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ISSN: 0953-7104 (print), 1369-1635 (electronic)

Platelets, Early Online: 1–13

! 2014 Informa UK Ltd. DOI: 10.3109/09537104.2014.881991

REVIEW ARTICLE

Platelet-rich plasma (PRP): Methodological aspects and clinical

applications
Laı́s Fernanda Marques1, Talita Stessuk2, Isabel Cristina Cherici Camargo1, Nemi Sabeh Junior3,
Lucinéia Dos Santos1, & João Tadeu Ribeiro-Paes1
1
Department of Biological Sciences, University of the State of São Paulo, UNESP, Assis, São Paulo, Brazil, 2Post Graduation in Biotechnology ICB, IPT,
I. Butantan, University of São Paulo, São Paulo, Brazil, and 3On Reabilita Clinic, Assis, São Paulo, Brazil
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Abstract Keywords
The clinical use of platelet-rich plasma (PRP) is based on the increase in the concentration of Bone, cartilage, muscle, platelet-rich plasma,
growth factors and in the secretion of proteins which are able to maximize the healing process tendon
at the cellular level. Since PRP is an autologous biologic material, it involves a minimum risk of
immune reactions and transmission of infectious and contagious diseases, and it has been History
widely used for the recovery of musculoskeletal lesions. Despite the great potential for
applicability, the implementation of the therapeutic employment of PRP as a clinical alternative Received 29 November 2013
has become difficult, due to the lack of studies related to the standardization of the techniques Revised 27 December 2013
and/or insufficient description of the adopted procedures. Therefore, it is required establish Accepted 7 January 2014
standard criteria to be followed for obtaining a PRP of high quality, as well as a larger number Published online 10 February 2014
of studies which should establish the proper concentration of platelets for the different clinical
For personal use only.

conditions. In this context, the purpose of this review is to discuss some methodological
aspects used for achieving the PRP, as well as to discuss the bioactive properties of PRP, and to
point out its therapeutic use in different fields of regenerative medicine.

