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By Harry A. Bade, III, MD, FACS

 

Can it Help You Heal Faster and Return to Play Quicker?

Platelet-rich plasma (PRP) is defined as autologous blood with a higher than normal concentration of platelets. It is made from anticoagulated blood that undergoes two centrifuge steps. The first step separates the red and white blood cells from the plasma and platelets. The second step further concentrates the platelets. The platelet-rich plasma needs to be clotted to allow platelet activation and the release of growth factors. The concentration of platelets should be at least four to eight times normal. Alpha granules within the platelets contain more than 30 growth factors, which are then released to promote both hemostasis and tissue healing.

Platelet-rich plasma has been used in maxillofacial, plastic, and orthopaedic surgery since the 1990s. It is administered as a putty- or gel-like clot directly applied or sutured into the surgical site. In sports medicine, its use is rapidly growing given its potential to enhance muscle, ligament, and tendon healing.

The growth factors released promote cell replication, blood vessel ingrowth, collagen production for tendon, and ligamentous healing, myoblasts and fibroblasts, which mediate skeletal muscle repair and growth and the production of mesenchymal and epithelial cells, which potentiate further growth factor release. All of these activities combine to accelerate repair of tendon skeletal muscle and bone.

Current surgical use includes the enhancement of tendon healing in Achilles tendon repairs and the repair of rotator cuff tendon ruptures. It is also used in anterior cruciate ligament (ACL) reconstructive procedures with the various ligamentous and tendon grafts.

Recent nonsurgical applications have included the use in lateral epicondylitis tennis elbow and for treatment of chronic patella tendinopathy jumpers knee. Clinical research has shown an approximate 80 percent success or satisfaction rate. It has also been used in plantar fasciitis with again a 75 to 80 percent rate of achieving complete resolution of symptoms. Interest in using PRP to treat acute ligamentous injuries increased after newspaper reports of a Pittsburgh Steelers player receiving PRP to expedite the healing of a medial collateral ligament injury before the 2009 Superbowl.

There is unpublished data in the use of PRP to treat acute Grade 2 medial collateral ligaments in professional soccer players. Injections were given within 72 hours of the medial collateral ligament injury, and the study showed that return to play time shortened by 27%. Other unpublished case series involved the treatment of acute muscle injuries in 14 professional athletes. PRP was injected directly into the muscle tear under ultrasonic guidance after aspiration of the hematoma. A 50 percent reduction in return to play time was reported.

A report in the February 2010 American Journal of Sports Medicine notes patients treated for lateral epicondylitis with PRP had significant reduction of pain and increased function far exceeding the effects of corticosteroid injections. The future of PRP treatments in sports medicine will likely continue to grow. At this time further investigations are needed to determine the timing of PRP injection, the optimal concentration of the PRP solution, the use of different activation agents and finally the postprocedure rehabilitation protocol that maximizes the athletes return to play.

Platelet-Rich Plasma

Since PRP contains growth factors, whether or not its use will be allowed in amateur and professional sports has been discussed by antidrug agencies. At their September 2009 meeting, the World Anti-Doping Agency prohibited the intramuscular injection of PRP to enhance athlete performance without injury. Perfomance enhancement is unlikely since it is known that the unbound growth factor in PRP has an inadequate half life to exert systemic effects. Its concentration is subtherapeutic by a factor of 500, making it unlikely to produce any systemic anabolic actions. Local injections at the site of injury, however, will require a declaration of use that is in compliance with the International Standard For Therapeutic Use Exemptions (TUE).

The US Anti-Doping Agency in 2009 also issued an athletes advisory declaration that a PRP injection is equivalent to an injection of growth factors and that an athlete will need both a TUE and a medical professional determination that a PRP injection is therapeutically necessary. Again, they state there is no evidence that there is any systemic or performance enhancing effect to PRP. Neither of these governing bodies has jurisdiction over U.S. professional athletes.

In conclusion, based on current clinical studies, PRP shows promise in treating chronic tendinopathies, acute ligamentous injuries, and acute muscles disorders/tears and enhances the healing of surgical repairs and reconstructions. I believe the book has just been opened with respect to the potentials of PRP, and its treatment will become more commonplace in the future.