. Participants reviewed and validated preliminary causal explanations.

RESULTS

Three causal explanations were consistently expressed by 11 participants to explain the benefits of exercise therapy: (1) shoulder strength; (2) changes to psychoemotional status; and (3) exercise has widespread health effects. However, the activation of these causal mechanisms depended on (1) the presence of a strong therapeutic relationship; (2) the provision of a structured and tailored exercise program; and (3) experiencing timely clinical progress.

CONCLUSION

Participants believed exercise improved their shoulder pain through associated health benefits, improved shoulder strength, and psychoemotional variables. Whether an exercise program was able to cause a clinical improvement for an individual with RCRSP was contingent on clinical contextual features. Thus, the clinical context that an exercise program is delivered within may be just as important as the exercise program itself.

IMPACT

Exercise is a recommended first-line intervention to manage RCRSP. The results of this study suggest that a positive experience and outcome with exercise for RCRSP is contingent on several clinical contextual features, such as a strong therapeutic relationship. The clinical context that an exercise program is prescribed and delivered within should be considered by clinicians.

Current Status and Advancements in Platelet-Rich Plasma Therapy

Platelet-rich plasma (PRP) as a treatment modality has been around for the last four decades, but only truly gained popularity over the last 10 to 15 years in medicine, in a variety of fields ranging from regenerative medicine to infertility treatment. It has gained popularity, especially in treating musculoskeletal conditions where the bulk of research has been performed and published. There is level I evidence available supporting its efficacy in the treatment of osteoarthritis (OA), epicondylitis, bursitis, compressive neuropathy, plantar fasciitis, muscular injuries and osteochondral lesions. Most published research with regards to PRP has been focused on knee OA (limited research in shoulder, elbow, and foot and ankle OA), lateral epicondylitis and carpal tunnel syndrome, whereas spinal and hand conditions have limited research available. Tendinopathies and partial tendon tears have conflicting evidence available, with level I evidence supporting PRP's use in rotator cuff tendinopathies and tears, with contradictory level I evidence discouraging its use in patella and Achilles tendinopathies and tears. The available evidence regarding the use of PRP continues to produce conflicting results, but despite this, there is an ongoing increase in the popularity and use of PRP in patients with musculoskeletal conditions.

Subacromial Platelet-Rich Plasma Injections Produce Significantly Worse Improvement in Functional Outcomes in Patients With Partial Supraspinatus Tears Than in Patients With Isolated Tendinopathy

PURPOSE

To compare the effect of subacromial leukocyte-rich platelet-rich plasma (PRP) injections in patients with isolated rotator cuff tendinopathy (RCT) and those with partial-thickness rotator cuff tears (PTRCTs) based on functional outcomes, pain improvement, sleep disturbances, and return to sports.

METHODS

Between November 2019 and March 2021, 150 patients underwent PRP injections at our institution for refractory rotator cuff tendinopathy and partial rotator cuff tears (105 RCTs and 45 PTRCTs). The American Shoulder and Elbow Surgeons (ASES) score, the visual analog scale (VAS) for pain, the Single Assessment Numeric Evaluation (SANE) and The Pittsburgh Sleep Quality Index were evaluated at 2-, 6-, and 12-month follow-up. Return to sports was also evaluated. An ultrasound examination was performed to evaluate structural outcomes 12 months after the injection.

RESULTS

The mean age was 36.6 years (±9.08). Overall, the ASES, VAS, SANE, and Pittsburgh scores showed statistical improvement after the injection (P < .01). Specifically, the improvement in the ASES score, which was the primary outcome measure was significantly greater in the group without tears than in the group with PTRCTs at all follow-up times. Moreover, 94% of the patients in the isolated RCT group and 49% in the PTRCTs group achieved a substantial clinical benefit at 12 months follow-up. Ten out of the 50 patients (20%) who received PRP injections due to a partial RC tear underwent surgery due to the lack of clinical improvement.

CONCLUSIONS

Subacromial PRP injections produced a significant improvement in shoulder function, pain, and sleep disturbances in most patients with RCT refractory to conservative treatment that was maintained at the 12-month follow-up. Moreover, most patients returned to sports at the same level prior to injury. However, improvement in symptoms and functional outcomes was significantly worse in patients who had a PTRCT compared with patients who had an isolated tendinopathy.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Exercise for rotator cuff tendinopathy: Proposed mechanisms of recovery

Rotator cuff (RC) tendinopathy is a common recurrent cause of shoulder pain, and resistance exercise is the first-line recommended intervention. Proposed causal mechanisms of resistance exercise for patients with RC tendinopathy consist of four domains: tendon structure, neuromuscular factors, pain and sensorimotor processing, and psychosocial factors. Tendon structure plays a role in RC tendinopathy, with decreased stiffness, increased thickness, and collagen disorganization. Neuromuscular performance deficits of altered kinematics, muscle activation, and force are present in RC tendinopathy, but advanced methods of assessing muscle performance are needed to fully assess these factors. Psychological factors of depression, anxiety, pain catastrophizing, treatment expectations, and self-efficacy are present and predict patient-reported outcomes. Central nervous system dysfunctions also exist, specifically altered pain and sensorimotor processing. Resisted exercise may normalize these factors, but limited evidence exists to explain the relationship of the four proposed domains to trajectory of recovery and defining persistent deficits limiting outcomes. Clinicians and researchers can use this model to understand how exercise mediates change in patient outcomes, develop subgroups to deliver patient-specific approach for treatment and define metrics to track recovery over time. Supporting evidence is limited, indicating the need for future studies characterizing mechanisms of recovery with exercise for RC tendinopathy.

