META-ANALYSIS

The use of platelet-rich plasma

for acute muscle tears: Systematic review
and meta-analysis of current evidence
Agustín R. Molina Rómoli,*,** Luciano A. Rossi,*** Agustín Bertona Altieri,*** Chukwuweike Gwan,# Nicolás S. Piuzzi*,##
*
Instituto Universitario de Ciencias Aplicadas al Deporte (Mendoza, Argentina)
**
Instituto Universitario del Hospital Italiano de Buenos Aires (Buenos Aires, Argentina)
**
Orthopedics Department, Hospital Italiano de Buenos Aires (Buenos Aires, Argentina)
#
Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore
(Baltimore, Maryland, United States)
****
Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, Ohio

Abstract
Introduction: Acute muscle tear is the most common type of injury in sports activities. There is a present interest in the search of
modalities that could shorten and improve healing time. The use of platelet-rich plasma (PRP) has increased over the past years,
but such popularity does not count with sufficient scientific support to back up its effectiveness. The purpose of this study is to
collect, analyze and summarize the available published data so as to clarify the effects of PRP use on muscle tears through a
systematic review and meta-analysis. Materials and Methods: We conducted a systematic review of the literature on the use of
PRP for the treatment of acute muscle injuries. A meta-analysis was conducted to evaluate the effects of PRP. Results: A total of 7
papers met the inclusion criteria for analysis: six randomized controlled trials and one cohort study. The overall time to return to play
after PRP treatment was a mean of 29 days (range, 10 to 50.9 days), and in the control groups was a mean of 35.4 days (range,
22 to 52.8 days). The meta-analysis (5 of the 7 papers) showed a significant difference in earlier return to sports with the use of
PRP when compared to conventional therapy (-7.80 days; P=0.007). No difference in the recurrence rate was reported. Conclu-
sions: The meta-analysis demonstrated a favorable effect of PRP when compared to conventional therapy. However, our analysis
demonstrated significant study heterogeneity. Thus, our findings should be interpreted with caution. We still cannot recommend the
use of PRP for the treatment of muscle tears.
Key words: Platelet-rich plasma; growth factors; muscle injuries, regenerative medicine, biologics.
Level of Evidence: II

El uso de plasma rico en plaquetas para desgarros musculares agudos: revisión sistemática y metanálisis
de la evidencia actual

Resumen
Introducción: El desgarro muscular agudo es el tipo de lesión más frecuente en actividades deportivas. El interés se ha centrado
en buscar modalidades que reduzcan y mejoren el tiempo de curación. El uso de plasma rico en plaquetas ha crecido en los úl-
timos años, pero no estuvo acompañado de suficiente respaldo científico sobre su eficacia. Este estudio intenta recabar, analizar
y sintetizar la información publicada para esclarecer los efectos del uso de plasma rico en plaquetas en desgarros musculares
agudos, mediante una revisión sistemática y un metanálisis. Materiales y Métodos: Se realizó una revisión bibliográfica sistemá-
tica sobre el uso de plasma rico en plaquetas para tratar lesiones musculares agudas. Se llevó a cabo un metanálisis para evaluar
los efectos del plasma rico en plaquetas. Resultados: Siete artículos cumplieron los criterios de inclusión (6 ensayos controlados
aleatorizados y 1 estudio de cohorte). La media del tiempo hasta el retorno al deporte en el grupo con plasma rico en plaquetas
fue de 29 días (rango 10-50.9) y de 35.4 días (rango 22-52.8) en el grupo de control. Cinco de 7 artículos fueron incluidos en el
metanálisis y se halló una diferencia significativa en el retorno deportivo con el uso de plasma rico en plaquetas comparado con
la terapia convencional (-7.80 días; p = 0,007). No se informaron diferencias en la tasa de recurrencia. Conclusiones: El metaná-

Received on 4-16-2019. Accepted after evaluation on 8-14-2019 • Agustín R. Molina Rómoli, MD • [email protected] ID
http://orcid.org/0000-0002-0970-7737
How to cite this paper: Molina Rómoli AR, Rossi LA, Bertona Altieri A, Gwan C, Piuzzi NS. The use of platelet-rich plasma for acute muscle tears: Systematic review and meta-analysis of current
evidence. Rev Asoc Argent Ortop Traumatol 2020;85(1):82-90. https://doi.org/ 10.15417/issn.1852-7434.2020.85.1.983