Introduction growth factors by Cohen [5] in 1962, are considered pioneer

events for the development of treatments. However, only in 1982
The cicatrization process comprehends four main stages, namely:
growth factors deriving from platelets themselves were described
clotting, inflammation, cell proliferation and repair of the matrix,
in detailed form [6, 7].
epithelialization and remodeling of the cicatricial tissue [1].
Platelets derive from megakaryocytes, and have no nucleus;
Following the injury, the platelets are stimulated to aggregate
therefore, are unable to divide themselves. From the morpho-
themselves and to secrete growth factors, cytokines and other
logical aspect, is worth observing the occurrence of a dense
homeostatic factors required for the clotting cascade which
cytoplasmic granulation. The alpha-granules store growth factors
characterize, therefore, the first stage [1, 2]. Clotting and platelet
that are responsible for the chemotaxis, proliferation, cell
degranulation lead to the inflammatory stage by means of the
differentiation and angiogenesis [8]. The dense granules carry
release of serotonin and histamine, bioactive factors which
the required bioactive factors for tissue recovery process such as
increase the capillary permeability which will allow the arrival
serotonin, dopamine, histamine, adenosine and calcium. The
of larger inflammatory cells to the place of would, such as
substances produced by the platelet granules are secreted during
leukocytes, macrophages and neutrophils, which act on the
the process of platelet activation, and they regulate the funda-
phagocytosis of the material resulting from the cellular lysis
mental aspects of the tissue repair [2].
[1, 3]. Once this stage is over, the number of anti-inflammatory
The rational for the clinical use of platelet-rich plasma (PRP)
cells is reduced and fibroblasts synthetize collagen, elastin and
is based on its ability to stimulate the production and, accordingly,
other components of the matrix. Residual epithelial cells or those
the increase in the concentration of growth factors and in the
which have migrated to the injured area multiply themselves and
secretion of proteins which are able to maximize the healing
form scars which are initially reddish and elevated. The scar is
process at the cellular level [2]. The use of PRP speeds the
then remodeled from a balance between the degradation by
vascularization of grafts, reduces post-surgery morbidity,
proteases and the production of extracellular matrix, besides the
improves the regeneration of different tissues, as well as reduces
reduction of fibroblasts and capillaries by means of the apoptosis
the formation of a scar, since it accelerates the maturity and
process [1]. Growth factors have been known since the 1950s,
regeneration of the epithelium of wound [9]. Furthermore, is
when Cohen and Levi-Montalcini [4], after extracting venon from
estimated that the PRP acts increasing the recruitment, prolifer-
snakes, isolated factors which could stimulate the growth of nerve
ation and differentiation of the cells involved in the tissue
fiber. The study along with the description of the epidermic
regeneration [2].
The modulation of the inflammatory process is an important
Correspondence: João Tadeu Ribeiro-Paes, MD, PhD, Department of
aspect in terms of the mechanism of action and repair of lesions
Biological Sciences, University of the State of São Paulo, UNESP, Av. mediated by PRP treatment. In the context of inflammatory
Dom Antonio, 2100, 19.806-900, Assis, São Paulo, Brazil. Tel: +55-18- lesions, PRP acts via secretion of growth factors, inflammatory
3322-5856. E-mail: jtrpaes@yahoo.com.br mediators such as cytokines and chemokines, as well as
 2 L. F. Marques et al.
expression of chemokine receptors. The enriched concentration of
activated platelets presents a balance of pro- and anti-inflamma-
tory factors well-orchestrated in order to resolve inflammation.
In this sense, the PRP is capable of modulating secretion and
recruitment of key inflammatory cells, such as monocytes and
leukocytes, in the injury site. Therefore, the therapeutic action and
tissue regeneration PRP-mediated process seems to result from
the control of the local inflammatory response [10, 11].
The first clinical use described in the literature dates back to
year 1987, when Ferrari et al. [12] described the use of autologous
PRP as an additional element for transfusion in cardiac surgeries,
for the purpose of avoiding the use of homologous products.
However, only in the 90’s decade PRP started to be widely used as
an adjuvant in different surgical procedures, mainly in the areas of
dentistry and orthopedics.
Thus, this article presents a brief review of the literature,
emphasizing methodological aspects of PRP isolation, as well as
the main clinical applications in bone, cartilage, tendon and
muscle lesions, besides aesthetic plastic and reconstructive
surgery.
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Platelet-rich plasma
PRP consists of a volume of plasma with platelet concentrations
higher than the basal levels, which are achieved by means of
centrifugation. Generally two centrifugations are employed with
set a time and speed previously defined in different experimental
protocols. After the first centrifugation, the red blood cells are
separated from the plasma in function of the different densities,
and sediment in the bottom portion. Just above, between the
For personal use only.
erythrocytes and the plasma, the buffy coat is formed, followed by
Figure 1. Process for obtaining the PRP. 1 and 2: After the collection, the blood undergoes the first centrifugation process. 3 and 4: The superior phase
corresponding to the PPP, PMP, PRP and buffy coat is removed to the second centrifugation. 5 and 6: Afterwards, the two superior thirds corresponding
to the PPP and PMP are discarded and the portion corresponding to the PRP is then mixed to the erythrocyte button and the buffy coat deposited in the
tube bottom.
Platelets, Early Online: 1–13
the PRP, the platelet-middle plasma (PMP) and the platelet-poor
plasma (PPP) [13]. The plasma and the buffy coat are collected
and undergo a second centrifugation for an increase in platelet
concentration. The two superior thirds of the achieved plasma
(corresponding to the middle- and poor-platelet plasma) are
discarded and the remaining portion is mixed with the erythrocyte
button deposited in the bottom, which originates the PRP. In order
to set a standard PRP volume to be achieved, some authors have
established the production of 1 ml of PRP for each 10 ml of
collected blood. Therefore, after the second centrifugation, the
superior portion corresponding to the plasma is collected so that
the remaining plasma volume plus to the erythrocyte button
provides 1 ml of PRP [14, 15]. Before being administrated to the
patient, PRP must be activated in order that the platelets release
their factors (Figure 1, Table I) and other products related to the
regeneration process. It is usually employed calcium chloride,
bovine thrombin or collagen to platelet activation [2].
The use of autologous PRP has the advantage of eliminating
the risk of crossed contamination, as well as the transmission of
microbial diseases or immune reactions [25]. In this regard,
several authors are against the inclusion of bovine thrombin in
