PRP at the Advanced Team Physician Course

Dr. Allan Mishra and Dr. Nicola Maffulli debated how to diagnosis and treat patellar tendinopathy at the Advanced Team Physician Course. It was a spirited discussion of when to use imaging, when to hold an athlete out of competition and then how to treat these patients. It was clear from the meeting that there is no consensus about how to treat this sometimes difficult problem. Dr. Mishra advocated early imaging and a biologically enhanced rehabilitation. The biologic enhancement would come from a platelet rich plasma procedure early on at 6-8 weeks after the onset of symptoms.

Obviously we need better prospective randomized trials of PRP, surgery and other therapies for chronic patellar tendinopathy.

PRP Improves Muscle Function

Platelet Rich Plasma in a study just published in the American Journal of Sports Medicine was found to significantly improve muscle function. This was in a high repetition injury model. This is excellent evidence to enable a human trial of PRP for muscle injuries.

AM
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Use of autologous platelet-rich plasma to treat muscle strain injuries.

Hammond JW, Hinton RY, Curl LA, Muriel JM, Lovering RM.

Am J Sports Med. 2009 Jun;37(6):1135-42.

BACKGROUND: Standard nonoperative therapy for acute muscle strains usually involves short-term rest, ice, and nonsteroidal anti-inflammatory medications, but there is no clear consensus on how to accelerate recovery. HYPOTHESIS: Local delivery of platelet-rich plasma to injured muscles hastens recovery of function. STUDY DESIGN: Controlled laboratory study. METHODS: In vivo, the tibialis anterior muscles of anesthetized Sprague-Dawley rats were injured by a single (large strain) lengthening contraction or multiple (small strain) lengthening contractions, both of which resulted in a significant injury. The tibialis anterior either was injected with platelet-rich plasma, was injected with platelet-poor plasma as a sham treatment, or received no treatment. RESULTS: Both injury protocols yielded a similar loss of force. The platelet-rich plasma only had a beneficial effect at 1 time point after the single contraction injury protocol. However, platelet-rich plasma had a beneficial effect at 2 time points after the multiple contraction injury protocol and resulted in a faster recovery time to full contractile function. The sham injections had no effect compared with no treatment. CONCLUSION: Local delivery of platelet-rich plasma can shorten recovery time after a muscle strain injury in a small-animal model. Recovery of muscle from the high-repetition protocol has already been shown to require myogenesis, whereas recovery from a single strain does not. This difference in mechanism of recovery may explain why platelet-rich plasma was more effective in the high-repetition protocol, because platelet-rich plasma is rich in growth factors that can stimulate myogenesis. CLINICAL RELEVANCE: Because autologous blood products are safe, platelet-rich plasma may be a useful product in clinical treatment of muscle injuries.

Unactivated Platelet Rich Plasma Proves Better

In a recently published study by Han et al published in the Journal of Bone and Joint Surgery (JBJS June 2009, American Volume), unactivated platelet rich plasma "stimulated chondrogenesis on Day 14 and osteogenesis on Days 28 and 56, whereas thrombin-activated platelet-rich plasma acted as an inhibitor of such events. In addition, inflammatory cells were detected in demineralized bone matrix samples that were mixed with thrombin-activated platelet-rich plasma. These cells were not present in matrix mixed with platelet-rich plasma alone." (See Full Abstract)

This data clearly supports the use of PRP that has NOT been activated by thrombin and/or calcium. This unactivated form of PRP has also proved useful for chronic tennis elbow. See References

AM
Total Tendon

Platelet Rich Plasma Beats Stem Cells

In our completely unscientific poll, PRP beat Stem Cells as the best regenerative therapy: 54% to 41%. This I believe points to the "potential" value of PRP as much as its immediate impact. Because PRP is available at the point of care and is significantly less expensive and less controversial, it may gain traction as a regenerative therapy over stem cells. Combination of these two valuable biologic treatments will likely with time and proper study prove to be better than either individually.

AM
Total Tendon

Platelet Rich Plasma and Cartilage Restoration

Platelet rich plasma was debated in a scientific session at the International Cartilage Research Society Meeting in Miami Florida this week. Dr. Allan Mishra, Dr. Vannini, Dr. Randelli and Dr. Johnson all spoke about PRP. It was moderated by Dr. Alberto Gobbi.

The discussion after these presentations centered around what type of PRP to use for what indications. It is clear that we need better data. The best published clinical data for tendon related injuries and disorders right now supports the use of PRP that is concentrated to 4-5x baseline platelets with an increased concentration of WBCs. See PRP Reference List.

Most studies so far have NOT been well controlled. However, Dr. Randelli (from Milan, Italy) presented the preliminary results of his prospective randomized controlled trial showing how PRP at a concentration of 4-5x baseline with increased WBCs DECREASES pain after arthroscopic rotator cuff repair and may improve healing in small and medium sized tears. Excellent work.