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82 Rev Asoc Argent Ortop Traumatol 2020; 85 (1): 82-90 • ISSN 1852-7434 (online) Obras Derivadas Igual 4.0 Internacional. (CC-BY-NC-SA 4.0).
 Meta-analysis. Platelet-rich plasma

lisis mostró un efecto favorable del plasma rico en plaquetas en comparación con la terapia convencional. Sin embargo, nuestro
análisis demostró una heterogeneidad significativa en el estudio. Los resultados deben interpretarse con cautela. Aún no podemos
recomendar el plasma rico en plaquetas para tratar desgarros musculares agudos.
Palabras clave: Plasma rico en plaquetas; factores de crecimiento; lesiones musculares; medicina regenerativa; biológicos.
Nivel de Evidencia: II

Introduction
Acute muscle injuries constitute up to one-third of all sports injuries and are associated with a reinjury rate of up
to 40% during the first year.1,2 Standard treatment modalities include early muscle activation and stretching exer-
cises with analgesic and anti-inflammatory therapy. The treatment for these injuries, despite being very common,
has seen little progress and these modalities remain the gold standard for acute muscle injuries.
During the past decade, the use of platelet-rich plasma (PRP) for muscle tear has increased on the basis of the
potential immunomodulation effect of growth factors (GFs) on the stimulation and acceleration of tissue regenera-
tion.3 In vitro studies have revealed that the use of PRP on muscle cells may result in the enhancement of cellular
proliferation, the differentiation of satellite cells and the synthesis of antiangiogenic factors.4 In addition, animal
studies have reported better muscle repair with the use of GFs.5-7
Several comparative prospective studies have examined the clinical outcomes obtained after the PRP was in-
cluded in more conventional treatments for muscle injuries; however, to date their results have been contradictory.
In light of the controversy surrounding the clinical effectiveness of PRP injections in the treatment of muscle
injuries, the purpose of this study was to conduct a systematic review and meta-analysis on the use of PRP in the
treatment of acute muscle injuries. Our specific objectives were to study the use of PRP in relation to: 1) the time
to return to play (TTRTP); 2) the pain during rehabilitation; 3) the reinjury rates; and 4) the complications associ-
ated with the procedure.

Materials and Methods

Identification and selection of papers
The study was performed in accordance with the PRISMA 2009 (Preferred Reporting Items for Systematic re-
views and Meta-Analysis) statement.8 We conducted a systematic review of the published literature on the use of
PRP in the treatment of acute muscle injuries, using PubMed, Medline and the Cochrane Database of Systematic
Reviews. The search took place on March 2017, as did the registration in the International Prospective Register of
Systematic Reviews (PROSPERO) (registration number: 42017065393).
Searches in MEDLINE/PubMed. Search 1: “Platelet-Rich Plasma”[Mesh] AND “Muscles”[Mesh]. Search 2:
(“platelet-rich plasma”[MeSH Terms] OR (“platelet-rich”[All Fields] AND “plasma”[All Fields]) OR “plate-
let-rich plasma”[All Fields] OR (“platelet”[All Fields] AND “rich”[All Fields] AND “plasma”[All Fields]) OR
“platelet rich plasma”[All Fields]) AND ((“muscles”[MeSH Terms] OR “muscles”[All Fields] OR “muscle”[All
Fields]) AND (“wounds and injuries”[MeSH Terms] OR (“wounds”[All Fields] AND “injuries”[All Fields]) OR
“wounds and injuries”[All Fields] OR “injury”[All Fields]).

Inclusion and exclusion criteria

Paper inclusion criteria included: 1) human clinical trials (level I or II); 2) English-language literature; 3) acute
muscle injuries diagnosed using ultrasound or MRI. Paper exclusion criteria included: case series, basic science
papers, editorial articles, surveys, special topics, letters to the editor, personal correspondence, review articles, and
nonorthopaedic studies.
Three members of the research team (AMR, LAR, NSP) independently reviewed the titles and abstracts of all
the papers produced by our established queries. When necessary, the complete paper was reviewed to apply the
inclusion/exclusion criteria. The literature references from the scientific papers were also reviewed to minimize
the risk of missing any relevant paper.

Rev Asoc Argent Ortop Traumatol 2020; 85 (1): 82-90 • ISSN 1852-7434 (online) 83
 A. R. Molina Rómoli et al.

Data collection
Data were recorded into a custom-made information extraction table. We collected data on the protocol used
for the preparation of the PRP, the initial whole blood volume, anticoagulant used, processing machine, dispos-
able equipment, method of separation and its characteristics (centrifugation or platelet-pheresis), platelet activa-
tion method, nomenclature, platelet count, final platelet concentration, GF analysis, final volume, and clinical
use.

