Orthopedic surgeons are beginning to utilize the healing potential of platelet rich plasma to improve outcomes for patients with rotator cuff injuries. The biological healing potential of PRP has been evaluated to adjunct with arthroscopic surgery and physical therapy.
Rotator Cuff Injuries in Context
Rotator cuff injuries affect millions every year, leading to 200,000 surgeries to repair torn tendons and another 400,000 surgeries for partial tears and tendinopathies. The rotator cuff secures the head of the humerus to the shoulder socket. Rotator cuff injuries can cause a dull ache in the shoulder which is easily aggravated by sleeping on the affected side, lifting and reaching overhead. Tendon vascularization decreases as we age which increases our risk for degenerative tears. Athletes and manual laborers are at a higher risk of acute ruptures.
Treating Rotator Cuff Injuries
Treatment depends on the severity of the tear. Traditional conservative therapies aim to reduce pain and increase mobility with physical therapy and hyaluronate injections. Surgery is recommended in cases with functional impairment, full thickness tears greater than 1 cm², or symptoms persisting more than one year. Results are generally favorable for patients electing surgical options which include minimally invasive arthroscopy, mini-open, and open repair surgery. Yet 38% of patients suffer post-operative complications and re-rupture rates can be as high as 68%.¹
PRP for Rotator Cuff Tears
Emerging regenerative therapies create supraphysiologic conditions inside the joint to reduce downtime and rates of rerupture. Platelet rich plasma injections at the rupture site increase local growth factors which amplifies tissue regeneration. Platelets circulate through the blood at about 150,000 to 450,000 platelets per microliter. Commercially available PRP preparations concentrate platelet levels 6-7 times by differential centrifugation. If this concentration of platelets is administered at the injury site, damaged tissues benefit by the release of bioactive proteins known as growth factors. Growth factors initiate wound healing by signalling to local cells. Some of the integral growth factors include: platelet derived growth factor (PDGF) which regulates collagen synthesis, transforming growth factor (TGF); responsible for regulating undifferentiated mesenchymal cell proliferation, and vascular endothelial growth factor (VEGF) which increases angiogenesis and blood vessel permeability.²
Platelet Rich Plasma Injections for Partial Thickness Rotator Cuff Tears
Clinical evidence supporting the use of PRP injections includes a 2017 case series of 19 patients with partial thickness rotator cuff tears. Patients received a single PRP injection centrifuged from a total of 20 ml of whole blood. The final preparation was injected into the subacromial bursa and intra-articular space. Patients were instructed to complete a home exercise and stretching routine then followed for 3 months. Researchers found a significant improvement in range of motion, pain and function in all patients.³ Results should be verified in a larger, placebo-controlled trial.
PRP Therapy for Full Thickness Rotator Cuff Tears
Level I evidence is available supporting the adjunct use PRP during arthroscopic surgery for full thickness tears. The same surgeon completed all procedures for the 53 patients who participated in this randomized, double blind, controlled trial. The 26 patients in the treatment group underwent a 54 ml blood draw which yielded 6 ml of activated PRP. The platelet rich plasma solution was coagulated with an autologous thrombin and applied post-arthroscopy to a dry subacromial space. Researchers found a statistically significant difference in all measured clinical outcomes between patients treated with RPR and those in the control group at 3 months. Subjective and objective measures indicated an early recovery attributed to the addition of PRP.⁴
References
- Clement ND, Nie YX, McBirnie JM. Management of degenerative rotator cuff tears: a review and treatment strategy. Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology: SMARTT. 2012;4:48. doi:10.1186/1758-2555-4-48.[ncbi]
- Dhurat R, Sukesh M. Principles and Methods of Preparation of Platelet-Rich Plasma: A Review and Author’s Perspective. Journal of Cutaneous and Aesthetic Surgery. 2014;7(4):189-197. doi:10.4103/0974-2077.150734.[ncbi]
- Zafarani Z, Mirzaee F, Guity M, Aslani H. Clinical Results of Platelet-Rich Plasma for Partial Thickness Rotator Cuff Tears: A Case Series. Archives of Bone and Joint Surgery. 2017;5(5):328-331.[ncbi]
- Randelli P, Arrigoni P, Ragone V, Aliprandi A, Cabitza P. Platelet rich plasma in arthroscopic rotator cuff repair: a prospective RCT study, 2-year follow-up. J Shoulder Elbow Surg. 2011;20(4):518-28.[ncbi]
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