Several papers, posters and presentations at the meeting supported the use of PRP for cartilage restoration. Level one human data (randomized controlled trials), does not yet exist.

More soon.

AM

Total Tendon

New York Yankee and Platelet Rich Plasma

New York Yankee outfielder Xavier Nady may be using Platelet Rich Plasma (PRP) to treat an ulnar collateral ligament injury in his elbow. This is another example of PRP going more mainstream. It will be important to follow his progress and potential return to play to better evaluate the role of PRP in this injury. Read more of the story.

AM
Total Tendon

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Platelet Rich Plasma presented at the NFL Sports Meeting

Platelet rich plasma was discussed today at the NFL Sports Medicine meeting in San Francisco. It was presented in the "alternative" therapies session. No data or specific recommendations were outlined. It is clear we need to actually study the use of PRP in elite athletes before drawing any specific conclusions. It is also important for clinicians and patients to understand that not all PRP is the same. When studies are designed and evaluated, actual platelet counts and white blood cell counts should be included. Only then will we be able to truly define the value of the formulation of PRP derived from any specific machine.

AM
Total Tendon

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Emerging Trends in Tendinopathy

AM with Dr. Robert Nirschl at AMSSM Meeting in Tampa

Dr. Kim Harmon, president of the American Medical Society for Sports Medicine organized an amazing group to discuss tendinopathy in Tampa last week. Dr. Robert Nirschl, the Godfather of tennis elbow spoke about his pioneering work in surgery. Dr. Hakan Alfredson from Sweden discussed the value of eccentric exercises for chronic tendinopathy. Dr. John McShane outlined the value of percutaneous tenotomy and Dr. David Connell from London spoke about the use of blood and stem cells for severe cases. AM presented the case for using platelet rich plasma for tendon related problems.

Overall, it was one of the best sessions ever presented on the topic. Great work and thanks to Dr. Harmon for bringing us all together.

AM
Total Tendon
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Platelet Rich Plasma at Elite Meetings

Platelet rich plasma is on the agenda for several elite meeting in the next month. The NFL team physician meeting, the American Medical Society for Sports Medicine and the International Cartilage Research Society all have PRP presentations. BloodCure will report on these meetings including the discussions. Post any questions you may have on this blog and we'll try to get the answers. This level of attention by these established academic conferences means PRP is close to becoming a mainstream treatment.

AM
Total Tendon

Platelet Rich Plasma for Muscle Injuries

This study supports the use of PRP for acute muscle injuries. PRP treated animals recovered faster and the authors suggest PRP may stimulate myogenesis. A prospective, randomized trial of PRP for acute severe strains is warranted.

AM
Total Tendon
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Use of Autologous Platelet-rich Plasma to Treat Muscle Strain Injuries.

Hammond JW, Hinton RY, Curl LA, Muriel JM, Lovering RM.

American Journal of Sports Medicine

BACKGROUND: Standard nonoperative therapy for acute muscle strains usually involves short-term rest, ice, and nonsteroidal anti-inflammatory medications, but there is no clear consensus on how to accelerate recovery. HYPOTHESIS: Local delivery of platelet-rich plasma to injured muscles hastens recovery of function. STUDY DESIGN: Controlled laboratory study. METHODS: In vivo, the tibialis anterior muscles of anesthetized Sprague-Dawley rats were injured by a single (large strain) lengthening contraction or multiple (small strain) lengthening contractions, both of which resulted in a significant injury. The tibialis anterior either was injected with platelet-rich plasma, was injected with platelet-poor plasma as a sham treatment, or received no treatment. RESULTS: Both injury protocols yielded a similar loss of force. The platelet-rich plasma only had a beneficial effect at 1 time point after the single contraction injury protocol. However, platelet-rich plasma had a beneficial effect at 2 time points after the multiple contraction injury protocol and resulted in a faster recovery time to full contractile function. The sham injections had no effect compared with no treatment. CONCLUSION: Local delivery of platelet-rich plasma can shorten recovery time after a muscle strain injury in a small-animal model. Recovery of muscle from the high-repetition protocol has already been shown to require myogenesis, whereas recovery from a single strain does not. This difference in mechanism of recovery may explain why platelet-rich plasma was more effective in the high-repetition protocol, because platelet-rich plasma is rich in growth factors that can stimulate myogenesis. CLINICAL RELEVANCE: Because autologous blood products are safe, platelet-rich plasma may be a useful product in clinical treatment of muscle injuries.

"Tennis" Article

An article about the use of Platelet Rich Plasma for chronic tendonitis was just published on Tennis.com

Article Link

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