Plasma rich in growth factors versus corticosteroid injections for management of chronic rotator cuff tendinopathy: a prospective double-blind randomized controlled trial with 1 year of follow-up

BACKGROUND

Rotator cuff tendinopathy (RCT) is a painful and dysfunctional shoulder condition traditionally considered as a degenerative pathology. However, evidence is pointing to immunocompetent cells and activated stromal fibroblasts as the drivers of a nonresolved inflammatory condition in RCT. As potent anti-inflammatory agents, corticosteroid injections have been among the first-line and the most common therapeutic strategies. Recently, another adjuvant therapy to treat musculoskeletal inflammation-driven painful conditions, namely, platelet-rich plasma (PRP), has emerged as safe and effective. The aim of this study was to compare the clinical efficacy of intratendinous injections of plasma rich in growth factors (PRGF) with conventional intratendinous corticosteroid injections on patients with chronic RCT using patient-reported outcome measures.

METHODS

A total of 39 patients received PRGF treatment (3 infiltrations, 1 every other week), whereas 40 patients, as a control group, received corticosteroid (3 infiltrations, 1 every other week). Patients were evaluated before treatment and at 3, 6, and 12 months of follow-up using the University of California Los Angeles (UCLA) scale, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), and Constant test. The primary outcome of the study was a 15% superior improvement of the PRGF group compared with the corticosteroid group in the UCLA scale and QuickDASH test at 6 months of follow-up, considering this difference to be clinically relevant.

RESULTS

Both PRGF and corticosteroid groups showed significant clinical improvement in the 3 scores at all time points of the study compared with baseline. However, at 6 and 12 months of follow-up, the PRGF group had 22.1% and 21.2% superior improvement of the UCLA test, 14.3% and 13.5% for QuickDASH, and 16.4% and 20.2% for the Constant-Murley test, respectively, compared to the corticosteroid group.

CONCLUSIONS

Three PRGF intratendinous injections every other week in patients with chronic rotator cuff tendinopathy show significantly superior and sustained pain-relieving and functional improvements compared with corticosteroid intratendinous injections assessed by 3 patient-reported outcome scales at 6 and 12 months of follow-up.

Ultrasound-guided injection of platelet-rich plasma for tendinopathies: a systematic review and meta-analysis

BACKGROUND

In this systematic review and meta-analysis, we evaluated ultrasound (US)-guided injections of platelet-rich plasma (PRP) as conservative treatment of tendinopathies.

MATERIALS AND METHODS

We searched MEDLINE, EMBASE, SCOPUS, OVID, and the Cochrane Library to identify randomized controlled trials (RCT) on the use of US-guided PRP for tendinopathies.

RESULTS

We found 33 RCT (2,025 subjects) that met our inclusion criteria: 8 in lateral epicondylitis, 5 in plantar fasciitis, 5 in Achilles tendinopathy, 7 in rotator cuff tendinopathy, 3 in patellar tendinopathy and 5 in carpal tunnel syndrome. PRP, given as a single injection (20 trials) or multiple injections (13 trials), was compared to US-guided injection of steroids, saline, autologous whole blood, local anesthetic, dry needling, prolotherapy, bone marrow mesenchymal stem cells, or with non-injective interventions. The outcomes more commonly reported included pain and functional measures, subgrouped as in the short-term (<3 months from the intervention), medium-term (3 to 6 months) or long-term (≥12 months). No clear between-group differences in these outcomes were observed in patients with lateral epicondylitis, plantar fasciitis, or Achilles, rotator cuff or patellar tendinopathy. In patients with carpal tunnel syndrome, visual analog scale scores for pain at 3 and 6 months and Boston Carpal Tunnel Questionnaire severity scores at 1, 3 and 6 months were significantly lower in PRP recipients than in controls. The certainty of evidence of all these comparisons was graded as low or very low due to risk of bias, imprecision and/or inconsistency. Pain at the injection site was more common among PRP recipients than among controls receiving other US-guided injections.

DISCUSSION

In patients with tendinopathies, a trend towards pain reduction and functional improvement from baseline was observed after US-guided PRP injection, but in the majority of the comparisons, the effect size was comparable to that observed in control groups.

Effectiveness of lyophilized growth factors injection for subacromial impingement syndrome: a prospective randomized double-blind placebo-controlled study

BACKGROUND

Platelet-derived lyophilized growth factors (L-GFs) use a standardized number of allogenic pathogen-free platelets instead of autologous platelets used in PRP as a source of growth factors. This study aimed to evaluate the efficacy of L-GF injection versus placebo in subacromial impingement (SIS) treatment.

METHODS

The current randomized double-blind placebo-controlled study included sixty patients (40 females and 20 males, aged between 24 and 75 years) diagnosed with SIS (both clinically and sonographically). Patients were randomly assigned to two equal groups. Under ultrasound guidance, group 1 received subacromial saline injection, and group 2 received L-GF injection. Clinical examination, pain visual analogue scale (VAS), shoulder pain and disability index (SPADI) and shoulder ultrasound were performed before and at the 8th week after injection.

RESULTS

Follow-up assessment showed statistically significant improvement in the L-GF group regarding active flexion, active and passive internal rotation and extension, SPADI-disability scale, VAS and thickness of the supraspinatus tendon by US. Regression analysis showed that group 1 was approximately 30 times more likely than the L-GF group to experience painful arc at follow-up. Both groups showed statistically significant improvement in SPADI-pain scale and SPADI-total, flexion and abduction (still the mean value of abduction was significantly higher in the L-GF group).

CONCLUSIONS

L-GF injection resulted in clinically significant reductions in pain and functional disability outcomes in patients with SIS. An objective significant reduction in the thickness of the supraspinatus tendon, measured by ultrasound, in the L-GF group hopefully encourages proper healing and functioning in SIS.

