What is the role of Platelet-rich Plasma (PRP) in shoulder surgery?

PRP in Shoulder Surgery: Evidence-Based Recommendations

Based on current evidence, PRP should be used selectively in shoulder surgery—specifically recommended for augmentation during rotator cuff repair of medium to large tears and for adhesive capsulitis, but NOT recommended for rotator cuff tendinopathy or subacromial impingement syndrome. 1, 2

Key Clinical Recommendations by Condition

Rotator Cuff Repair (Surgical Augmentation)

Use PRP as an adjunct during surgical repair of medium to large rotator cuff tears. 2

• PRP improves structural healing of repaired rotator cuff tendons regardless of tear size, with evidence showing reduced retear rates (26.7% vs 41.2% in controls, though not statistically significant in smaller studies) 3, 4
• Patients experience less pain in the early postoperative period when PRP is used during repair 3
• Apply PRP in gel form threaded to sutures at the tendon-bone interface during arthroscopic repair 4
• The American Academy of Orthopaedic Surgeons acknowledges potential benefits for tissue regeneration and bone healing in this context 1, 5

Common pitfall: Do not expect accelerated functional recovery or range of motion improvements—PRP primarily affects structural healing and early pain, not functional scores 4

Rotator Cuff Tendinopathy (Non-Surgical)

Do NOT use PRP for rotator cuff tendinopathy or partial tears. 1, 2

• The American Academy of Orthopaedic Surgeons states that limited evidence does not support routine use of PRP for rotator cuff tendinopathy 1
• Most studies fail to demonstrate clinical benefit compared to other non-operative treatments 3
• This represents a critical distinction—PRP may help surgical repair but not conservative management of tendinopathy 2

Adhesive Capsulitis (Frozen Shoulder)

Consider PRP injection for adhesive capsulitis, particularly as prophylaxis in at-risk patients. 2, 6

• PRP reduces posterior synovial membrane structural changes in experimental models (median grade 1 vs 2 in controls, p=0.028) 6
• May be valuable for prophylaxis of secondary frozen shoulder in immobilized or post-operative shoulders 6
• The American Society of Plastic Surgeons notes PRP promotes angiogenesis and healing in poorly vascularized tissues, relevant to capsular pathology 5

Subacromial Impingement Syndrome

Do NOT use PRP for subacromial impingement syndrome. 2

• Current evidence does not support its use in this condition 2

Critical Implementation Details

Preparation and Administration

• Use anticoagulated blood with gravitational centrifugation techniques and standard cell separators 5
• Maintain strict sterile technique during preparation and application 5
• Use commercial PRP preparation devices according to manufacturer specifications 5
• For surgical augmentation, apply PRP gel at the tendon-bone interface using suture threading technique 4

Setting Realistic Expectations

Critical caveat: The field suffers from severe lack of standardization in preparation methods, terminology, purity, and quality control, resulting in significant variations in platelet yields, concentration, and activation status 1, 5

• Different preparation techniques directly impact clinical efficacy 1
• Many clinical trials fail to adequately define PRP biological properties, leading to unreliable conclusions 7
• PRP is safe due to its autologous nature with minimal immunogenicity risk 1

Contraindications to Screen For

• Active infection at injection site 3
• Systemic disease presenting at injection site 3
• Bone marrow pathology 3
• Thrombocytopenia 3
• Current systemic steroid use 3
• Anticoagulant therapy 3

Algorithm for Clinical Decision-Making

Step 1: Identify the specific shoulder pathology

• Medium-to-large rotator cuff tear requiring surgery → Use PRP as surgical augmentation 2
• Adhesive capsulitis or high-risk for secondary frozen shoulder → Consider PRP injection 2, 6
• Rotator cuff tendinopathy or subacromial impingement → Do NOT use PRP 1, 2

Step 2: If proceeding with PRP, verify no contraindications exist 3

Step 3: Use standardized preparation protocol with proper sterile technique 5

Step 4: Counsel patient that benefits are primarily structural healing and early pain reduction, not accelerated functional recovery 3, 4