How PRP works for Tendonitis and Tendon Tears

Platelet Rich Plasma produced by AM at Total Tendon

Platelet rich plasma (PRP) continues its advance as a novel and increasingly valuable treatment for tendon related problems like chronic tendonitis (also medically known as tendinosis). It is important to realize that not all physicians and machines produce clinically valuable (meaning it helps improve your pain and function) PRP. Published peered reviewed data suggests that PRP should contain at least 5 times the number of whole blood platelets.

(See Dr. Mishra's study published in American Journal of Sports Medicine Nov. 2006 for details)


As PRP evolves, it is important to find physicians and surgeons who base their clinical decisions on the literature not on opinion. Also, they should use devices that produce PRP with the appropriate concentrations of platelets. Not all methods are the same.

PRP Website: ApexPRP.com

Platelet rich plasma has been found to work via three mechanisms:

1. Release of Growth Factors increase local cell division (producing more cells)

2. Inhibition of excess inflammation (decreased early macrophage proliferation)

3. Recruitment of circulating or bone marrow derived cells that help repair tissue.

This combination of mechanisms helps heal a tendon. Animal data confirm that PRP helps produce a biomechanically stronger tendon.

All of these statements are based on peer reviewed publications.


AM

Total Tendon.com
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Platelet Rich Plasma and Rotator Cuff Repair

We now have published evidence that PRP is safe and may be useful in arthroscopic rotator cuff repair. This excellent study by Dr. Randelli and his colleagues will lead the way to larger trials.

Autologous platelet rich plasma for arthroscopic rotator cuff repair. A pilot study.

Here is Dr. Randelli's excellent rotator cuff video. (Thanks for sharing it.)

Randelli PS, Arrigoni P, Cabitza P, Volpi P, Maffulli N.

Dipartimento di Scienze Medico-Chirurgiche, Policlinico San Donato, Universita degli Studi di Milano, Milano.

Background and purpose. Arthroscopic repair of rotator cuff tears can produce excellent results. The application of platelet rich plasma during arthroscopic rotator cuff repair is safe, and produces results which do not deteriorate over time. Methods. A total of 14 patients undergoing arthroscopic repair of a rotator cuff tear received an intra-operative application of autologous platelet rich plasma in combination with an autologous thrombin component after tear repair. Following the procedure, patients were given a standardized rehabilitation protocol, and followed for 24 months. Outcome measures included a pain score (VAS) as well as functional scoring (UCLA and Constant scores). Results. Of the original 14 patients, 13 were seen at a final follow-up appointment 24 months after the index operation. Patients demonstrated a significant decrease in VAS scores and significant increases in the UCLA and Constant scores at 6, 12 and 24-month follow-ups compared to a pre-operative score. Conclusion. No adverse events related to this application were noted during the procedure. The application of platelet rich plasma during arthroscopic rotator cuff repair is safe and effective, and produces results which seem to be stable with time. A prospective randomized investigation will be necessary to ascertain the efficacy of platelet rich plasma application to improve or expedite the surgical outcome following arthroscopic rotator cuff repair.

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Platelet Rich Plasma beats Cortisone

Gosens and Sluimer in a prospective, randomized controlled trial of 100 patients with tennis elbow found PRP beat cortisone in terms of improvement in pain and function at 24 weeks. This excellent study (Level 1 evidence) for the first time confirms platelet rich plasma performs better than the "gold standard" of treatment for patients with tennis elbow that don't respond to simple treatments.

Gosen and his colleagues will be hosting a "Trends in Tendinopathy" course next week in Europe. AM will be presenting and in this space, I will report the details of that important conference.

Total Tendon

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Platelet Rich Plasma Treats Stanford Football Player

A San Francisco based TV station just aired a segment on the use of platelet rich plasma to treat a Stanford football player. Here is a link to the spot.

Total Tendon

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Tendon Tips

PRP Used in Chronic Knee Tendonitis

Dr. Mishra's method of using platelet rich plasma to treat chronic knee tendonitis was discussed in a recent story about a college football Player. Here is a link to the story.

Please also visit our new website: Tendon Tips to view a story about Tiger Woods' recent knee surgery

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Total Tendon

Platelet Rich Plasma on TV in Los Angeles

A TV story on ABC7 in Los Angeles California just aired. The story discusses the value of using platelet rich plasma for chronic tennis elbow. It follows a patient who is an avid tennis player who was able to return to her game with a single PRP injection.

Link to TV Story

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Platelet Rich Plasma Basic Science

This is a video produced by Dr. Allan Mishra discussing the basic science of PRP. Future videos will discuss cell culture, animal and human studies. For more information, please visit either Total Tendon or ApexPRP.

More Evidence that PRP may heal Tendons

In this study the authors found that PRP releasate stimulated cell proliferation and total collagen production. It is an interesting article that adds to the growing body of PRP knowledge.

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Can Platelet-Rich Plasma Enhance Tendon Repair? A Cell Culture Study.

de Mos M, van der Windt AE, Jahr H, van Schie HT, Weinans H, Verhaar JA, van Osch GJ.

