International Journal of

Review Article Clinical Rheumatology

Platelet rich plasma therapy for

shoulder tendinopathy: a systematic
review
Background: There is a fascinating interest in platelet-rich plasma (PRP) injection as a treatment for Pooja Pithadia*1, Sharmila S.
shoulder tendinopathy. Tulpule2, Mrinalini singh3 &
Pratham Surya4
Objective: To determine the efficacy of platelet-rich plasma (PRP) injections for shoulder
tendinopathy compared with other existing conventional methods.
1
Department of Biochemistry, Medica Stem
Cells, Pain management clinic, London, UK
Design: Systematic review 2
Department of Orthopaedics, Medica Stem
Cells, Pain management clinic, Dubai, UAE
Data Sources: PubMed, Scopus, EMBASE, and Cochrane Library published up to October 15, 2020
3
Department of Biochemistry, Medica Stem
Study Eligibility Criteria: Randomized controlled trials, single-arm interventional study, and a Cells, Pain management clinic, London, UK
prospective open-label study comparing PRP with conventional methods (saline, sham injection, 4
Department of Orthopaedics, Medica Stem
dry needling, corticosteroid. non-steroidal anti-inflammatory drugs, physiotherapy, and hyaluronic Cells, Pain management clinic, London, UK
acid) in patients with shoulder tendinopathy. The search included only in vivo studies and excluded
*Author for correspondence:
non-human studies.
[email protected]
Study Appraisal and Synthesis Methods: A systematic review was carried out in accordance with
the PRISMA statement. The authors reviewed and tabulated data according to the year of study
and journal, study type and level of evidence, study population, intervention, outcomes, and
interpretation.
Results: Among the 228 records screened, 11 studies were included in the systematic review study.
The selected studies focused on the application of PRP in the treatment of shoulder tendinopathy.
Among 11 studies, 9 studies demonstrated favourable outcomes such as improved pain and
functional scores after the PRP application for shoulder tendinopathy. In two studies, no statistically
significant differences were seen regarding clinical outcomes.
Conclusions: Injection of PRP is more efficacious than control injections in patients with shoulder
tendinopathy.
Keywords: PRP ● platelet-rich plasma ● systematic review ● rotator cuff tendinopathy ● shoulder
tendinopathy
Abbreviations: PRP: Platelet-Rich Plasma; EMBASE: Excerpta Medica Database; RCT: Rotator Cuff
Tendinopathy; NSAIDs: Non-Steroidal Anti-Inflammatory Drugs; TGF-β: Transforming Growth
Factor-beta; PGDF: Platelet-Derived Growth Factor; VEGF: Vascular Endothelial Growth Factor;
EGF: Epidermal Growth Factor; PRISMA: Preferred Reporting Items for Systematic Reviews and
Meta-Analyses; MRI: Magnetic Resonance Imaging; ROM: Range of Motion; VAS: Visual Analogue
Scale; SDQ: Shoulder Disability Questionnaire; SPADI: Shoulder Pain and Disability Index; WORC:
Western Ontario Rotator Cuff Index; DASH: Disabilities of the Arm, Shoulder and Hand; SH: Sodium
Hyaluronate; PTRCT: Partial-Thickness Rotator Cuff Tendinopathy; ASES: American Shoulder and
Elbow Surgeons Shoulder Score; CMS: Constant-Murley Score; SST: Sterling Structural Therapy

Introduction the shoulder joint by allowing its complete

Supraspinatus, infraspinatus, teres minor, range of motion [1]. However, hypermobility,
and subscapularis tendons together constitute strain, irritation, and poor mechanics leads
the rotator cuff, which provides stability to to tendons' painful conditions, termed

Int. J. Clin. Rheumatol. (2021) 16(5), 149-157 ISSN 1758-4272 149

Review Article Pithadia P, et al.

