Comparison of a Platelet-Rich Plasma Injection and a Conventional Steroid Injection for Pain Relief and Functional Improvement of Partial Supraspinatus Tears.
Rotator cuff tendinopathy is a very frequent cause of shoulder pain, and the progression to a rotator cuff muscle or tendon tears, which can be very difficult to treat. Because of poor region has a very poor blood supply the tendons have a limited ability to heal and regenerate, Often leading to chronic pain and disability.
A subacromial corticosteroid injection is a frequently used option for patients, although clinical evidence of its efficacy is conflicting. Most studies have shown pain relief and functional improvement from a steroid injection treatment in the short term but no clear benefit in the long term. Infact, there is evidence to suggest that it can be counter-productive long-term.
Recently, the use of orthobiologics, such as platelet-rich plasma (PRP), has been identified to promote healing and regeneration of damaged tissue, including cartilage and tendons. PRP is an autologous high concentration of self platelets in a small volume of plasma. It is a quick, easy and effective treatment to perform, hence its popularity. Platelets contain a wealth of bioactive protein growth factors and mediators, which are concentrated using the centrifugation process and can then be delivered to a site of damaged or injured tissue to promote and facilitate the body’s natural healing process.
There is high amounts of convincing evidence of the efficacy of PRP in the treatment of lateral epicondylitis, patellar tendinopathy, and knee osteoarthritis. Alongside this, research is growing very strong into the efficacy of PRP for rotator cuff injuries. The purpose of the recent study below was to compare pain relief, functional improvement, and complications after an intratendinous PRP injection versus a subacromial corticosteroid injection for partial supraspinatus tears.
The results showed that both PRP and a corticosteroid had beneficial effects for the treatment of partial supraspinatus rotator cuff tears, in respect to pain relief. However, the corticosteroid effects were short lived and plateaued after 1 month, with no significant change between the 1-6 months during assessments. In contrast, at the 6-month point, the differences were statistically significant, identifying the extended clinical benefits of PRP treatment in comparison to the corticosteroid injection. Furthermore, a comparison of the 2 groups at month 1 indicated that there was no significant difference between them in terms of pain and function, both showing good effects in reducing pain and inflammation. A review by Chen et al., reported that LP-PRP appeared to significantly reduce the retear rate compared with the control and can improve healing based on. It is well understood that the primary cause of chronic tendinopathy is not related to the inflammatory process but to an insufficient healing process. To this understanding, PRP as a regenerative treatment has the functional role in promoting tissue healing, due to platelets releasing growth factors, cytokines, and chemokines to modulate inflammation and facilitate tissue repair and regeneration. In the below study, they used pain as a primary outcome, giving relative clinical evidence on PRP injections supporting beneficial effects on long pain improvements for rotator cuff injuries.
Partial rotator cuff tears of the supraspinatus are considered a chronic overuse degenerative disease process in which inflammation is not of primary concern - hence, a corticosteroid as an anti-inflammatory drug might not be an appropriate management option long-term. In fact, evidence has previously shown significantly better functional outcome, sustained for 6 months, with exercise therapy in rotator cuff diseases. In the initial phase, inflammation is prevalent, whereas in the later phase, degenerative overuse is commonly seen. During relapses, inflammation is frequently superimposed over degeneration.
A corticosteroid injection is often used to counteracts the inflammatory and immune cascade, showing benefit in the early phase of inflammation. However, its efficacy is limited or absent in the late phase when degeneration is more so. In the mentioned study here, the corticosteroid group, results showed improvements initially at 1-3 months, but very limited improvement beyond.
Other than the huge importance of clotting, platelets are known for their success in promotion of revascularisation of damaged and injured tissues. They are very specialist cells that promote tendon healing, resulting in the improvement of pain and function. Both LP-PRP and leukocyte-rich PRP promote the regeneration of many kinds of injured tissue, including tendons and cartilage. Understanding the regenerative benefits of PRP and the detrimental effects of repetitive steroid injections to tissues, PRP appears to be an increasingly good option for injured tendons, whether it be inflammation predisposing tendinitis or a degenerative process identifying tendinosis.
According to biological knowledge of PRP and corticosteroids, injection techniques have to be performed differently. You can not inject corticosteroid directly in to the tendon, but you can with PRP. This is because steroid can have detrimental effects on tendons, weakening them. Side effects can including an impairment of fibroblast viability, and decreased collagen synthesis.
PRP is injected directly into the injured tendon, where growth factors are released and can promote and facilitate the healing. PRP injections are generally safe, well tolerated, come with minimal down time and cost effective. Reactions from additives are also rarely reported.
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