Statistical analysis
Patients were divided into two groups: those who underwent PRP therapy and those who underwent con-
ventional therapy for acute muscle injury. Studies that did not report the group means and standard deviations
were excluded from the analysis. Both group mean TTRTP (days) was extracted together with their standard
deviations, in order to assess the weighted mean effect sizes and its standard error. The study heterogeneity
was assessed using the Cochran’s Q statistic and the I² statistic test. We used the z-test to determine the clinical
significance with a statistical significance level set at P<0.05. All statistical analyses were performed using the
software Stata 5.3.

Results
Identification and selection of papers
Figure 1 shows the paper selection process. The search strategy identified 251 papers. Application of inclusion
and exclusion criteria eliminated 239 studies, leaving 12 papers for full-text review. After a comprehensive review
of these papers, 7 met the inclusion criteria for analysis (Table 1); 6 randomized controlled trials (level of evidence
I) and 1 cohort study (level of evidence II).

Records identified through Additional records identified

Identification

database searching through other sources

(n=362) (n=2)

Records after removal

of duplicates
(n=251)
Screening

Records screened Records excluded

(n=251) (n=239)
Eligibility

Full-text articles assessed Full-text articles

for eligibility excluded
(n=12) (n=5)
Included

Studies included in qualitative

synthesis
(n=7)

Figure 1. Flow diagram presenting the systematic review process used in this study (PRISMA)

84 Rev Asoc Argent Ortop Traumatol 2020; 85 (1): 82-90 • ISSN 1852-7434 (online)
 Meta-analysis. Platelet-rich plasma

Table 1. Characteristics of the selected studies

Study Level of Follow-up Number Mean Inclusion Intervention Control group Outcome measure
Evidence (months) of patients age criteria
(years)
Martinez- I 12 57 45.6 Grade 2 A 4-8ml PRP Rehabilitation Primary: time to healing
Zapata et al. gastrocnemius injection guided (weeks)
(2016) muscle by ultrasound + Secondary: recurrence,
or quadriceps muscle rehabilitation VAS pain score, quality
(classified of the regenerated area
by ultrasound (ultrasound), adverse
examination) events

Rossi et al. I 24 75 22.3 Grade 2 A PRP injection Rehabilitation Primary: TTRTP (days)
(2016) gastrocnemius guided by Secondary: recurrence,
muscle, ultrasound + VAS pain score
quadriceps muscle rehabilitation
or hamstring
muscle (classified
by ultrasound
examination)

Guillodo et al. II 4 34 26.3 Grade 2 A 3ml PRP Rehabilitation Primary: TTRTP (days)
(2016) hamstring muscle injection guided
(classified by by ultrasound +
ultrasound rehabilitation
examination)

Hamilton I 6 90 26.6 Grade I or II PRP group: three Platelet-poor Primary: TTRTP (days)
et al. (2015) hamstring muscle 1ml injections plasma group: Secondary: recurrence
(classified by administered three 1ml
ultrasound adjacent to the injections
examination) injured area administered
(confirmed with adjacent to the
palpation) + injured area
rehabilitation (confirmed with
palpation) +
rehabilitation

No injection group:
rehabilitation
Reurink I 12 80 29.0 Grade I or II Two 3ml PRP A 3ml NS Primary: TTRTP
et al. (2015) hamstring muscle injections (at injection (at days 5 Secondary: recurrence
(classified by days 5 and and 10-12) guided
ultrasound 10-12) guided by ultrasound +
examination) by ultrasound + rehabilitation
rehabilitation
A Hamid I 10 28 21.0 Grade II hamstring A 3ml PRP Rehabilitation Primary: TTRTP (days)
et al. (2014) muscle (classified injection guided Secondary: pain
by ultrasound by ultrasound +
examination) rehabilitation

Bubnov et al. I 1 30 24.0 Grade I or II muscle A 5 ml PRP Rehabilitation Primary: VAS pain score
(2013) injury in thigh, foot injection guided Secondary: strength,
or ankle (classified by ultrasound + range of motion,
by ultrasound rehabilitation subjective global
examination) function, ultrasound
result,
TTRTP (days)
NS: normal saline; PRP: platelet-rich plasma; TTRTP: time to return to play; VAS: visual analog scale.

Rev Asoc Argent Ortop Traumatol 2020; 85 (1): 82-90 • ISSN 1852-7434 (online) 85
 A. R. Molina Rómoli et al.