'Tendinitis' [2]. Degeneration weakens the tendon Factor (PDGF), Vascular Endothelial Growth Factor
and exacerbates the pain further with complete failure, (VEGF), and Epidermal Growth Factor (EGF) found
termed as 'tendinosis' [2, 3]. Both these tendinitis and in Platelet-Rich Plasma (PRP) play a critical role in
tendinosis represent tendon issues and together called cell proliferation, cell differentiation, chemotaxis, and
tendinopathy [4]. Neer believed that the shoulder angiogenesis [11]. Using PRP in tendon healing is
tendinopathy process started with tendonitis, progressed based on the fact that tendinopathy reduces stem cell
to tendinosis with degeneration and partial-thickness numbers, disorganise matrix and hypoperfusion. The
tears, and ultimately resulted in full-thickness tears [5]. use of autologous platelets can revascularise the tendon
injury site, accelerate its healing, and improve pain and
Rotator Cuff Tendinopathy (RCT) is the most common
functional limitations in rotator cuff pathologies [12].
cause of shoulder discomfort. A cross-sectional study
Platelet-Rich Plasma (PRP) is the plasma's cellular
reported that around 86% of all clinical diagnoses
component with a higher platelet concentration more
of shoulder ache and disability were rotator cuff
than baseline levels of 1,50,000/ml to 3,00,000/ml than
abrasions [6]. A combination of intrinsic factors
whole blood, obtained by centrifuging the whole blood
(tendon hypervascularity, changes in the composition
[10, 13].
of the matrix of the tendon, and decreased cellular
activity), as well as extrinsic factors (repetitive According to the American College of Rheumatology
microtrauma, compression from anatomical structures, (ACR) and European League Against Rheumatism
and impingement), causes inflammation followed by (EULAR) recommendations, Platelet-Rich Plasma
progressive rotator cuff degeneration [1, 6]. Usually, (PRP) treatment is recommended despite having
shoulder pain and stiffness will worsen at night, where concerns like heterogeneity and lack of standardization
the patient cannot lie on the affected side. As the disease in PRP preparation. Moreover, the use of PRP therapy
progresses, the intensity of pain and stiffness increases, was based on the clinical experience of the experts [14].
restricting even simple activities such as hair grooming
or dressing. Objectives
In this review, we aim to investigate PRP injection's
Furthermore, palpable snapping and coarse crepitation
effectiveness regarding pain reduction and functional
on the passive rotation of the shoulder show fibrosis
improvement compared with the conventional
or partial/ complete rotator cuff rupture, severely
methods, including saline, sham injection, dry needling,
restricted movements, followed by secondary shoulder
corticosteroid, non-steroidal anti-inflammatory drugs,
osteoarthritis [7]. Conservative treatments for RC
physiotherapy, and hyaluronic acid in adult patients
tendinopathy include rest, activity modification, Non-
with rotator cuff tendinopathy.
Steroidal Anti-Inflammatory Drugs (NSAIDs), physical
therapy, and corticosteroid injections. However, none Methods
of the existing therapies shows consistent improvement This systematic review was performed following the
in functional, clinical, and radiological outcomes PRISMA (Preferred Reporting Items for Systematic
and available evidence recommends that effective Reviews and Meta-Analyses) statement in Figure 1 [15].
intervention for early tendinosis and low-grade tears is
still vague [6]. Physical therapy (exercise and manual Eligibility criteria
therapy) takes a prolonged time for recovery, where All participants in the trials had to have a clinical
patient compliance is required to get maximal effect [8]. diagnosis of shoulder tendinopathy. We excluded articles
Though NSAID treatment and corticosteroid injections published before the year 2000.
are known to alleviate inflammation and pain, severe
gastrointestinal complications after prolonged oral Search strategy
NSAID administration, as well as inhibition of collagen A comprehensive, systematic literature search and analysis
synthesis and increased risk of tendon failure caused were performed on October 15, 2020, by the authors
by repeated corticosteroid injections, are important involved in this study. The databases of MEDLINE
concerns [9]. Hence, the use of growth factors has (PubMed), Scopus, EMBASE, and the Cochrane
been recommended to improve the healing process and library were searched without time limits. The following
promote tendon regeneration during treatment [10]. keywords were used in different combinations: 'shoulder
tendinopathy', 'rotator cuff tendinopathy, 'platelet-rich
The autologous growth factors like transforming
plasma', 'PRP therapy', 'PRP vs corticosteroids', 'PRP
growth factor-beta (TGF-β), Platelet-Derived Growth
vs physical therapy', and 'non-surgical methods for

150 Int. J. Clin. Rheumatol. (2021) 16(5)

 Platelet rich plasma therapy for shoulder tendinopathy: a systematic review
Review Article

Figure 1. PRISMA 2009 flow diagram.