TRIAL REGISTRATION

The identification number is NCT04330027, date of first registration (01/04/2020). Unique on 21/11/2019, Protocol ID: 0106178.

Platelet-rich plasma does not improve clinical results in patients with rotator cuff disorders but reduces the retear rate. A systematic review and meta-analysis

PURPOSE

To assess whether the use of Platelet-rich plasma (PRP) produces a clinical benefit in patients with rotator cuff disorders, treated either conservatively or surgically.

METHODS

A systematic review was performed according to PRISMA guidelines on three databases (PubMed, Cochrane Library, Web of Science) to identify randomised controlled trials (RCTs) on the use of PRP in patients with rotator cuff disorders, treated either conservatively or surgically. A meta-analysis was performed on articles reporting results for Constant, UCLA, VAS, SST scores and retear rate. The RoB 2.0 and the modified Coleman Methodology Score were used to assess methodological quality.

RESULTS

A total of 36 RCTs (20 surgical, 16 conservative) were included, for a total of 2,443 patients. Conservative treatment showed high heterogeneity and no clear consensus in favour of PRP. The meta-analysis of the studies with surgical treatment showed no benefit in using PRP in any of the clinical outcomes, either at the short or medium/long-term follow-up. However, the retear rate was lower with PRP augmentation (p < 0.001). The overall quality of the studies was moderate to high, with the surgical studies presenting a lower risk of bias than the conservative studies.

CONCLUSION

The use of PRP as augmentation in rotator cuff surgical repair significantly reduces the retear rate. However, no benefits were documented in terms of clinical outcomes. PRP application through injection in patients treated conservatively also failed to present any clear advantage. While there are many studies in the literature with several RCTs of moderate to high quality, the high heterogeneity of products and studies remains a significant limitation to fully understanding PRP potential in this field.

LEVEL OF EVIDENCE

Level I.

Platelet-rich Plasma in the Management of Shoulder Disorders: Basic Science and Implications Beyond the Rotator Cuff

Platelet-rich plasma (PRP) is an autologous mixture produced by centrifugal separation of whole blood. Understanding the clinical efficacy of PRP remains a challenge in the field of sports medicine, including the treatment of various shoulder conditions. Animal studies have examined the biologic actions of PRP on the rotator cuff tendon and shoulder capsule. Human studies have reported the outcomes of PRP in the management of subacromial impingement syndrome, rotator cuff tears, frozen shoulder, and glenohumeral osteoarthritis. These studies highlight the role of PRP in the nonsurgical management of these conditions and its utilization in the perioperative setting to augment tissue healing and optimize the surgical outcomes. The role of PRP as an adjunct therapy in patients undergoing rotator cuff repair has been in the spotlight during the last decade; however, a limited number of studies have examined the role of PRP in the management of non-rotator cuff shoulder conditions. This article aims to provide an overview of the biologic actions of PRP on shoulder tissues and to summarize the outcomes of PRP injection in patients with rotator cuff and non-rotator cuff disease of the shoulder. We sought to organize the existing literature and to provide recommendations on the use of PRP in various shoulder conditions, based on the existing evidence.

Physical Therapy Combined With Subacromial Cortisone Injection Is a First-Line Treatment Whereas Acromioplasty With Physical Therapy Is Best if Nonoperative Interventions Fail for the Management of Subacromial Impingement: A Systematic Review and Network Meta-Analysis

PURPOSE

To construct an algorithm to optimize clinical outcomes in subacromial impingement based on current, high-level evidence.

METHODS

A systematic review of all clinical trials on subacromial impingement published from 1999 to 2020 was performed. Demographic, clinical, range of motion (ROM), and patient-reported outcome measure (PROM) data were collected. Interventions were compared via arm-based Bayesian network meta-analysis in a random-effects model and treatments ranked via surface under the cumulative ranking curves with respect to 3 domains: pain, PROMs, and ROM.

RESULTS

A total of 35 studies comprising 3,643 shoulders (42% female, age 50 ± 5 years) were included. Arthroscopic decompression with acromioplasty ranked much greater than arthroscopic decompression alone for pain relief and PROM improvement, but the difference in absolute PROMs was not statistically significant. Corticosteroid injection (CSI) alone demonstrated inferior outcomes across all 3 domains (pain, PROMs, and ROM) with low cumulative rankings. Physical therapy (PT) with CSI demonstrated moderate-to-excellent clinical improvement across all 3 domains whereas PT alone demonstrated excellent ROM and low-moderate outcomes in pain and PROM domains. PT with nonsteroidal anti-inflammatory drugs or alternative therapies ranked highly for PROM outcomes and moderate for pain and ROM domains. Finally, platelet-rich plasma injections demonstrated moderate outcomes for pain, forward flexion, and abduction with very low-ranking outcomes for PROMs and external rotation.

CONCLUSIONS

Arthroscopic decompression with acromioplasty and PT demonstrated superior outcomes whereas CSI demonstrated poor outcomes in all 3 domains (pain, PROMs, and ROM). For patients with significant symptoms, the authors recommend PT with CSI as a first-line treatment, followed by acromioplasty and PT if conservative treatment fails. For patients with symptoms limited to 1 to 2 domains, the authors recommend a shared decision-making approach focusing on treatment rankings within domains pertinent to individual patient symptomatology.

LEVEL OF EVIDENCE

I, systematic review and network meta-analysis of Level I studies.

Efficacy of Single Injection of Platelet-Rich Plasma in Shoulder Impingement Syndrome

Introduction

To analyze the change in Visual Analog Scale (VAS), QuickDASH score, and the range of motion at the shoulder joint following a single injection of platelet-rich plasma (PRP) in shoulder impingement syndrome.