PRP preparation and application protocol

The used PRP protocol varied among studies, there is a detail of their characteristics in Table 2 (when available).
Only four studies reported the PRP platelet concentration before its application.1,5,9,10 A Hamid et al.11, in particular,
reported the median levels for the transforming GF-b1 and for the fibroblast GF of the final product. The remain-
ing studies did not report GF values. Six out of the seven analyzed studies described the use of ultrasound for the
muscle injury localization and ultrasound-guided PRP injections.1,8-12

Table 2. PRP therapy characteristics of the selected studies

Authors Anticoa- Processing Separation Method RPM Time Spin RPM Time Acti- Platelet Platelet Final
gulant machine system (min) 2 (min) vating count concentra- injected
agent (x 109/l) tion volume
(ml)
Martinez- NR Multicomponent MCS+, Density 4800 10-15 No No No 0.05 289.32 ± 4.89 ± According
Zapata cell separator Haemonetics, separation cc of 126.85 0.87 to the
et al. Braintree, MA, CaCl2 volume of
USA the injured
area
Guillodo NR NR Ortho. Pras 20 kit Density NR NR No No No NR NR NR NR
et al. separation

Hamilton ACD-A GPS III Biomet Recover, Density 3200 15 No No No No 237.2 ± 3.2 (765.8 3
et al. centrifuge GPS III Platelet separation 50.2 ± 423.6)
separation system Separation System

A Hamid NR The Biomet (GPS III; Biomet, Density NR NR NR NR NR No 234 1297 3

et al. Gravitational Warsaw, Indiana, separation
Platelet USA)
Separation
System

Reurink EDTA Arthrex ACP Arthrex Density - - - - - NR 232 1.9 (433 ± 3

et al. double-syringe Medizinische separation 128)
system Instrumente
GmbH, Garching,
Germany

Bubnov NR NR NR Density NR NR No No No NR NR NR 2
et al. separation

Rossi et al. EDTA NR NR Density 1400 3 Yes 3000 4 min No NR NR According

separation to the
volume of
the injured
area
ACD-A: anticoagulant citrate dextrose solution A; EDTA: ethylenediaminetetraacetic acid; NR: not reported; RPM: revolutions per minute.

Time to return to play

The overall mean TTRTP in PRP treatment was 29 days (range, 10 to 50.9 days), and in the control groups was
35.4 days (range, 22 to 52.8 days). The patients of three studies5,11,12 were professional athletes before injury, while
the other studies included patients who engaged in competitive and recreational sports.
Five out of the seven studies were eligible for meta-analysis,8-12 which together included 224 patients with data
on the TTRTP after PRP therapy. The meta-analysis showed a significant difference in the TTRTP in PRP patients
against conventional-treatment patients (-7.80 days; CI95%: -13.48 to -2.12; P=0.007), as well as considerable
heterogeneity (I2= 96%; P<0.00001) (Figure 2).

86 Rev Asoc Argent Ortop Traumatol 2020; 85 (1): 82-90 • ISSN 1852-7434 (online)
 Meta-analysis. Platelet-rich plasma

Table 3. Time to return to play, according to the selected studies

Authors Year Journal Cohort 1 Mean Range Statistical
(PRP)/Cohort 2 significance (P)
(control)
Martinez-Zapata 2016 Blood Transfus Cohort 1 4.51 weeks SD: 0.42 0.261
et al.
Cohort 2 5.49 weeks SD: 0.48 0.261

Guillodo et al. 2016 Muscles Ligaments Cohort 1 50.9 days ± 10.7 NS

Tendons J
Cohort 2 52.8 days ± 15.7 NS

Hamilton et al. 2015 Br J Sports Med Cohort 1 21 days CI95%: 17.9-24.1 0.004 PRP
vs. PPP
Cohort 2 27 days CI95%: 20.6-33.4 0.13 PPP
vs. no injection
Cohort 3 25 days CI95%: 21.5-28.5 0.15 PRP
vs. no injection
A Hamid et al. 2014 Am J Sports Med Cohort 1 26.7 days ±7 0.006

Cohort 2 42.5 days ± 20.6 0.006

Reurink et al. 2015 Br J Sports Med Cohort 1 42 days 30-58 0.66

Cohort 2 42 days 37-56 0.66

Bubnov et al. 2013 Med Ultrason Cohort 1 10 days ± 1.2 NR

Cohort 2 22 days ± 1.5 NR

Rossi et al. 2016 Knee Surg Sports Cohort 1 21.1 days ± 3.1 0.001
Traumatol Arthrosc
Cohort 2 25 days ± 2.8 0.001
PPP: platelet-poor plasma; PRP: platelet-rich plasma; NR: not reported; NS: not significant.