shoulder tendinopathy'. We limited the search to articles physiotherapy, and hyaluronic acid. The quantity of
in English, and only human studies were included. After injections or the injection-guiding technique was not
assessing all titles and abstracts, the relevant articles limited. The post-interventional follow-ups were allotted
were selected. All bibliographies for each selected article for not more than a year.
were also searched to identify further relevant literature.
These articles were finally collected and subjected to Summary measures
the already established inclusion and exclusion criteria We considered pain reduction and functional
before the review's commencement. improvement as the primary and secondary outcome,
respectively.
Study selection
All studies were included if their design could be Synthesis of results
classified into one of the three categories: randomised The researchers independently recorded the study
controlled trial, single-arm interventional study, and design, population, intervention, outcome measure and
prospective open-label study. interpretation.
The inclusion criteria of shoulder tendinopathy Results
comprise tendinosis, rotator cuff tendinopathy, and
Study selection
partial rotator cuff tear. Studies that included subjects of
complete rotator cuff tears, adhesive capsulitis, trauma, Of the 228 articles initially identified by the search, 11
calcific rotator cuff disease, or rheumatological disease met the inclusion criteria. These articles describe PRP
were excluded. outcome with respect to other conservative treatment
modalities in Table I for systematic reviewing.
Data collection
Study characteristics
Studies that have a PRP-treated group along with a
control group were eligible for inclusion. The control The search strategy included studies from 2013 until
group included saline, sham injection, dry needling, a 2020. The study characteristics extracted from the
corticosteroid: non-steroidal anti-inflammatory drugs, eleven selected studies (research author, publication

151
Review Article Pithadia P, et al.

year, the study design, type of intervention, the number Safety of PRP therapy
of patients assigned, the duration of the study, outcomes None of the studies analysed in this systematic
measured, and conclusion) are summarised in Table 1. review reported any adverse side effect related to PRP

Table I. Chronological list of published literature studies included in the systematic review and their findings.
Subjects enrolled (n)/
Articles Study Intervention Outcome Conclusion
controls enrolled (n')
Autologous PRP
PRP Vs Dry
39 RCT patients with a causes a progressive
Single-centre, needling
supraspinatus tendon PRP shows significant improvement reduction in pain
prospective, (ultrasound
lesion (tendinosis or a in mean Shoulder Pain and and disability,
double-blinded, guidance); PRP
[9] partial tear less than 1.0 Disability Index with no severe compared to dry
randomized preparation:
cm, but not a complete complication in either group. needling. Hence, PRP
controlledtrial (3 ml extracted
tear) (20/19). injections are safe,
(Level 1) from centrifuged
6 months follow-up useful, & superior to
25 ml blood)
the dry needling
PRP therapy may
Both groups showed statistically
be employed in
35 patients with chronic significant improvements in
patients more than
PRP Vs rotator cuff tendinopathy outcome after injection when
Randomised 40 years old instead
Corticosteroid for more than 40 years compared with before injection.
[12] clinical trial of corticosteroid
injection (MRI old; (17/18) No statistically significant
(Level 2) injection due to lack
guidance) Assessment - 1, 3, 6 differences between the two
of severe adverse
months follow-up groups.
effects unlike steroid
group
Significant improvement in both
groups after injection regarding
Both PRP and
the range of motion (ROM) (flexion,
corticosteroid
abduction, extension, internal and
PRP Vs injections were
external rotation), Visual Analogue
corticosteroid 30 patients with RCT effective. PRP is
Scale (VAS), & Shoulder Disability
Randomised injection (15/15). a safe and good
[15] Questionnaire (SDQ).
clinical trial (ultrasound Assessment - before & 8 alternative to
Significant improvement in the
guidance) weeks after injection corticosteroid. The
frequency of tendinitis/bursitis in
ultrasound-guided
the steroid group compared to PRP.
injection may
In contrast, the improvement in the
improve efficacy.
tear and effusion was higher in PRP
compared to steroid group.
No significant difference between
two groups in SPADI, WORC PRP injection was
PRP Vs Sham
(Western Ontario Rotator Cuff not more effective
injection;
Index), and VAS scores. in improving pain,
(ultrasound- 40 patients (18 years to
Double-blind Within each group, the SPADI, disability, quality
guided). 70 years age) with RCT
Randomised WORC, and VAS scores showed of life, and range of
[10] PRP preparation: or partial tear (20/20);
controlled trial; significant improvements motion than placebo
(5 mL PRP Assessment - 3, 6, 12, 24
Level 1. compared with baseline at all time in patients who
extracted from weeks & 1-year follow-up
points. No significant group × time were treated with an
centrifuged 54
interactions in the range of motion exercise program.
mL blood)
measures