some protocols, for the activation of the platelets due to the risk of
coagulopathy through the production of antibodies against
clotting factors. Therefore, the use of autologous thrombin must
be reconsidered. Alternatively, the use of the collagen to the
detriment of thrombin providing lower clot retraction and without
the reduction of growth factors [26].
The use of PRP in liquid or gel form has shown an
improvement in the cicatrization process. However, the gel
preparation requires a longer time for the achievement of the
autologous thrombin, thus leading to a more complex and longer
 DOI: 10.3109/09537104.2014.881991
Table I. Growth factors with the sources of obtaining and respective functions.
Growth factor Source
TGF-b Platelets, neutrophils, macrophages, Regulates the mitogenic effect of other growth factors, stimulates
monocytes, natural cell killers, Th1
cells, bone extracellular matrix and
cartilaginous matrix
FGF Platelets, macrophages, chondrocytes, Mitogen for mesenchymal cells, chondrocytes and osteoblasts,
osteoblasts and mesenchymal cells
PDGF a-b Platelets, macrophages/monocytes, endo- Stimulates the chemotaxy and mitosis of fibroblasts, smooth and
thelial cells, osteoblasts and smooth
muscle cells
Epidermic Platelets, macrophages/monocytes Stimulates mitosis of mesenchymal cells, regulates the secretion of
growth factor
VEGF Platelets, endothelial cells Stimulates mitosis of endothelial cells, increases angiogenesis and
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IGF Platelets, macrophages, osteoblasts, bone Stimulates the differentiation and mitogenesis of mesenchymal
matrix and mesenchymal cells
preparation [26]. Another difficulty is the loss of the material
which has a tendency to flow off until the gel formation is
completed [26, 27]. The direct injection of PRP at the site of the
lesion, without the need for activation, is an attractive and
palpable alternative because activation can be supposedly
For personal use only.
attributed to the trauma caused by the needle and/or the residual
collagen, implying in the reduction of costs and the preparation
time [27].
Generally, the therapeutic use of PRP in the past 20 years has
demonstrated to be a safe and effective treatment; however, there
is some conditions that the indication must be availed with
caution, as in cases of thrombocytopenia, platelet dysfunction
syndrome, septicemia, hypofibrinogenemia, recent fever condi-
tion, anemia, cancer, skin lesions in the area of the injection,
use of corticosteroids (in up to 2 weeks before the procedure), or
non-steroid anti-inflammatories (in up to 48 hours before
procedure) and active infections with Pseudomonas, Klebsiella
or Enterococcus [28–31].
Nevertheless, the literature has reported conflicting results
on the benefits of PRP. The number of participants in different
studies, is usually small and the techniques used are not
standardized [2, 28, 32]. Different platelet concentrations
are achieved by means of different methodologies with results
which are sometimes not well defined as to the improvement
of cicatrization [33]. The increase in the rotation force is known
to provide a higher platelet concentration; however, too high
forces may lead to the loss of growth factors in the supernatant
plasma due to an early activation of the platelets and to the
rupture of the tubes which mean losses to therapeutic efficiency
of PRP [14, 34]. In general, the unsatisfactory results reported
may be associated with the quality of the material obtained, since
the platelet concentrations obtained are highly divergent among
the studies. Other important variables are related to the mainten-
ance of platelet integrity and effective activation of the material,
which often are not elucidated in the studies.
Clinical applications
Bone lesions
Bone defects may arise out of mechanical traumas, pathologies
and physiologic stress. Due to the high prevalence of injuries,
PRP: Methodologies and clinical applications 3
Function References
[6, 15, 16]
the proliferation of undifferentiated mesenchymal cells, fibro-
blast and osteoblast mitogen, endothelial regulator and regula-
tor of the collagen synthesis and secretion of collagenase,
stimulates angiogenesis and endothelial chemotaxy, inhibits the
proliferation of macrophages and lymphocytes
[6, 17, 18]
stimulates the growth and differentiation of chondrocytes and
osteoblasts
[6, 15, 19]
glia muscle cells, regulates the secretion of collagenase and
collagen synthesis, mitogen for mesenchymal cells and osteo-
blasts, stimulates the chemotaxy of macrophages and
neutrophils
[6, 20, 21]
collagenase, stimulates chemotaxy and angiogenesis of endo-
thelial cells
[6, 21, 22]
permeability of the vessel
[6, 23, 24]
cells and of lining cells, stimulates osteoblasts and the
production of type I collagen, osteocalcin and alkaline
phosphatase
bone is the second most transplanted human tissue, overcome only
by hematopoietic tissue. It is estimated that annually 2.2 million
people are subjected to grafting procedures to repair bone defects
in orthopedics, odontology and neurosurgery [35].
The use of autologous grafts is considered a gold standard
among the biomaterials employed in filling of bone cavities.
However, the need for two surgical procedures, the limitation of
tissue available, risks of infection, necrosis and re-absorption in
up to 30% of patients, motivated the proposition on synthetic
biomaterials, which by turn are not biologically functional and
adapted to remodeling bone tissue [36, 37].
The use of biological factors, such as PRP and bone
morphogenetic proteins (BMP), associated or not with graft, has
shown promising results in regard to bone reconstructions, since
they are directly associated with the normal physiology of this
tissue (Table II). Platelet growth factors such as platelet-derived
growth factor (PDGF), transforming growth factor-b (TGF-b),
fibroblast growth factor (FGF), vascular endothelial growth factor
(VEGF)-A and insulin-like growth factor (IGF-1) regulate bone
regeneration through migration, proliferation and differentiation
of osteoblasts, justifying the therapeutic use.
Since the 1990s, the use of the PRP in the treatment of bone
lesions has shown significant results. It is used as an alternative to
fibrin glue or platelet gel frequently employed in maxillofacial
reconstructions. The therapeutic benefits that extend beyond the
reparative power, consisting of one action faster than conventional
treatments maximized by autologous growth factors and therefore
free from complications of immune origin [25, 38, 39].
Batista et al. (2011) [40] compared the PRP action with the
concentration of bone marrow, had better consolidation and
greater bone quantity by area in the PRP group. The superior
result obtained can be explained by the immediate recruitment of
all proteins necessary to start the healing cascade, while the
concentrated of bone marrow demanded longer time to recruit
these elements. Thus, it can be assumed that the monitoring for a
period of time up to 4 weeks, this group might have had similar
results of consolidation. However, there were no new studies that
could confirm this hypothesis.
Several studies reporting the association of PRP and artificial
bone grafts showed improvement in the quality of healing.
However, when it was employed only PRP the results obtained
 4 L. F. Marques et al. Platelets, Early Online: 1–13