PRP Control Mean difference Mean difference

Study Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
1.1.1 Days to return to play
A Hamid MS 2014 26.7 7 14 42.5 20.6 14 13.0% -15.80 [-27.20, -4.40]

Bubnov R 2013 10 1.2 15 22 1.5 15 27.2% -12.0 [-12.97, -1.03]

Guillodo 2016 50.9 10.7 15 52.8 15.7 19 16.4% -1.90 [-10.80, 7.00]
Martinez-Zapata MJ 2016 31.63 15.38 27 38.43 18.58 30 16.5% -6.80 [-15.62, 2.02]
Rossi L 2016 21.1 3.1 35 25 2.8 40 27.0% -3.90 [5.24, -2.56]
Subtotal (95% CI) 106 100.0% -7.80 [-13.48, -2.12]
Heterogeneity. Tau2=30.71, Chi2=95.72, df=4 (P<0.00001), I2=96%
Test for overall effect: Z=2.69 (P=0.007)

Total (95% CI) 106 118 100.0% -7.80 [-13.48, -2.12]

Heterogeneity. Tau2=30.71, Chi2=95.72, df=4 (P<0.00001), I2=96%
Test for overall effect: Z=2.69 (P=0.007) - 50 - 25 0 25 50
Test for subgroup differences: Not applicable Favors PRP Favors controls

Figure 2. Forest plot of comparison: mean differences in the time to return to play after an acute muscle injury between both
groups.

Rev Asoc Argent Ortop Traumatol 2020; 85 (1): 82-90 • ISSN 1852-7434 (online) 87
 A. R. Molina Rómoli et al.

Five out of the seven studies reported that the TTRTP was significantly shortened in PRP patients.2,9-11 In a
randomized controlled trial, A Hamid et al.11 compared 12 patients treated with PRP, in addition to rehabilitation,
with 12 patients treated exclusively with rehabilitation. The PRP patients had a mean TTRTP of 26 days (range,
19-33) against 42 days (range, 22-62) in the control group (P=0.006). Bubnov et al.9 reported less TTRTP for PRP
patients (10±1.2 days) as compared to the control group (22±1.5 days). Rossi et al.10 compared 35 patients treated
with PRP therapy combined with a rehabilitation program and 40 patients with rehabilitation program only, and
the mean TTRTP was 21.1±3.1 days and 25±2.8 days, respectively. Likewise, Hamilton et al.3 reported 21 days for
the PRP group and 25 for the control group.
The remaining three studies did not report statistically significant differences in the TTRTP between both
groups.8,12,13

Pain
The assessment of pain progression after PRP injection was reported in five out of the seven studies. Reurink et
al.13 studied the pain using specific tests (Hamstring Outcome Score) at weeks 1 and 26, and found no significant
differences between the PRP group and the control group. Four studies9-12 evaluated pain as a variable and reported
its progression at different follow-up time points. Martinez-Zapata et al.12 studied the pain intensity (visual ana-
logue scale) on a weekly basis for 8 weeks and then at 6 and 12 months. They reported similar pain intensities for
both groups during follow-up. On the other hand, the other three studies9-11 reported an average pain score sig-
nificantly lower among the PRP patients during the healing process; however, these studies also failed to find any
differences in the average pain score at the end of the follow-up period.

Recurrence
Four studies failed to find any differences in the reinjury rates between both groups (PRP and control). Martínez-
Zapata et al.12 had no reinjury cases (0/27 patients) in the PRP group and only one case in the control group (1/30).
At 6-month follow-up, Hamilton et al.2 reported a reinjury rate of 7.7% (2/30) in PRP patients and 10.3% (3/29)
in the control group (P=0.905). Rossi et al.10 reported a reinjury rate of 5.7% (2/34) for the PRP group and of 10%
(4/48) for the control group (P not significant). Reurink et al.13 reported the highest reinjury rates: 27% (10/37) for
the PRP group and of 30% (11/37) for the control group (P=0.80).

Complications
Four out of the seven cases report no complications associated with PRP.5,8,10,11,14 Reurink et al.13 reported one
case of painful skin hyperesthesia at the PRP injection site, which extended the TTRTP. Martinez-Zapata et al.12
reported complications, however, none were related to PRP therapy. Finally, Bubnov et al.9 failed to assess com-
plications.