BACKGROUND: Autologous platelet-rich plasma (PRP) application appears to improve tendon healing in traumatic tendon injuries, but basic knowledge of how PRP promotes tendon repair is needed. HYPOTHESIS: Platelet-rich plasma has a positive effect on cell proliferation and collagen production and induces the production of matrix-degrading enzymes and endogenous growth factors by human tenocytes. STUDY DESIGN: Controlled laboratory study. METHODS: Human tenocytes were cultured 14 days in 2% fetal calf serum medium complemented with 0%, 10%, or 20% vol/vol platelet-rich clot releasate ([PRCR] the active releasate of PRP) or platelet-poor clot releasate (PPCR). At day 4, 7, and 14, cell amount, total collagen, and gene expression of collagen Ialpha1 (COL1) and IIIalpha1 (COL3), matrix metalloproteinases ([MMPs] MMP1, MMP3, and MMP13), vascular endothelial-derived growth factor (VEGF)-A, and transforming growth factor (TGF)-beta1 were analyzed. RESULTS: Platelet numbers in PRP increased to 2.55 times baseline. Growth-factor concentrations of VEGF and platelet-derived growth factor (PDGF)-BB were higher in PRCR than PPCR. Both PRCR and PPCR increased cell number and total collagen, whereas they decreased gene expression of COL1 and COL3 without affecting the COL3/COL1 ratio. PRCR, but not PPCR, showed upregulation of MMP1 and MMP3 expression. Matrix metalloproteinase 13 expression was not altered by either treatment. PRCR increased VEGF-A expression at all time points and TGF-beta1 expression at day 4. CONCLUSION: In human tenocyte cultures, PRCR, but also PPCR, stimulates cell proliferation and total collagen production. PRCR, but not PPCR, slightly increases the expression of matrix-degrading enzymes and endogenous growth factors. CLINICAL RELEVANCE: In vivo use of PRP, but also of PPP to a certain extent, in tendon injuries might accelerate the catabolic demarcation of traumatically injured tendon matrices and promote angiogenesis and formation of a fibrovascular callus. Whether this will also be beneficial for degenerative tendinopathies remains to be elucidated. Am J Sports Med. 2008 Mar 7

Platelet Rich Plasma Wins!

In our informal survey of best names, "Platelet Rich Plasma" won with 61% of the vote with "PRP" taking 22%, "Platelet Gel" 8% and "Platelet Enriched Plasma and Growth Factors" 4% each. With a total of 83% of the votes, Platelet Rich Plasma/PRP wins in a landslide.

I propose we end the argument of what to name it and begin to define it in studies moving forward. The landscape of PRP is scattered at best. In order to figure out how best to use this important tool, we must agree on what we are talking about. Please see the post below for a definition that is published in the literature.

I am repeating the survey of what machine producing the best PRP. I'll post the results in a month.

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What is platelet rich plasma (PRP)?

Marx one of the pioneers of PRP defined it quite simply: "it is a volume of autologous plasma that has a platelet concentration above baseline". (Marx, Implant Dentistry Dec. 2001, pp. 225-228) There have been other attempts to specific what define PRP but I think this one is the best.

I would add that PRP naturally is unactivated. In his paper, Dr. Marx states that activation of platelet results 70% of the stored growth factors being secreted with in 10 minutes and close to 100% within the first hour. That makes it clear that PRP should NOT be activated until it is ready to be used. As I have consistently suggested, PRP should not be activated at all except in vivo by the collagen that is abundant within most connective tissues.

Any comments on this paper would be appreciated.

Total Tendon

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PRP activates Circulating Cells

The article referenced below discusses how locally injected PRP can mobilize cells to help heal a tendon. This provides solid mechanistic evidence to use PRP for tendon injuries and disorders and helps explain the positive clinical results. It is an excellent study and the authors have contributed significantly to our understanding of how PRP works.

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Platelet-rich plasma enhances the initial mobilization of circulation-derived cells for tendon healing.

Kajikawa Y, Morihara T, Sakamoto H, Matsuda KI, Oshima Y, Yoshida A, Nagae M, Arai Y, Kawata M, Kubo T.

J. Cell Physiology Jan. 2008

Circulation-derived cells play a crucial role in the healing processes of tissue. In early phases of tendon healing processes, circulation-derived cells temporarily exist in the wounded area to initiate the healing process and decrease in number with time. We assumed that a delay of time-dependent decrease in circulation-derived cells could improve the healing of tendons. In this study, we injected platelet-rich plasma (PRP) containing various kinds of growth factors into the wounded area of the patellar tendon, and compared the effects on activation of circulation-derived cells and enhancement of tendon healing with a control group (no PRP injection). To follow the circulation-derived cells, we used a green fluorescent protein (GFP) chimeric rat expressing GFP in the circulating cells and bone marrow cells. In the PRP group, the numbers of GFP-positive cells and heat-shock protein (HSP47; collagen-specific molecular chaperone)-positive cells were significantly higher than in the control group at 3 and 7 days after injury. At the same time, the immunoreactivity for types I and III collagen was higher in the PRP group than in the control group at early phase of tendon healing. These findings suggest that locally injected PRP is useful as an activator of circulation-derived cells for enhancement of the initial tendon healing process. J. Cell. Physiol. (c) 2008 Wiley-Liss, Inc.