Table II. Use of PRP in animal models with bone lesions.

Therapeutic Therapeutic
Lesion site PRP production (treated group) (control group) Outcomes References
Defects at the distal Ten milliliter of periph- PRP Femurs were alternated There was no increase in [54]
region of the eral blood of isogenic one application between the right and the inflammatory
femur mouse were collected left sides process.
Mice and centrifuged to Showed a tendency to
enact blood phase increase bone matrix
separation formation.
Bone defect (3.3 mm The blood was centri- PRP with b-tricalcium bone marrow concen- PRP promoted better [40]
in diameter) in fuged for ten minutes phosphate one trate with b-trical- consolidation than
the proximal at a speed of application cium phosphate the centrifugation of
metaphysis of 1200 rpm at room the bone marrow
rabbit’s right tibia temperature. group
PRP received 0.2 ml of
10% calcium
gluconate.
Critical-sized Blood with EDTA was Three groups: No PRP or coragraft PRP with bone grafts [46]
defects measuring centrifuged two PRP, coragraft, improved the quality
2 cm rabbit times: first at 150 g PRP and coragraft of healing bone
Platelets Downloaded from informahealthcare.com by University of Otago on 09/11/14

Tibias for 20 minutes and

second at 450 g for 10
minutes
Mandibular intra- The centrifugations: at Bony cavity on the right The left side was empty Increase bone cell [47]
osseous defects 5600 rpm for 10 side filled with and used as a control proliferation
Dogs minutes autogenous PRP
At 2400 rpm for 10
minutes.
The PRP was actived
with thrombin and
For personal use only.