Improvement in VAS pain score,

PRP for patients'
functional outcomes, external
refractory PRP - safe,
18 RCT patients (3 mL 1% rotation test
Prospective to physical significant, sustained
xylocaine followed by 3.5 It improved MRI appearance by 1 to
[16] open-label therapy and improvement in
mL PRP) 3 points in 16 patients.
study corticosteroid pain, function, and
Satisfactory score: 12 completely
(ultrasound- MRI outcomes
satisfied, 5 satisfied, & 1 unsatisfied
guided)

152 Int. J. Clin. Rheumatol. (2021) 16(5)

 Platelet rich plasma therapy for shoulder tendinopathy: a systematic review
Review Article

Improvement in VAS score and

PRP for patients' 20 RCT patients (4 mL functional outcome
Prospective refractory to autologous PRP) Improvement in empty cane test, PRP - safe and
[7]
clinical study physical therapy Assessment – 3 months drop arm test, and theta band effective
& corticosteroid follow up external rotation at 90°
The decline in mean analgesic use
Significant improvement in pain
PRP - safe, cheap, and
and disability score
30 RCT (supraspinatus painless outpatient
Single-arm No significant radiological
PRP (ultrasound- tendon thickness). procedure showing
[17] interventional improvement in tendon thickness
guided) Assessment –- 4, 8, 12, promising results
study till 12 weeks, but observed a
and 24 weeks follow up compared to other
decrease in tendon thickness finally
treatment modalities
at 24 weeks
PRP Vs Placebo
(4ml saline ) PRP injection
Patients receiving PRP showed
Randomized (ultrasound- 9 (7/2) RCT patients showed
improvements in pain (VAS),
[18] controlled trial+ guided) Assessment – 1, 2, 3, 6 improvement in
disability (DASH), and tendon
observational + 3-month months pain, function, and
pathology, unlike placebo group.
home-based, tendon pathology.
daily exercise
PRP Vs Physical
therapy (PT). 70 (35/35) RCT patients
Compared with PT,
PRP preparation: with chronic partial Improved ROM in the physical
PRP will be a well-
Randomised 6 mL extracted supraspinatus tears in therapy group, while significantly
[19] tolerated application
controlled trial from 15 mL MRI. better DASH score is seen in the
that showed
peripheral blood Assessment – 12 months PRP group
promising results
activated by
CaCl2
PRP Vs Sodium
45/47 patients with
hyaluronate (SH) PRP best in healing
partial-thickness RCT
PRP small to medium
(PTRCT) detected by Significant improvement in the
A double-blind, preparation:4mL PTRCT. Moreover, the
clinical examination PRP group &PRP+SH group in the
[20] random sed PRP extracted combined PRP+SH
&MRI. tear size, Constant, ASES score, and
controlled trial from centrifuged injection yielded a
Assessment – before visual analogue scale.
20 mL better outcome than
& after 1, 3, 6, and 12
autologous PRP or SH alone.
months
venous blood
Both injection groups showed
significantly better outcomes over PRP showed better
PRP vs time compared to before injection. results compared
corticosteroid. Statistically significant to corticosteroid;
20/20 RCT patients with
PRP preparation: improvement in the PRP group still, no significantly
painful partial RC tears
Randomised (2.5 ml PRP regarding VAS, ASES, CMS and SST better results could
diagnosed by MRI.
[21] controlled trial/ extracted from when compared with the steroid be observed after
Assessment – before &
level 1 centrifuged group. 6 months. Hence,
after 6 weeks, 3 and 6
10 ml blood) MRI showed a slight nonsignificant PRP could be an
months
Leucocyte improvement in tendinopathy/ excellent alternative
reduced tear in both groups; however, no to corticosteroid
significant difference between the injection
two groups.

administration. NSAIDs, physical therapy, or corticosteroid injections

conservative treatment modalities.
Discussion
Rest and ice therapy are the well-accepted first-line
Rotator cuff tendinopathies is one of the most common
options. Physical therapy is often considered the first line
causes of shoulder pain and discomfort. There is still an
of RCT management. A good rehabilitation program
ongoing debate in the medical community regarding
for the rotator cuff muscles should include a range of