Methods

Twenty patients (21 shoulders) of either sex above the age of 18 years with a clinical diagnosis of shoulder impingement having a positive shoulder impingement test (positive Hawkins-Kennedy impingement test and/or positive Neer's impingement sign), ultrasonographic confirmation of shoulder impingement, and a failure to respond to standard non-operative methods for a minimum period of four weeks were included in this prospective interventional study. PRP was injected at the proposed site. At three months after the injection, the changes in the VAS, QuickDASH score, and the range of motion at the shoulder joint were analyzed.

Results

There were significant changes in the VAS, QuickDASH score, and range of motion at the shoulder joint following a single injection of PRP.

Conclusions

Platelet-rich plasma (PRP) injection results in a significant decrease in pain and improvement in the range of motion and an overall excellent functional outcome in shoulder impingement syndrome. However, future studies with a bigger sample size and longer follow-up are needed.

Use of Behavior Change Techniques Alongside Exercise in the Management of Rotator Cuff-Related Shoulder Pain: A Scoping Review

OBJECTIVES

The aims of this scoping review were to: (1) determine the frequency and types of behavior change techniques (BCTs) and education utilized in trials investigating exercise interventions for rotator cuff related shoulder pain (RCRSP); (2) subcategorize the BCTs and education found in the trials to summarize all behavior change approaches reported by trials; and (3) compare the frequency, types, and subcategories of BCTs and education utilized in the clinical guidelines for managing RCRSP between the trials.

METHODS

Data sources included Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Ovid EMBASE, CINAHL Plus, Google Scholar and PubMed, which were searched from inception to June 2020. Trials assessing exercise interventions for RCRSP were included. Three authors independently determined eligibility and extracted data. The frequency and types of BCTs and education in the trials and clinical practice guidelines were reported and compared descriptively. Two authors assessed the content of the BCTs to develop subcategories.

RESULTS

Most trials reported including at least 1 type of BCT (89.2%), which was most commonly feedback and monitoring (78.5%). There were many different approaches to the BCTs and education; for example, feedback and monitoring was subcategorized into supervised exercise, exercise monitoring, and feedback through external aids, such as mirrors. Clinical guidelines recommend supervision, goal setting, activity modification, pain management recommendations, information about the condition, and exercise education.

CONCLUSION

Although over two-thirds of trials reported including a BCT alongside exercise interventions for RCRSP, the breadth of these interventions is limited (supervision is the only common one). Future trialists should consider using any type of BCT that may improve exercise adherence and outcomes.

IMPACT

The findings of this review have: (1) identified gaps in the literature; and (2) contributed to the design of future exercise interventions for RCRSP.

Platelet-rich plasma versus corticosteroid injections for rotator cuff tendinopathy: a comparative study with up to 18 months follow-up

Background

Given the complications involved in corticosteroid (CS) injections, subacromial platelet-rich plasma (PRP) injections may provide a valid alternative to CS in the treatment of rotator cuff (RC) tendinopathy.

Methods

We retrospectively reviewed a total of 98 patients affected by RC tendinopathy who were treated with either subacromial injection of PRP or CS. The PRP group received three injections of autologous PRP at 2 weeks interval, and the CS group received one injection of CS. The Western Ontario Rotator Cuff Index (WORC) was the primary outcome measure, while the secondary outcome measures were the visual analog scale (VAS), range of motion (ROM), and need for cuff repair surgery, which were analyzed at intervals of 6, 12, and 18 months.

Results

A total of 75 patients were included in the analysis (PRP, n=35; CS, n=40). The mean follow-up for PRP was 21.1±8.7 months and for CS was 33.6±16.3 months (p<0.001). Both groups showed improvement in WORC, VAS, and ROM. No significant differences were detected between the two groups in any of the primary (WORC) or secondary outcomes over 6, 12, and 18 months (all p>0.05). No adverse events were detected.

Conclusions

Both treatments improved patient symptoms, but neither resulted in a significantly better outcome in this series of patients. PRP can be a safe and feasible alternative to CS, even at long-term follow-up, to reduce local and systemic effects involved with CS injections.

Orthobiologics: Diagnosis and Treatment of Common Tendinopathies

Orthobiologics, including platelet-rich plasma, prolotherapy, and mesenchymal stem cells, are seeing increasing use in the treatment of osteoarthritis (OA), muscle injury, and tendinopathy. This article reviews the biology and applications of orthobiologics in tendons, muscles, and joints, and focuses on platelet-rich plasma (PRP). Clinical evidence-based literature related to the use of PRP in the treatment of rotator cuff injury, lateral epicondylosis, Achilles tendinopathy, plantar fasciitis, knee OA, and acute muscle injury are discussed.

Can platelet-rich plasma injections provide better pain relief and functional outcomes in persons with common shoulder diseases: a meta-analysis of randomized controlled trials

Background

To evaluate the efficacy of autologous platelet-rich plasma (PRP) injections in the treatment of common shoulder diseases.

Methods

The PubMed, Medline, and Central databases and trial registries were searched from their inception to October 2020 for randomized controlled trials of autologous PRP injections for shoulder diseases versus placebo or any control intervention. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were followed in the selection, analysis, and reporting of findings. The primary outcome was pain intensity (visual analog scale), and secondary outcomes were changes in function and quality of life (QoL).

Results

A total of 17 randomized controlled trials of PRP versus control were analyzed. From 8–12 weeks to ≥1 year, PRP injections were associated with better pain relief and functional outcomes than control interventions. PRP injections were also associated with greater QoL, with an effect size of 2.61 (95% confidence interval, 2.01–14.17) at medium-term follow-up. Compared with placebo and corticosteroid injections, PRP injections provided better pain relief and functional improvement. In subgroup analyses, trials in which PRP was prepared by the double centrifugation technique, the platelet concentration in the PRP was enriched ≥5 times, leucocyte-rich PRP was used, or an activating agent was used before application reported the most effective pain relief at 6–7 months.