CaCl2.

were inferior, probably due to the lack of connective tissue which
provides adequate reparation [41, 42].
In cell culture, the use of the PRP has evidenced the potential
of growth factors by means of the modulation of cellular
processes. The use of homologous PRP, in osteoblasts derived
from patients with periodontitis, showed an increase in the
proliferative response [43]. This result was corroborated by
another study on osteogenic potential of PRP, showing increase in
cell proliferation and osteogenic differentiation in vitro, as well as
the increase in the bone formation around the acellular graft and a
high arterial perfusion around the bone defect [44].
Although different studies indicate satisfactory results, some
researchers have reported conflicting results [25, 45]. The
application of PRP in combination with bone marrow concentrate
on defects of tibia and in combination with bovine cancellous
bone critical defects in the skull increased bone healing in rabbits
[46]. When applied on mandibular bone lesions in dogs, there was
bone regeneration of the PRP group in a shorter period of time
compared to the control group [47]. On the other hand, the use of
the PRP combined with bone graft has not shown better results
compared to graft alone in dogs and rats [48–50]. The conflicting
results may be related to the type of methodology employed to
produce the PRP, which can result in inadequate concentration of
growth factors required for the repair of bone lesions. Although
the use of calcium and thrombin for activation of PRP is
associated with increased proliferation and migration of bone
marrow stem cells, it is known that high concentrations may
interfere with angiogenesis due to the impairment of migration
and proliferation of vascular endothelial cells and reducing the
release of VEGF [51, 52]. Another important aspect is related to
possibility of activated platelets compromise the osteogenic
differentiation [53]. The search for alternative forms of platelet
activation may be the key to obtain better therapeutic results of
PRP employment. The use of tiny concentrations of thrombin
supplemented with collagen and mechanical stimulation led to
increased levels of VEGF compared to using only thrombin and
calcium chloride [44].
Considering the homeostatic function performed by platelets,
it is natural to conclude that the concentrate contributes to repair
injuries. However, the presence of different factors, sometimes
antagonists, tends to create an imbalance unable to promote tissue
recovery. Thus, it is important to emphasize the need for more
detailed studies on the concentration of each growth factor
obtained, since it can vary between individuals, and especially
among the different animal species (Table II) that are widely
studied in order to validate the therapeutic properties of PRP in
bone lesions.
Cartilage lesions
The practitioners of physical activities have a high incidence of
articular cartilage lesions, while treatment remains a challenge to
sports medicine due to the limited regenerative capacity of
cartilaginous tissue [55]. Therefore, PRP has been offered as an
alternative treatment to articular cartilage lesions of knee, hip and
ankle [8]. Different studies have shown the action of growth
factors in stimulating the proliferation of chondrocytes, the
chondrogenic differentiation of mesenchymal stem cells derived
from bone marrow and control of the synthesis of cartilaginous
matrix [56–58].
Studies of migration and chondrogenic differentiation of
human subchondral progenitors, cultured in the presence of
PRP, confirms the chemotaxy potential in the chondrogenic
migration and differentiation. PRP-stimulated cells achieve a
significant increase in the formation of a cartilaginous matrix, and
the analysis of gene expression shows the presence of chondro-
cyte, adipocyte and osteocyte-marker genes, although an evident
differentiation of these last two cell types did not exist [59].
 DOI: 10.3109/09537104.2014.881991 PRP: Methodologies and clinical applications 5

References
In another study of cell culture involving chondrocytes derived
from humans with osteoarthritis, at different concentrations of

[66]

[61]

[75]

[78]

