Background: Several meta-analyses have evaluated the use of platelet-rich plasma (PRP) in the treatment of Achilles tendinopathy. Although they generally did not find PRP to be effective, an updated meta-analysis containing all the available, high-quality randomized trial evidence that addresses the methodological shortcomings identified in earlier meta-analyses needs to be performed.
Question/purposes: This systematic review and meta-analysis aimed to evaluate the efficacy of PRP in improving (1) pain and function as assessed using the Victorian Institute of Sports Assessment-Achilles (VISA-A) score 3 months, 6 months, and 1 year after treatment and (2) VAS pain scores 3 months after treatment in patients with chronic Achilles tendinopathy.
Methods: We conducted a systematic search of PubMed, Scopus, Embase, and Cochrane CENTRAL from their inception until June 2024, focusing on randomized clinical trials (RCTs) comparing PRP with placebo or other treatments for Achilles tendinopathy. Our search identified 1289 studies, of which 1262 were excluded after removing duplicates and screening titles and abstracts, leaving 27 studies for detailed review. Six RCTs met the inclusion criteria, encompassing 422 patients, with a predominance of participants who were men. Publication bias was suggested by funnel plot asymmetry, which suggested that, if anything, the results may have overstated the apparent benefit of PRP treatment. Risk of bias was evaluated using the Cochrane Risk of Bias tool for randomized trials, revealing an overall low or unclear risk of bias. The primary outcomes were pain relief and functional improvement, assessed using the VAS, scored 0 to 10, with higher scores representing more severe pain, and VISA-A score, scored 0 to 100, with higher scores representing better pain and function. Heterogeneity was assessed using the Cochran Q test and I2 statistics, and a random-effects model was applied due to substantial heterogeneity. Statistical analyses were performed using Review Manager 5.4 and RStudio, version 764.
Results: We found no benefit in terms of VISA-A scores favoring PRP over placebo at 3 months (mean difference 1.7 [95% confidence interval (CI) -1.8 to 5.2]; p = 0.34), 6 months (mean difference 0.5 [95% CI [-8.5 to 9.3]; p = 0.92), or 1 year (mean difference -7.9 [95% CI -27.3 to 11.6]; p = 0.43). PRP did not improve VAS pain scores at 3 months (mean difference -0.22 [95% CI -0.56 to 0.12]; p = 0.21). Sensitivity analyses confirmed these findings. PRP showed no difference compared with stromal vascular fraction and was less effective in the short term compared with high-volume injection.
Conclusion: Until future high-quality RCTs show a clear clinical benefit, PRP should not be used to treat Achilles tendinopathy. Our analysis found that PRP does not improve pain or function compared with placebo, and potential publication bias suggests that the apparent benefits may be inflated. Surgeons should be cautious when considering PRP for this condition, and future research should focus on larger trials with standardized protocols to provide more definitive guidance.
Level of evidence: Level II, therapeutic study.
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