PRP for Rotator Cuff Tendinosis and Partial Tears
Limited evidence does not support the routine use of platelet-rich plasma (PRP) for the treatment of rotator cuff tendinopathy or partial tears, and you should not offer it as a first-line treatment. 1, 2
Guideline Recommendations
The American Academy of Orthopaedic Surgeons provides a Limited strength recommendation against routine PRP use for rotator cuff tendinopathy and partial tears. 1 This limited designation means:
- You should feel little constraint in not offering PRP 1
- Exercise clinical judgment based on individual circumstances 1
- Patient preference should play a substantial role only after explaining the lack of supporting evidence 1
- Remain alert for emerging evidence that may change this recommendation 1
What to Offer Instead
First-Line Conservative Management
Exercise therapy combined with NSAIDs should be your initial approach: 2
- Rotator cuff strengthening exercises are the cornerstone of treatment 2
- Scapular stabilization exercises should be incorporated 2
- Range of motion exercises are essential components 2
- NSAIDs provide first-line pharmacological pain control and inflammation reduction 2
Second-Line Options When Initial Treatment Fails
A single corticosteroid injection with local anesthetic has moderate evidence supporting short-term improvement in both pain and function. 1, 2 This is a more evidence-based option than PRP for patients not responding to exercise and NSAIDs.
Hyaluronic acid injections have limited evidence but more support than PRP in the nonsurgical management of rotator cuff pathology. 1, 2
The Research Evidence on PRP
While some individual studies show promise, the overall body of evidence is conflicting:
Studies Showing No Benefit
A 2013 randomized controlled trial with 1-year follow-up found no significant difference between PRP and placebo (saline) injections in patients with chronic rotator cuff tendinopathy when combined with exercise programs. 3 Both groups improved equally, suggesting the exercise program—not the injection—drove outcomes.
Studies Showing Short-Term Benefit Only
A 2021 double-blind RCT demonstrated that PRP provided superior improvement compared to corticosteroid at 3 months for pain (VAS), function (ASES), and quality of life (WORC) scores. 4 However, this benefit disappeared by 12 months, with no difference between groups at long-term follow-up. 4 There was also no difference in conversion to surgery rates. 4
Studies With Methodological Concerns
Two smaller studies from 2016 and 2021 showed improvements with PRP, but both lacked control groups or placebo comparisons, making it impossible to determine if improvements were due to PRP or natural history/exercise programs. 5, 6
Critical Nuances About PRP
Not all PRP preparations are equivalent. 7 Different formulations may act differently:
- Higher leukocyte concentrations may be detrimental to tendon healing 7
- Thrombin activation may actually inhibit parts of the healing response 7
- Results may be dose-dependent, requiring specific thresholds to achieve benefit 7
The PRP fibrin matrix version shows the most promise for rotator cuff applications, but this is primarily in the context of surgical repair augmentation, not conservative treatment of tendinopathy or partial tears. 7
Common Pitfalls to Avoid
Do not offer PRP as first-line treatment when exercise therapy and NSAIDs have stronger evidence and lower cost. 1, 2
Do not neglect exercise therapy, which forms the cornerstone of conservative management and has proven benefits. 2 Even studies showing PRP benefit included structured exercise programs, making it unclear whether PRP added value beyond exercise alone. 3
Avoid overreliance on any injection therapy (including corticosteroids) at the expense of active rehabilitation, as this may lead to tendon weakening and potential rupture. 2
Clinical Algorithm
Initial 0-6 weeks: Exercise therapy (rotator cuff strengthening, scapular stabilization, ROM) + NSAIDs + activity modification 2
If inadequate response: Consider single corticosteroid injection for short-term relief while intensifying physical therapy 1, 2
For persistent symptoms: Obtain advanced imaging (MRI or ultrasound) to assess for progression to full-thickness tears 1, 2
If conservative management fails: Surgical consultation for patients with persistent pain and functional limitations 2
PRP does not fit into this evidence-based algorithm as a routine treatment option. 1