153
Review Article Pithadia P, et al.

motion exercises, stretching, eccentric strengthening, et al., 2016 [7] and Scarpone et al. [26] also reported
balancing of muscular tone, and scapular stabilisation. that a single injection of PRP is safe and effective in
Eccentric strengthening can improve tendon healing treating refractory RCT. No side effect was observed
and reduce pain in chronic RCT patients [16]. Exercise during PRP treatment except pain at the injection site,
therapy has its possible beneficial effect on tendon which lasted for only ten minutes and relieved naturally
homeostasis, prevent adverse effects of immobilisation, [7]. Furthermore, Scarpone et al. [26] found significant
and aids in collagen turnover [17]. The exercise had improvement in function, pain, and radiological scores.
statistically significant effects on pain reduction and Similarly, there is a drastic improvement in pain score
function improvement but not on the range of motion after the single PRP injection dose [27]. Hence, it is
or strength. Manual therapy enhances exercise's effects; worth studying the comparison of PRP injections with
still, supervised exercise was not different from home the available conventional methods.
exercise programs [18]. If there has been no significant
In a double-blinded RCT, Kesikburun et al. [10]
relief from shoulder pain in two to three months, then
compared the effect of a single PRP injection with a
other treatment options will be considered.
placebo where PRP had no benefit over placebo in terms
A current meta-analysis recommended that NSAIDs of pain, disability, quality of life, and range of motion.
are less effective than corticosteroid injections achieving This study utilised a leukocyte rich PRP formulation
patient remission rate with shoulder pain at 4- weeks that could have caused a harmful effect in the early
or 6-weeks post-treatment [19]. Hence, corticosteroid healing stages.
injections are often used to treat the shoulder pain
Rha et al, [9] compared PRP therapy with dry needling,
associated with rotator cuff tendinopathies.
where PRP provided more symptomatic relief and
Corticosteroid injection, due to its anti-inflammatory functional improvement than dry needling. It shows
effect, limits the accumulation of macrophages and that exercise might have improved the tendinopathy
leukocytes and the release of vasoactive kinins. It condition, which might have concealed PRP's positive
reduces the prostaglandin formation, contributing to effect. Whether PRP remains beneficial to those who do
the inflammation procedure that may lead to pain relief not respond to exercise therapy requires further research.
and mechanical improvement [20]. Several in vitro Even the needling causes bleeding, which can stimulate
studies revealed that corticosteroid provided therapeutic inflammation and promote tendon healing. However,
effect to the tendon and the surrounding connective the range of motion was improved equally in both the
tissues by inhibiting collagen along with inflammatory PRP and dry needling groups. The reason for PRP's
suppression [21]. Such a positive therapeutic outcome dominance to dry needling may be the more substantial
of corticosteroids may last only for a short duration therapeutic effects of PRP injections than dry needling
since its repetitive administration may reduce cell or a different therapeutic mechanism synergistic to dry
viability and proliferation and deteriorate specific needling. Finnoff et al. [28] recommended that the
parts of the injected tendon to make it more prone to PRP fills the void created by dry needling treatment
rupture [22]. However, the efficiency of corticosteroid and stimulates tissue regeneration, leading to dominant
injections for RCT is still questionable. A systematic results. Due to its coagulative properties, PRP solidifies
review by the American Academy of Orthopaedic to form a gel-like three-dimensional structure that helps
Surgeons revealed the least efficacy for corticosteroid stay at the target area long enough to heal the injured
injections in RCT treatment [23]. Considering the low part without exogenous platelet activation. Additionally,
efficacy and complications of corticosteroid injections, exogenous platelet activation with calcium chloride or
patients and providers are looking for better options. As bovine thrombin can control the speed of the release of
all participants in this cohort were refractory to former growth factors. Further study will help in elucidating the
conservative modalities, PRP seems to have provided PRP therapeutic mechanism.
additional benefits.
IIhanli et al. [19] 29 compared PRP therapy with
PRP consists of proteins that change the patient's physiotherapy in supraspinatus tendinopathy treatment
pain receptors and reduce pain sensation with its anti- and concluded that PRP therapy might be as effective
inflammatory effect on injured tendons [24]. Studies as physiotherapy. Cai et al., 2019 [25] showed that SH
revealed that the PRP injection significantly improved and PRP's combined injection yielded a better clinical
pain, joint ROM, and shoulder function in patients outcome than SH or PRP alone. Niazi et al, 2020 [30]
with partial rotator cuff tear [1, 25]. Deepak Chaudhary reported that PRP is a cheap, safe, and easily prepared