Discussion
Over the past years, there has been a growing interest in the use of PRP to treat acute muscle injuries.15 However,
despite its growing popularity, evidence to support PRP use is lacking. Therefore, the objective of this review was
to assess the published results on PRP therapy for acute muscle injuries. Overall, the studied results may suggest
that PRP therapy reduces the TTRTP when compared to conventional treatment (-7.80 days; CI95%: -13.48 to
-2.12; P=0.007). However, a thorough and critical evaluation of the measures taken in each published study is key
to properly interpret the results and, thus, to prevent us from only relying on statistics or individual outcomes and
taking them as absolute truths.
The limitations of this study include: the meta-analysis design, which, although it is considered the highest
level of evidence, uses data from previously published studies (ideally, level of evidence I or II), and thus, may
magnify or reduce any bias present in each individual study; in addition, our meta-analysis showed considerable
heterogeneity in the studied data. Despite these limitations, this is one of the few reviews that study the use of PRP
in patients who had sustained acute muscle tears, and as such a we consider it a potentially useful tool for clinical
decision making.
In terms of pain, PRP therapy has been found useful to relieve pain in patients with knee osteoarthitis and epi-
condylitis.8,16-18 In terms of pain associated with PRP in the treatment of acute muscle tear, the results suggest there
is no difference between PRP patients and control patients at the end of the follow-up period, and most patients
achieve full recovery. However, three studies9-11 found a significant difference related to pain relief during treatment.

88 Rev Asoc Argent Ortop Traumatol 2020; 85 (1): 82-90 • ISSN 1852-7434 (online)
 Meta-analysis. Platelet-rich plasma

This relief during the rehabilitation period may in part account for most of the evaluated studies showing a shorter
TTRTP in PRP patients. These outcomes may justify the use of this therapeutic option in the elite sport context
while bearing in mind that pain relief may not be associated with an accelerated tissue repair.
As having a muscle injury history constitutes a significant risk factor for a new muscle tear,19 treatment must
prioritize achieving scar tissue formation with as less fibrous scarring as possible. Four studies10,12-14 that analyzed
recurrence rates found no differences between PRP patients and control patients. In our study, the recurrence
rates were between 5.7% and 30%, not unlike the recurrence rates reported by Orchard et al.15 However, due to
the limited evidence available, the effects of PRP therapy on reinjuries remains an uncertainty. In other words,
the stimulation of the myoblast differentiation and the ensuing tissue regeneration, as suggested by some in vitro
studies, would result in better muscle tissue quality and a resultant decrease in the recurrence rate; however, such
hypothesis is still to be proven by clinical trials.
The application of PRP therapy in the muscle tear treatment seems to be a safe option, as it has a low rate of
reported complications. In the assessed studies, there were no serious adverse events, with the exception of a case
of painful skin hyperesthesia at the injection site, reported by Reurink et al.13
Some in vitro and animal experimental studies have proven the PRP effectiveness for inducing myoblast re-
generation.4,6,7,20 However, these results have not yet been translated to the clinical practice. One reason for this
discrepancy may be that the current formulation of PRP may not be appropriate to induce muscle regeneration. To
date, leucocyte-rich PRP is the most widely used formulation in most clinical trials. However, the in vitro study of
Dragoo et al.4 has raised a number of new questions with its suggestion that platelet-poor plasma and leukocyte-
poor PRP would stimulate myoblast differentiation, which is necessary for adequate muscle regeneration. All of
these issues incite the rethinking of PRP greatest problem, all the enthusiasm related to its use and its application
has not gone hand in hand with the understanding of its components, of the different actions, and of the time pe-
riods and points related to its application. Future clinical trials should include a thorough description of the PRP
preparation protocols, which together with the qualitative and quantitative description of the used formulations are
essential for an adequate interpretation of the results and a subsequent replication.

––––––––––––––––––
Conflict of interests: Authors claim they do not have any conflict of interest.

L. A. Rossi ORCID ID: http://orcid.org/0000-0002-1397-2402

A. Bertona Altieri ORCID ID: http://orcid.org/0000-0002-7380-3045
C. Gwan ORCID ID: http://orcid.org/0000-0003-0579-3524
N. S. Piuzzi ORCID ID: http://orcid.org/0000-0003-3007-7538

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90 Rev Asoc Argent Ortop Traumatol 2020; 85 (1): 82-90 • ISSN 1852-7434 (online)