Conclusions

PRP injections could provide better pain relief and functional outcomes than other treatments for persons presenting with common shoulder diseases. PRP injections have a greater capacity to improve shoulder-related QoL than other interventions.

Nonoperative and Operative Soft-Tissue, Cartilage, and Bony Regeneration and Orthopaedic Biologics of the Shoulder: An Orthoregeneration Network (ON) Foundation Review

Orthoregeneration is defined as a solution for orthopaedic conditions that harnesses the benefits of biology to improve healing, reduce pain, improve function, and optimally, provide an environment for tissue regeneration. Options include drugs, surgical intervention, scaffolds, biologics as a product of cells, and physical and electro-magnetic stimuli. The goal of regenerative medicine is to enhance the healing of tissue after musculoskeletal injuries as both isolated treatment and adjunct to surgical management, using novel therapies to improve recovery and outcomes. Various orthopaedic biologics (orthobiologics) have been investigated for the treatment of pathology involving the shoulder including the rotator cuff tendons, glenohumeral articular cartilage, glenoid labrum, the joint capsule, and bone. Promising and established treatment modalities include hyaluronic acid (HA); platelet-rich plasma (PRP) and platelet rich concentrates (PRC); bone marrow aspirate (BMA) comprising mesenchymal stromal cells (MSCs alternatively termed medicinal signaling cells and frequently, misleadingly labelled "mesenchymal stem cells"); MSC harvested from adipose, umbilical, or placental sources; factors including vascular endothelial growth factors (VEGF), basic fibroblast growth factor (FGF), platelet-derived growth factor (PDGF), transforming growth factor-beta (TGFβ), bone morphogenic protein (BMP), and matrix metalloproteinases (MMPs); prolotherapy; pulsed electromagnetic field therapy; microfracture and other marrow-stimulation techniques; biologic resurfacing using acellular dermal allografts, allograft Achilles tendons, allograft lateral menisci, fascia lata autografts, and porcine xenografts; osteochondral autograft or allograft); and autologous chondrocyte implantation (ACI). Studies involving hyaluronic acid, platelet rich plasma, and medicinal signaling cells of various origin tissues have shown mixed results to-date as isolated treatments and as surgical adjuncts. Despite varied results thus far, there is great potential for improved efficacy with refinement of current techniques and translation of burgeoning preclinical work. LEVEL OF EVIDENCE: Level V, expert opinion.

Acupuncture Treatment for Shoulder Impingement Syndrome: A Review of Randomized Controlled Trials

To evaluate the effectiveness of acupuncture treatment for shoulder impingement syndrome (SIS) a literature review was conducted of randomized controlled trials (RCTs) where acupuncture was used as an intervention for patients diagnosed with SIS. Relevant clinical studies (N = 181) were retrieved from several databases based on the inclusion/exclusion criteria, and the interventions and results were analyzed. Six RCTs were selected to review based on the inclusion and exclusion criteria. In all 6 studies, the acupuncture treatment group showed significant positive changes in indicators evaluating pain, disability, and quality of life. A significant decrease in the evaluation indicators (Shoulder Pain and Disability Index, numeric rating scale, Visual Analogue Scale, Constant Murley Shoulder Assessment Score, patient’s global assessment, and doctor’s global assessment) and a significant increase in the questionnaire scores (UCLA, AL-score, EuroQol 5 Dimension Self-Report Questionnaire, and disabilities of the arm, shoulder, and hand) were observed. In addition, 1 study showed similar improvements in pain and quality of life measures in the acupuncture group and corticosteroid injection group. No major side effects were reported. Acupuncture may be an effective and safe treatment for SIS however, further RCTs are required.

Platelet-rich plasma for rotator cuff tendinopathy: A systematic review and meta-analysis

Shoulder rotator cuff tendinopathy is a common debilitating condition that affects a person daily function and the quality of life. Despite its frequent occurrence, the best treatment is still inconclusive. This review assessed the clinical effect of platelet-rich plasma injection for rotator cuff tendinopathy. A systematic literature search was conducted using CINAHL, Medline, SCOPUS, SPORTSDiscus and Web of Science databases to retrieve articles published in peer-reviewed journals until December 2020. Randomised controlled trials (RCTs), which compared clinical effects of PRP injection to the usual care among adults diagnosed with rotator cuff conditions were reviewed. The main outcomes of interest were changes in shoulder pain symptoms and shoulder functions. All variables were analysed using random effects meta-analyses. Eight RCTs were reviewed in this study. The risk of bias for randomization was low for 6 RCTs, one study had unclear risk and the other was a high risk. Studies vary on the PRP techniques including preparation and injections. Moreover, the control intervention also differs. Four studies compared PRP with normal saline injection while in the remaining 4 RCTs the control intervention were rehabilitation program and dry needling. Meta-analysis of selected studies showed that PRP injection was safe and effective intervention for long-term pain control and shoulder function in patients with RC disorders.

Platelet-Rich Plasma in Patients With Partial-Thickness Rotator Cuff Tears or Tendinopathy Leads to Significantly Improved Short-Term Pain Relief and Function Compared With Corticosteroid Injection: A Double-Blind Randomized Controlled Trial

PURPOSE

To perform a randomized controlled trial comparing platelet-rich plasma (PRP) with standard corticosteroid (CS) injection in providing pain relief and improved function in patients with rotator cuff tendinopathy and partial-thickness rotator cuff tears (PTRCTs).