154 Int. J. Clin. Rheumatol. (2021) 16(5)

 Platelet rich plasma therapy for shoulder tendinopathy: a systematic review
Review Article

outpatient procedure showing promising results when subacromial space or injured tendon may influence
compared to physiotherapy, arthroscopy, and surgeries. the outcome. Seven of the included studies in our
However, PRP injection could provide further functional systematic review used ultrasound guidance. But there is
benefits over exercise therapy or physiotherapy, which no description of the guidance method in the remaining
requires further investigation. studies. Hence, it is not possible to compare the effect of
varied guidance methods.
Thus, PRP's dominance over the control group,
including sham injection with saline, physical therapy, Third, there are various control groups, such as saline,
and dry needling, maybe due to its more potent sham injection, dry needling, a corticosteroid: non-
therapeutic effects and increased regenerate tissue steroidal anti-inflammatory drugs, physiotherapy, and
homeostasis [9, 29]. hyaluronic acid.
Fourth, this systematic review includes randomised
Though Mohaghegh S et al. [12] could not find any
controlled trials, a single-arm interventional study, and
significant differences between PRP and corticosteroid
a prospective open-label study. Hence, it is not possible
injection in terms of pain relief, range of motion,
to interpret either patient age or symptom duration with
and function improvements for chronic rotator cuff
treatment outcomes.
tendinopathy. It is recommended to follow PRP
treatment in patients with more than 40-years-old Fifth, there is no detailed information about the
instead of corticosteroid injection due to the lack of exact PRP composition, including platelet/leukocyte
complications in PRP group unlike corticosteroid group, concentration, biochemical analysis, and preparation
especially for the elderly. On the contrary, Shams et al. method. There were heterogeneities in doses, preparation,
[23] reported a statistically significant improvement in and regimen within every group of injectants in the
pain and functional scores in the PRP group compared enrolled studies, which may influence the outcomes.
to the corticosteroid group for patients with a partial Conclusion
supraspinatus tear. The use of leucocyte reduced
The present systematic review showed that PRP injection
PRP in this study may have yielded better results.
might be safer and more effective than the control group
Direct comparison studies of PRP with corticosteroid
(saline, sham injection, dry needling, corticosteroid.
injections in the RCT treatment are conflicting. Some
non-steroidal anti-inflammatory drugs, physiotherapy,
show a significant benefit of PRP over corticosteroids, and hyaluronic acid) in pain reduction for patients
while others show no difference [15]. with rotator cuff tendinopathy. The current evidence
Thus, PRP has been used as an adjunct to accelerate is promising, but there is a lack of a clinical study
healing in soft tissue injuries and decrease blood loss. exploring combination regimens for treating rotator cuff
This PRP application is relatively novel and has been tendinopathy. Though PRP's use has potential benefits
proven to work in other forms of tendinopathy. But such as faster recovery, improved functional outcomes,
there is minimal research when it comes to the efficacy and a reduction in a relapse of tendon injuries, its
of rotator cuff tendinopathy treatment. Furthermore, application in shoulder tendinopathy is still weakly
higher-quality studies should be performed to determine supported due to the lack of standardisation. Hence,
high-quality double-blinded randomised controlled
PRP's efficacy in comparison with other conventional
trials with a larger study population must be undertaken
treatment modalities [31, 32].
further to compare PRP with other treatment methods
Limitations and characterise PRP's optimal preparation to maximise
its benefit in treating shoulder tendinopathy.
First, there was heterogeneity in the patient groups and
diagnostic criteria among different studies. Shoulder Declarations
tendinopathy, including supraspinatus tendinosis, Ethics approval and consent to participate
supraspinatus tear, rotator cuff tendinosis, rotator cuff Not Applicable.
tear, and subacromial impingement, was enrolled in
Consent for publication
different studies. Additionally, a diagnostic image via
MRI or ultrasonography was used for confirmation. Not Applicable.

Hence, it was impossible to categorise the patients Availability of data and materials
accurately for a subgroup analysis classified by clinically Not Applicable.
or image-diagnosed subgroups. Competing Interests
Second, the PRP injection guidance technique to the The authors declare that they have no competing interests.

155
Review Article Pithadia P, et al.

Funding to October 15, 2020. According to the year of study and journal,
the authors reviewed and tabulated data, study type and level
Not Applicable. of evidence, study population, intervention, outcomes, and
Acknowledgements interpretation.

We would like to Thank James Corcoran, Director of Medica Stem Author Contribution
Cells and Medica Pain Management Clinic for sopporting us PP recommended the title, concept and drafted an outline of the
throught out the process. paper. MJS carried out the selection of the papers included in the
Data availability present review and drafted the systematic review article. PP, ST
and PS carried out the final editing of the paper. All authors read
PubMed, Scopus, EMBASE, and Cochrane Library published up and approved the final review article.

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