[68]
platelet lyse, showed a reduction of the inflammatory effects,
including the inhibition of the nuclear factor-kB (NFkB), the
chief factor involved in osteoarthritis pathogenesis [60].
Sanchez et al. [61] were the pioneers in using PRP in the

with mild degradation of the scores at

PRP with scaffold stimulated osteochon-

Results positive at 6 months follow-up,

Increased cartilage matrix metabolism;

treatment of avulsion of knee articular cartilage in football

Statistically significantly better results

investigators postulated that may have

dral formation with cartilaginous

players. The avulsed fragment was fixed with absorbable pins and

preventative implications in OA
Healing functional and accelerated
the existent gaps between the fragment and the receiving area

matrix and type II collagen

were filled with PRP. After using a platelet concentrate obtained

Improved articular cartilage

by a single centrifugation, named by the authors as preparation

Outcomes
rich in growth factors (PRGF), the clinical results obtained were
very satisfactory, with the acceleration of the cure and functional

1-year follow-up

Return to activity
recovery of the lesion.

management
In total knee arthroscopy (TKA), several studies obtained the
reduction in the need of blood transfusions, less infectious
processes, less post-surgery complication, as well as a shorter
time in the hospital [62–64]. The direct application of PRP in
athletes with chronic patellar tendinitis, in patients with knees
joint osteoarthritis (OA) and osteochondral lesions of the talus,
Platelets Downloaded from informahealthcare.com by University of Otago on 09/11/14

demonstrated functional improvement and pain management

Untreated lesions or PLGA

[65–67]. Spaková et al. [68], compared the efficiency of PRP
with hyaluronic acid in patients with different degrees of OA and

administered alone
(control group)
Therapeutic
obtained more satisfactory results in the group treated with PRP,
although the two treatments have been statistically significant.

Hyaluronic acid
Regarding the treatment of anterior cruciate ligament injuries,
application of PRP has shown significant effects from a clinical

3% PPP
standpoint, resulting in an improved biomechanical and a faster
recovery [69, 70]. However, some authors have pointed to the

–
absence of significant results [71–73].
For personal use only.

The potential of growth factors in cartilage repair is well

established regarding the regulation of the physiology of articular
PRP intra-articular knee injections

gelatina hydrogel microspheres

3% PRP or PRP in biodegradable
Knee arthroscopy reattached the
fragment, supplemented with
cartilage. Growth factors such as TGF-b and FGF have been
administered every 21 days

shown to stimulate the chondrogenic proliferation and biosynthe-

Intra-articular application of
sis of the extracellular matrix of articular chondrocytes in vitro,
(treated group)
Therapeutic

allowing to presume the obtaining of clinically satisfactory results

[59, 74–76]. However, the discrepancies between the results

autologous PRP
obtained can be related to different methods of obtaining the PRP,
forms of activation and isolated application or aggregated with
Table III. Clinical studies and animal models with the use of PRP in cartilage lesions.

PRP–PLGA
other elements (Table III).
Scaffold
PRP

The use of PRP in soluble form cannot support the biological

activity by being rapidly degraded, and employment in the gel
form does not contain high levels of growth factors, besides the
application with needles to be hampered by high viscosity.
Depending on the location and extent of the lesion it is possible to
3200 rpm at 22 C, 10 m at 1500 rpm to
minutes and a second at 3.500 rpm for
10 minutes produced a unit of 20 ml of

gation step at 3200 rpm for 10 minutes

Blood was centrifuged at 1800 rpm for 8
Two centrifugations: at 1.800 rpm for 15

Two centrifugations: at 4 C for 15 min-

separate the leukocytes and centrifu-

choose the way that best fits the needs of the patient, but it is
utes at 800 rpm and at 4 C for 15

Three centrifugations: 15 minutes at

important to note that the newly obtained PRP may have an

minutes with trisodium citrate

acidified pH (6.9–7.0) and can interfere in the functions naturally

performed by cytokines [76]. Studies have reported that the use of
PRP production

alkaline PRP (7.4) has allowed a stimulating effect on cell

minutes at 2000 rpm

proliferation due to the release of additional components [78, 79].

