Tendons attach muscles to bones, allowing movement by directing high forces from the muscle to the bone. Tendon disease, also known as tendonitis, develops due to overload and results in pain and reduced function. We offer a range of treatments for tendonitis, including exercise, GTN patches, shockwave therapy, and injections. A type of injection called a platelet-rich injection is used in problematic cases. Does PRP for tendonitis work, and is there an optimal formula of Platelet-rich plasma injection for tendonitis that gets the best results?
Tendonitis: an overuse injury in tendons
Excessive force on the tendon can lead to tendon swelling, a condition known as tendinitis. At the cellular level, excessive forces cause the tendon cells to produce excess sugar molecules. This sugar production leads to water seeping into the tendon, causing tendon swelling and attracting abnormal blood vessels and nerves. Eventually, this rush of water, blood vessels, and nerves leads to the breakdown of collagen and the formation of small, partial tears. If left unchecked, these small partial tears can develop into larger tears and ultimately lead to complete rupture.
What is a PRP injection?
PRP is plasma containing a higher concentration of platelets without the red cells.
We obtain PRP from whole blood from your arm. The blood is centrifuged, allowing the heavier red blood cells to move to the bottom. The top part of the sample contains plasma with a higher concentration of platelets and white cells.
Not all PRP formulas are the same. Some PRP systems are a single spin, meaning the platelet concentration is only 2- 3x that of normal blood. Other systems are a ‘double’ spin, producing platelet concentrations of up to 10% with a high white cell count. An Example of a double spin PRP is Arthrex ACP Max.
How does PRP injection for tendonitis work?
We think injecting PRP into diseased tendons releases growth factors and signalling cells. These cells attract inflammatory cells, which start the process of natural healing and remodelling. We believe the natural process of healing is accelerated. However, the exact mechanism by which PRP improves tendon pain and function remains largely unknown.
Evidence for PRP in tendonitis:
Some tendons respond more effectively to PRP than others. We provide a summary of the evidence for common upper and lower body tendonitis below:
Tennis elbow
Studies on PRP in tennis elbow have yielded mixed results, with some showing improvement while others showing no effect. However, a recent review of all systematic reviews on tennis elbow injections found that PRP is more effective than cortisone in the medium to long term.
Overall, we believe PRP is a more effective injection option than cortisone for tennis elbow. Dry needling, which we prefer for tendon calcification, is another option. However, non-injection options should be tried first.
Plantar fasciitis
Evidence for PRP in plantar fasciitis is growing.
Recent evidence suggests that PRP is more effective than cortisone after six months for treating plantar fasciitis. It may also be more effective than other treatments, such as shockwave therapy.
Generally, we recommend simple treatments for plantar fasciitis, including ice, stretching, and calf strengthening exercises. Seeing a podiatrist may help. For more challenging cases, we suggest shockwave therapy followed by plantar fascia injections. Our preferred injectable is PRP, as cortisone has risks, including plantar fascia rupture and soft tissue changes.
Greater trochanteric pain syndrome
Like other tendons, the results of PRP injections for greater trochanteric pain syndrome are mixed. However, a good study comparing high white blood cell count PRP with cortisone found that PRP was more effective after two years. PRP was effective in curing 80% of people, while corticosteroids were effective in curing only 20%.
Generally, for greater trochanteric pain syndrome, we suggest exercises and shockwave therapy first. For challenging cases, either cortisone or PRP is used, with a preference for PRP.
Shoulder tendonitis
PRP has shown better effects than cortisone in shoulder tendonitis in the medium to long term. Moreover, it is better than cortisone for partial rotator cuff tears after three months.
In biceps tendonitis, PRP is more effective than cortisone for reducing pain and improving function.
Achilles tendonitis
Studies have shown no difference between PRP and placebo for Achilles tendonitis, and no studies have tested its effectiveness for partial tears.
We recommend exercise therapy for Achilles tendonitis combined with other treatments such as GTN patches, collagen supplementation and shockwave therapy. In certain cases, Achilles tendon scraping may be a suitable option.
Patellar tendonitis
A recent review found that PRP was no more effective than injectables, such as high-volume or dry needling. However, it was better than shockwave therapy.
Generally, we suggest heavy-weight training for patellar tendonitis combined with GTN patches and collagen supplementation. Sometimes, a patellar tendon scraping or a TENEX procedure might help.
What is the best system of PRP for tendonitis?
Traditionally, we use standard PRP systems for tendonitis. These systems use a small amount of blood and one spin. Platelet concentrations range from 2-3X normal blood concentrations. However, given the low concentration of platelets, we recommend three injections performed every 1-2 weeks.
Recent systematic reviews, which summarise higher-level studies, have shown a trend toward a more significant effect with higher concentrations of platelets (up to 10 times). Generally, these systems require more blood and two spins, resulting in highly concentrated platelet cells. Additionally, due to the high platelet concentration, a single injection is recommended. An example of a super-concentrated PRP system is Arthrex ACP Max.
Other frequently asked questions on PRP for tendonitis:
How do you prepare Platelet-rich plasma for tendonitis?
You must take simple steps to improve the quality of your platelets. Generally, we recommend the following:
- It would be best to hydrate before a PRP injection. We suggest drinking 1-1.5 litres of fluid 3 hours before the procedure.
- Avoid NSAIDS and Aspirin ten days before the procedure.
- Reduce alcohol and caffeine intake for 2-3 days before the procedure
What should you do after a Platelet-rich plasma for tendonitis?
After the PRP injection, you should follow a strict post-injection protocol to optimise the natural healing effect of PRP. These post-injection guidelines include:
- After the Platelet-rich plasma injection for tendonitis, the specified area should be rested for a specified period, depending on the location and the condition being treated.
- Pain management. You could experience short-term pain after a joint or tendon injection. Generally, joint injection soreness lasts a few days, while tendon injection soreness can last up to 7 days longer. Pain-relieving techniques include regular ice 15 minutes every 4 hours to the injected area to reduce swelling. Additionally, over-the-counter or prescription analgesia (examples include paracetamol, Co-Codamol, and Co-Dydramol) may be required for the first 24-48 hours after an injection.
- Avoid NSAIDS such as ibuprofen or Aspirin for at least two weeks after a PRP injection.
In this blog, we outline the post-injection activity that follows a PRP injection for tendonitis.
Final word from Sportdoctorlondon about PRP for tendonitis
We can use PRP injection for tendonitis cases. However, not all tendonitis responds to PRP. We limit PRP use for tennis and golfer’s elbow, plantar fasciitis, greater trochanteric pain syndrome and shoulder tendonitis. Moreover, we believe that super-concentrated PRP with a high concentration of white blood cells might be more effective.
Dr Masci specialises in sports and exercise medicine and is interested in tendonitis. He has published over 20 peer-reviewed papers on tendonitis.
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