METHODS

This double-blind randomized controlled trial enrolled patients with ultrasound-proven or magnetic resonance imaging-proven PTRCTs who received either an ultrasound-guided PRP or CS injection. Patients completed patient-reported outcome assessments at baseline and at 6 weeks, 3 months, and 12 months after injection. The primary outcome was improvement in the visual analog scale (VAS) score for pain. Secondary outcomes included changes in American Shoulder and Elbow Surgeons (ASES) and Western Ontario Rotator Cuff Index (WORC) scores. Treatment failure was defined as subsequent injection, consent to undergo surgery, or operative intervention.

RESULTS

We followed up 99 patients (47 in the PRP group and 52 in the CS group) until 12 months after injection. There were no differences in baseline patient demographic characteristics including age, sex, or duration of symptoms. Despite randomization, patients in the PRP group had worse baseline VAS (46.0 vs 34.7, P = .01), ASES (53.9 vs 61.8, P = .02), and WORC (42.2 vs 49.5, P = .03) scores. At 3 months after injection, the PRP group had superior improvement in VAS (-13.6 vs 0.4, P = .03), ASES (13.0 vs 2.9, P = .02), and WORC (16.8 vs 5.8, P = .03) scores. There were no differences in patient-reported outcomes at 6 weeks or 12 months. There was no difference in the rate of failure (P = .31) or conversion to surgery (P = .83) between groups.

CONCLUSIONS

Patients with PTRCTs or tendinopathy experienced clinical improvement in pain and patient-reported outcome scores after both ultrasound-guided CS and PRP injections. Patients who received PRP obtained superior improvement in pain and function at short-term follow-up (3 months). There was no sustained benefit of PRP over CS at longer-term follow-up (12 months).

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Autologous Platelet Rich Plasma (PRP) in the treatment of elbow epicondylitis and plantar fasciitis: medium to long term clinical outcome

Background and aim:

Platelet-Rich-Plasma(PRP) is a popular biological therapy especially used to regenerate different musculoskeletal tissues by releasing growth-factors and cytokines promoting cell proliferation, chemotaxis, differentiation, and angiogenesis. The

aim

was to evaluate the clinical effectiveness and safety of PRP for Lateral-Epicondylitis (LE) of the elbow and Plantar-Fasciitis (PF).

Methods:

A retrospective study was conducted including patients treated with a single topic autologous-PRP-injection between 1-1-2009 and 7-18-2019 for LE or PF at our institution; patients operated for the same problem, patients refusing the study or not traceable were excluded. Patients were assessed with VAS for pain and clinical scales.

Results:

33 patients were treated with PRP and 13 (8F, 5M) included: 4LE and 9PF for a total of 16 cases. The average pain level was 0.61±0.63: 1±1.41 for LE and 0,44±0 for PF. No significant side effect was reported. 4 PRP-treatments failed: 2LE and 2PF. OES and PRTEE gave excellent results for elbow. Average foot scores were AOFAS 98.2±5 and FADI 91.3±1. Patients were stratified and compared according to plantar arch conformation, follow-up length, healing time, time from diagnosis to PRP-treatment, therapies before PRP (physiotherapy, steroid infiltration or shock-waves), risk factors (standing work, sport, age, sex).

Conclusions:

As in other studies, our results do not allow to draw sufficiently valid conclusions regarding the effectiveness and safety of PRP in the treatment of LE and PF: in particular the statistical significance is limited by the small sample size. PRP can be chosen as a non-first-line treatment for LE and PF.

Participant characteristics are poorly reported in exercise trials in tendinopathy: A systematic review

OBJECTIVE

To evaluate the reporting of eligibility criteria and baseline participant characteristics in randomised controlled trials investigating the effects of exercise interventions in tendinopathy.

METHODS

Randomised controlled trials investigating the effects of exercise therapy compared to a non-exercising intervention in upper and lower limb tendinopathy were included. Data extraction was categorised into the following domains: participant demographics, tendinopathy descriptors, general health, participant recruitment and eligibility criteria.

RESULTS

The review included the following tendinopathies: Achilles (n = 9), gluteal (n = 2), lateral elbow tendinopathy (n = 15), patellar (n = 3) plantar (n = 3), and rotator cuff (n = 13). Age, sex, duration of symptoms and symptom severity were commonly reported across the review, while prior history of tendinopathy was poorly reported (6/45). Variables such as physical activity level (17/45), sleep (0/45), psychological factors (2/45), medication at baseline (8/45), co morbid health complaints (10/45) and sociodemographic factors (11/45) were poorly reported across the included studies. Substantial variation existed between studies in the specific eligibility criteria used.

CONCLUSION

The findings of this systematic review demonstrate that participant characteristics are poorly reported in exercise trials in tendinopathy. To improve effectiveness of exercise interventions in tendinopathy, improved reporting of participant characteristics may allow better comparisons and targeted interventions for specific subgroups.

Systematic Review and Meta-Analysis of Nonoperative Platelet-Rich Plasma Shoulder Injections for Rotator Cuff Pathology

BACKGROUND

Platelet-rich plasma (PRP) injections have been introduced to augment the recovery of patients with shoulder pathology. Although multiple studies have been published, no large-scale trials or meta-analyses have assessed the efficacy of nonoperative shoulder PRP injection.

OBJECTIVE

To assess the efficacy of nonoperative PRP shoulder injection in rotator cuff pathology for pain as measured by the visual analog scale (VAS) and range of motion (ROM).

DESIGN

Two authors independently screened the Medline and Cochrane databases to include prospective studies that reported VAS and ROM outcomes for nonoperative shoulder PRP injections for rotator cuff pathology. Study quality was assessed using the revised Cochrane Collaboration risk-of-bias tool and modified Downs and Black checklist. Subsequent meta-analysis was performed to determine the effect of nonoperative PRP injections on pain and ROM 3 to 12 months after intervention.

