In recent years, platelet-rich-plasma (PRP) injections have been used to treat a variety of sports injuries, ranging from severe tendonitis to muscle tears. As with any new treatment, there are a range of issues surrounding its use, particularly with children. Any parent facing tough medical decisions for their children understands this dilemma. Having quality information about treatment options is therefore critical.
Dr. Nathan Mall, associate physician for the St. Louis Cardinals and Director for the St. Louis Center for Cartilage Restoration and Repair  at Regeneration Orthopedics , recently completed researching the topic of PRP injections. As a parent himself, he knows that, when your child is hurt, you will do anything to get them better. When it comes to PRP injections, though, he wants you to know to make an informed decision that is the best for your child.
"PRP is created when blood is drawn and placed in a centrifuge, a machine that spins the blood at a high rate of speed, which separates the various components of the blood," reports Dr. Mall. "The platelet component has various growth factors, which are thought to influence the healing process."
There are 4 major types of PRP.
"It is important to note, " stresses Dr. Mall, "we do not fully understand which of these ratios are best for each condition to be treated.
PRP is used to treat a variety of musculoskeletal conditions, including acute and chronic injuries.
"The pathology of acute and chronic injuries are completely different," states Dr. Mall, " thus the use of PRP for each of these injuries must be evaluated."
Acute injuries include:
These injuries often occur in a very short time frame, if not instantaneously, setting off the process of inflammation, regeneration, and repair.
Chronic injuries, in contrast, are the result of repeated trauma preventing the normal healing mechanisms from occurring. They include injuries such as:
In my professional opinion," concludes Dr. Mall, "PRP should only be used for patients where all other treatments have failed who want to try one additional solution prior to surgical intervention." He notes that PRP injections can cost anywhere from $400 to $2,000 and, because the treatment is considered by health insurers to be experimental, are completely out-of-pocket.
"Furthermore, a series of three injections is sometimes suggested, making this treatment very pricey, says Dr. Mall, despite the fact that "there is little to no data to support the practice of using a series of three injections either." Additionally, he says, "We have not found the optimal platelet count that will produce improvement in symptoms or healing of tissue. The correct ratio of platelets to white blood cells also has not been determine and likely differs for various conditions."
The main side effects or risks with PRP injections are a painful flare reaction and the possibility of infection. While parents, coaches, and athletes should know that there are no significant side effects, and the risks associated with PRP injections are quite low, there is a significant differenc of opinion about the effectiveness of the treatment.
"PRP unfortunately is being used to treat many musculoskeletal problems," says Dr. Mall, "but we do not have hard and fast evidence that it works for any of these conditions. Studies that do show some improvement in pain or symptoms typically have low numbers of patients, do not report platelet concentration of the injected fluid, or lack control groups, or there are other studies that show no effect."
There are a variety of treatments that are utilized to address acute and chronic injuries. Common treatments include:
The majority of theses treatments can be facilitated with a combination of physical therapy, home exercises, and interventions as needed, such as steroid injections, as indicated by the child's physician.
"Bottom line," Dr. Mall concludes, "it is hard to justify recommending PRP when it is so expensive out-of-pocket, and there is little to no data supporting its use."
Not all sports medicine doctors, however, agree with Dr. Mall. One is Andrew M. Blecher MD, a Primary Care Sports Medicine physician and Medical Director of the Center for Rehabilitation Medicine at the Southern California Orthopedic Institute in Van Nuys, California.
"I have had great success using PRP for many different tyes of ligament injuries," says Dr. Blecher. " I have found treating partial tears [of the UCL]  with PRP is an excellent, minimally-invasive, office procedure which will allow for a quicker return to play than Tommy John surgery. " In Dr. Blecher's view, PRP "may be an excellent option for the thousands of youth pitchers who suffer from this injury every year."
"I do agree with many of Dr. Mall's statements, including that PRP is expensive, not covered by insurance, may not be the most cost-effective first line treatment and is often used when all other conservative treatments fail," says Dr. Blecher. I also agree that much more research needs to be done in order to establish the optimal concentrations, protocols and procedure techniques for the various musculoskeletal indications for which PRP is being used." (for a companion article in which Drs. Mall and Blecher review the results of recent PRP studies, click here ).
Early adopters v. late adopters
"As with any new medical technology or advancement, there will always be early adopters and late adopters," says Dr. Blecher. "The late adopters will continue to repudiate the new technology until there is so much overwhelming evidence in its favor that they would be below the medical standard of practice if they continued to reject it."
"On the other hand, early adopters run the risk of providing a treatment that, years later, may end up to be proven to be of no benefit or may cause harm. I believe that the use of PRP has clearly been shown to be safe and effective, and is actually a much healthier option than a steroid injection is for children (as Dr Mall suggests). I have personally seen hundreds of my patients who were either cured or significantly improved by the use of PRP, sometimes after all else had failed and they had nowhere else to turn. PRP often gets a bad rap because it is considered "unproven and expensive", but for many patients it has truly been a remarkable treatment."
1. Podesta L, Crow SA, Volkmer D, Bert T, Yocum LA. Treatment of Partial Ulnar Collateral Ligament Tears in the Elbow With Platelet-Rich Plasma. Am J Sports Med. 2013;20(10). DOI: 1177/0363546513487979.
2. Ahmad CS, Redler LH, Ciccotti MG, Maffulli N, Longo UG, Bradley J. Evaluation and Management of Hamstring Injuries. Am J Sports Med. 2013;20(10). DOI:1177/0363546513487063.
Posted October 4, 2013; revised October 8, 2013 to include extended commentary from Dr. Blecher.