Is there evidence to support the use of Platelet-Rich Plasma (PRP) for treating a supraspinatus tear in an adult patient with a history of shoulder pain?

PRP for Supraspinatus Tears: Evidence-Based Recommendation

For partial-thickness supraspinatus tears, the evidence does not support routine use of PRP, though it may provide modest benefit in carefully selected patients without adverse anatomical features. 1

Guideline-Level Evidence

The American Academy of Orthopaedic Surgeons provides the most direct guidance for this clinical scenario:

• Limited evidence does not support routine use of PRP for rotator cuff tendinopathy or partial tears (Limited strength recommendation) 1
• This recommendation reflects insufficient data to justify widespread adoption in clinical practice 1
• For surgical augmentation, strong evidence shows PRP does not improve patient-reported outcomes, though limited evidence suggests liquid PRP may decrease retear rates 1

Critical Anatomical Contraindications

If you proceed with PRP despite limited evidence, avoid PRP in patients with type 3 acromion or severe acromioclavicular arthrosis, as these anatomical features predict treatment failure:

• Type 3 acromion morphology is the strongest predictor of unfavorable outcomes (p < 0.001) 2
• Severe AC arthrosis similarly predicts poor response regardless of acromion type 2
• PRP effects are insufficient when these mechanical impingement factors are present 2

Comparative Effectiveness Data

When comparing PRP to standard treatments, the evidence reveals mixed and contradictory findings:

Short-term outcomes (1-3 months):

• One trial showed no difference between PRP and corticosteroid injections at 1 month for pain or function 3
• Another study found physical therapy superior to PRP for range of motion and pain reduction at 3 months 4

Medium-term outcomes (6-12 months):

• PRP demonstrated superior pain relief and functional scores compared to corticosteroids at 6 months (VAS: 14.5 vs 37.5; p < 0.01) 3
• Physical therapy showed better range of motion improvements than PRP throughout 12-month follow-up 4
• However, PRP showed better DASH scores (disability measure) than physical therapy at 12 months 4

Structural healing:

• A high-quality double-blind RCT found no difference in tendon healing between PRP and saline placebo at 7 months (lesion size change: -0.3 mm³ vs -8.1 mm³; p = 0.175) 5
• PRP showed 71% favorable tear evolution at 3 months in an uncontrolled series, but this was heavily influenced by anatomical factors 2

Safety Concerns

PRP carries a significantly higher adverse event rate than placebo:

• 54% adverse event rate with PRP versus 26% with saline (p = 0.020) 5
• Complications include prolonged pain >48 hours, frozen shoulder, and lesion extension 5
• Despite these risks, PRP is generally well-tolerated with minimal immunogenicity due to autologous nature 6

Standardization Problem

A fundamental limitation affecting all PRP evidence is severe lack of standardization:

• Preparation methods, platelet concentration, purity, and activation status vary dramatically between studies 6, 7
• Different techniques produce significant variations in platelet yields and viability 6
• This heterogeneity makes it impossible to determine optimal PRP formulation or predict individual response 7

Clinical Decision Algorithm

If conservative management (physical therapy, NSAIDs) has failed after 3+ months:

1. Obtain MRI to assess:

   • Acromion morphology (avoid PRP if type 3) 2
   • AC joint arthrosis severity (avoid PRP if severe) 2
   • Tear size (PRP studied only in tears <1.5 cm) 2

2. If anatomical features are favorable:

   • Consider corticosteroid injection first for rapid short-term relief 3
   • Reserve PRP for patients requiring longer-term benefit (>3 months) who failed corticosteroids 3
   • Use ultrasound guidance for accurate intratendinous delivery 3

3. Set realistic expectations:

   • PRP will not heal the structural tear 5
   • Pain relief and functional improvement are possible but inconsistent 4, 3
   • Physical therapy remains essential regardless of injection choice 4
   • Adverse events occur in >50% of patients 5

4. If PRP is chosen:

   • Plan for 2 injections with 1-month interval 5
   • Use leukocyte-poor preparation if available 3
   • Combine with structured rehabilitation program 4
   • Monitor for complications (pain, stiffness, progression) 5

Bottom Line

Physical therapy with or without corticosteroid injection remains the evidence-based standard for partial supraspinatus tears. 1, 4 PRP should be considered experimental, reserved for highly selected patients who have failed standard treatments, lack adverse anatomical features, and understand the limited evidence and significant adverse event risk. 1, 2, 5