RESULTS

Six studies met systematic review criteria. The included studies used different PRP formulations (concentration, leukocyte count), injection protocols (approach, injection number), and varied study designs. Three studies concluded that PRP provided no significant benefit for pain and ROM when compared to physical therapy. Within-group meta-analysis of six fairly heterogeneous studies (I² 77.8%) demonstrated a statistically significant (P < .001) improvement in pain 3 to 12 months after PRP injection. Within-group meta-analysis for four studies for shoulder flexion and abduction was found to be too heterogeneous to derive meaningful results.

CONCLUSION

There is a limited quantity of high-quality studies that assess the efficacy of nonoperative PRP shoulder injection for pain and ROM. Systematic review of PRP injections did not demonstrate an improvement in pain or ROM compared to physical therapy. Although within-group meta-analysis of nonoperative PRP statistically showed that nonoperative PRP improved pain, the lack of adequate negative controls precludes the ability to conclude whether improvements were due to natural recovery or nonoperative PRP.

Influence of Acromial Morphologic Characteristics and Acromioclavicular Arthrosis on the Effect of Platelet-Rich Plasma on Partial Tears of the Supraspinatus Tendon

OBJECTIVE. The purposes of this study were to determine the medium-term effect of ultrasound-guided infiltration of platelet-rich plasma (PRP) on partial tears of the supraspinatus tendon (SST) and to identify prognostic indicators of an unfavorable outcome. SUBJECTS AND METHODS. Over a period of 4 years, patients with a partial SST tear smaller than 1.5 cm referred for ultrasound-guided PRP infiltration (1 mL) for shoulder pain lasting more than 3 months were recruited consecutively. MRI was used to analyze the type of acromion and presence of acromioclavicular (AC) arthrosis. Primary (size of the tear and associated bursitis) and secondary (mobility and pain) results were collected at 3 months. RESULTS. The study included 128 patients (66 men, 62 women; mean age, 48.3 years; range, 20-59 years). At 3 months, favorable evolution of the tear repair was recorded in 71.1% (91/128) of patients and resolution of bursitis in 66.7% (42/63). Changes in tear size had large effect sizes (Cohen d ≥ 1.16), as did pain and shoulder mobility (Cohen d ≥ 0.95). The strongest predictors of unfavorable evolution of tear and bursitis were type 3 acromion and types 1 and 2 acromion with AC arthrosis (p < 0.001; β = 20.412). CONCLUSION. Ultrasound-guided PRP infiltration of partial tears of the SST relieves pain and improves shoulder mobility, but its effect on the size of the tear is influenced by the morphologic characteristics of the acromion and the presence of AC arthrosis. The effect of PRP is insufficient in patients with a type 3 acromion or severe AC arthrosis.

Post-Procedure Protocols Following Platelet-Rich Plasma Injections for Tendinopathy: A Systematic Review

OBJECTIVE

Platelet-rich plasma (PRP) has been increasingly studied as a treatment for tendinopathy. Many factors may influence outcomes after PRP, including different protocols following administration. It was hypothesized that there would be heterogeneity in post-PRP protocols.

LITERATURE SURVEY

A systematized review of the literature on post-PRP protocols for tendinopathy was conducted using an electronic search of MEDLINE and Embase databases through September 2018.

METHODOLOGY

After duplicates were removed, English language articles involving adult patients who received PRP for tendinopathy were reviewed. Exclusion criteria included studies with fewer than 10 patients, PRP used to treat pathology other than tendinopathy, multiple protocols in one study, and surgical settings. Protocol specifics were extracted including nonsteroidal anti-inflammatory drugs (NSAID) restrictions before and after injection, postinjection restrictions on movement and weight bearing, use of orthoses, activity modifications, and postinjection rehabilitation protocols. Given limitations in the data, a meta-analysis was not performed.

SYNTHESIS

Eighty-four studies met inclusion criteria. Following PRP injection, weight-bearing restrictions were mentioned rarely (12% of protocols). Orthosis use was uncommon overall (18%) but more common in Achilles tendinopathy protocols (53%). The majority of protocols instituted a period of stretching (51%) and strengthening (54%). Stretching programs generally began 2-7 days following injection, and strengthening programs began within 2-3 weeks. Preinjection NSAID restriction was reported rarely (20%), whereas postinjection NSAID restriction was more common (56%), with a typical restriction of greater than 2 weeks (38%). Return to play or full activity was reported in 42% of protocols, most commonly at 4-6 weeks following injection.

CONCLUSION

Although the clinical effectiveness of PRP remains controversial, even less is known about the effect of post-PRP protocols, which may affect the outcomes attributed to PRP itself. No studies directly compare post-PRP protocols, and the protocols studied demonstrate substantial heterogeneity. Some consensus regarding post-PRP protocols exists, although the rationale for these recommendations is limited.

Effectiveness of Platelet-Rich Plasma Injection in Rotator Cuff Tendinopathy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

To investigate the effectiveness of platelet-rich plasma (PRP) injection among patients with rotator cuff tendinopathy in comparison with sham injection, no injection, or physiotherapy alone.

METHODS

From the earliest records to November 1, 2018, all published or unpublished randomized controlled trial (RCTs) comparing PRP injection with a control group (sham injection, no injection, or physiotherapy alone) in patients with rotator cuff tendinopathy were included. Eligible trials were included from the search results of electronic databases including PubMed, EMBASE, Scopus, The Cochrane Library, as well as the bibliographies of relevant trials. Five RCTs were enrolled in our meta-analysis. Two authors independently assessed the quality of RCTs with the Cochrane risk of bias tool. We designated pain reduction as the primary outcome and functional improvement as the secondary outcome. Standardized mean difference (SMD) was applied for random-effect meta-analysis.

RESULTS

In the short term (3-6 weeks) and medium term (12 weeks), the effectiveness of PRP injection and control group was indistinguishable in terms of both outcomes (pain reduction and functional improvement). Nevertheless, PRP injection led to significant long-term (>24 weeks) pain relief (SMD: 0.42, 95% confidence interval (CI): 0.12-0.72, without heterogeneity). For functional improvement in the long term, PRP injection was not more effective than the control group (SMD: 1.20, 95% CI: -0.20-2.59, with heterogeneity).

CONCLUSIONS

PRP injection may provide benefit over the control group (sham injection, no injection, or physiotherapy alone) in reducing pain at long-term follow-up for patients with rotator cuff tendinopathy.

Nonoperative Treatment of Rotator Cuff Disease With Platelet-Rich Plasma: A Systematic Review of Randomized Controlled Trials

PURPOSE

To perform a systematic review of randomized controlled trials on the use of platelet-rich plasma (PRP) for nonoperative treatment of rotator cuff disease.

METHODS

Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 2 reviewers independently screened the MEDLINE, Embase, and Cochrane Library databases for prospective, randomized controlled trials comparing PRP with a control in the nonoperative treatment of chronic rotator cuff disease for inclusion. Clinical data were extracted and evaluated. The quality of evidence was assessed using The Cochrane Collaboration risk-of-bias tool.

RESULTS

Five randomized controlled trials met the inclusion criteria, with 108 patients treated with PRP and 106 treated with a control. The mean age was 53.7 years, and 61.6% of patients were female patients. All of the studies found that the groups receiving PRP injections experienced improved clinical outcomes at final follow-up compared with baseline. Two studies found that PRP resulted in improved outcomes, mostly pain scores, compared with a control. One study compared PRP with formal exercise versus a saline solution injection with formal exercise therapy. It showed no difference in clinical outcomes between PRP and a saline solution injection when formal exercise therapy was used. Two other studies reported that PRP alone resulted in inferior outcomes to control groups receiving formal exercise therapy.

CONCLUSIONS

The currently limited available evidence on PRP for nonoperative treatment of chronic rotator cuff disease suggests that in the short term, PRP injections may not be beneficial. When directly compared with exercise therapy, PRP does not result in superior functional outcomes, pain scores, or range of motion. However, interpretation of this literature is confounded by the lack of reporting of the cytology and characteristics of PRP.

LEVEL OF EVIDENCE

Level II, systematic review of Level I and II evidence.

Platelet-rich plasma and the shoulder: clinical indications and outcomes

PURPOSE OF REVIEW

The orthopedic community has seen a rapid rise in the clinical use of platelet-rich plasma (PRP) in the management of shoulder pathologies over the past decade. The purpose of this paper is to review the current literature regarding the indications and outcomes of PRP for the surgical and non-surgical management of common shoulder pathologies, including rotator cuff tears.

RECENT FINDINGS

Multiple studies have been published recently regarding the use of PRP for the operative and non-operative treatment of rotator cuff tears. There has been less research published on the use of PRP in the management of other conditions of the shoulder. Despite attempts to standardize and classify PRP formulations, there remains great variation in the inter- and intra-subjection composition, preparation, and administration techniques of PRP, limiting the conclusions that can be drawn regarding the utility and effectiveness of this biologic treatment as reported by Mazzocca et al. (J Bone Joint Surg Am. 94(4):308-16, 2012). Recent literature has shown equivocal to minor benefit of PRP use for shoulder pain, function, and healing. While few complications have been reported and PRP administration appears to carry little risk to the patient, the body of literature is currently inconclusive regarding the clinical benefit and cost-effectiveness of PRP in the treatment of shoulder pathology. As for PRP use specifically as an adjunct to surgical rotator cuff repairs, there is no clear consensus on its effectiveness in either clinical or structural outcomes. To further delineate the efficacy of PRP for shoulder pathology, it is essential that more double-blinded, randomized controlled investigations with large sample sizes and standardized PRP preparations be performed.

Efficacy of platelet-rich plasma as conservative treatment in orthopaedics: a systematic review and meta-analysis

BACKGROUND

The aim of this systematic review and meta-analysis was to evaluate the benefit of platelet-rich plasma (PRP) in non-surgical orthopaedic procedures.

MATERIAL AND METHODS

We searched the Cochrane Wounds Specialized Register, CENTRAL, MEDLINE (through PUBMED), Embase, and SCOPUS. We also searched clinical trials registries for ongoing and unpublished studies and checked reference lists to identify additional studies.

RESULTS

We found 36 randomised controlled trials (2,073 patients) that met our inclusion criteria. The included studies mostly had small numbers of participants (from 20 to 225). Twenty-eight studies included patients with lateral epicondylitis or plantar fasciitis. PRP was compared to local steroids injection (19 studies), saline injection (6 studies), autologous whole blood (4 studies), local anaesthetic injection (3 studies), dry needling injection (3 studies), and to other comparators (4 studies). Primary outcomes were pain and function scores, and adverse events. On average, it is unclear whether or not use of PRP compared to controls reduces pain scores and functional score at short- (up to 3 months) and medium- (4-6 months) term follow-up. The available evidence for all the comparisons was rated as very low quality due to inconsistency, imprecision, and risk of bias in most of the selected studies. There were no serious adverse events related to PRP injection or control treatments.

CONCLUSIONS

The results of this meta-analysis, which documents the very marginal effectiveness of PRP compared to controls, does not support the use of PRP as conservative treatment in orthopaedics.