The general proposition that PRP stimulates chondral anabol-
Two centrifufations

ism and reduces catabolic processes may explain the improvement

of clinical symptoms. Filardo et al. (2011) [80] indicate that PRP
should act in articular homeostasis, resulting in the reduction of
PRP

hyperplasia of the synovial membrane and modulating cytokine

levels, although these mechanisms of action have not been clearly
determined. Thereby, more detailed studies related to PRP
obtainment, concentration of growth factors, gender, age and
degree of degeneration should be considered when analyzing the
changes in the joint

defects of rabbits
Articular cartilage
Rabbit model OA

results, since they may interfere with treatment. Another aspect to

3 osteoarthritis
Chondral loose

be considered is the follow-up of patients to determine whether the

Grade 1, 2 or
Degenerative

original structure of the joint was resumed or if the recovery was

Lesion site

only temporary, aiming to standardize the number and time

Human

Human

between applications in order to enable the routine use of this

body

therapy in clinical practice and avoid invasive surgical procedures.

 6 L. F. Marques et al. Platelets, Early Online: 1–13

References
Muscle lesions
Muscle lesions are usually caused by direct trauma or by decom-

[94]

[91]

[84]

[88]
pensation of the eccentric load during muscle contraction, and they
are very common, especially in elite athletes [2]. In the majority of
the cases, the recommended treatments are conservative and the best

Absence of significant differences

therapies have not been clearly defined. Thus, muscular injuries

Pain relief, functional improve-

stimulation of myogenesis
represent a challenging problem for traumatology and sport

ment; to sports activities

medicine [81]. Therefore, the more clinically serious muscle injuries

Minor recovery period,

Minor recovery period

are among the most indicated for PRP treatment [82].

Outcomes
The background of previous lesions represents a great risk

between groups
factor of muscle injuries, probably due to the formation of scar
tissue on the trauma area. Since muscle lesions imply a high
morbidity rate within amateur and professional sports, the use of
PRP means a promising alternative since it accelerates muscle
regeneration and minimizes the occurrence of new lesions [83, 84].
The muscle regeneration process is regulated by the presence
of growth factors and cell interactions, and it features a high
concentration of cytokines found in muscles. Growth factors,
especially the IGF, improving muscle regeneration and increased
strength [85, 86]. It is also known that PRP induces the
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Arthroscopy without PRP

(control group)
proliferation of muscle cells, as well as the differentiation of

Therapeutic
satellite cells and are active in the angiogenesis process [87].

PPP or no treatment

Actovegin/Traumeel
The first clinical study to employ growth factors in the
recovery of muscle lesions used conditioned autologous serum.
Eight professional athletes were enrolled in the study and
compared with 11 athletes with similar previously treated lesions
(control group). The treatment started 3 days after the lesions, all
of them ranked as moderate degree lesions, and it led to the

–
reduction of the edema and bleeding of the treated group, with
For personal use only.

full functional recovery within 2 weeks, which represented half

Four applications of 100 ml of PRP

the expected time for regeneration of these kinds of lesions [85].

Autologous conditioned serum

Application of PRP guided by
Other studies with elite athletes showed that percutaneous PRP
injections in the muscle injured area improved the functional Injection ultrasound-guided
(treated group)
Therapeutic

recovery, and they enable the continuation of sports activities

[88]. Cugat et al. [89] used PRP in muscle lesions caused by
mechanical traumas. Aided by ultrasound equipment, the author arthroscopy
injected PRP directly into the injured area, and this way recovery
injection

or PPP
time was reduced in half.

(ACS)
Studies conducted by three independent teams, which were
seeking to cure the limited regenerative capacity of the rotator
cuff led to the evaluation of its repair potential in the presence of
PRP. Patients were randomized for the treatment by arthroscopy
gel with 10% sodium gluconate
One centrifugation activation with

with and without PRP. None of the assessed scores presented

One centrifugation: 3.500 rpm at
platelet concentration system
Apheresis with Leukoreduction

PRP obtained by Symphony II

statistically significant difference, and one of the studies also hints

at negative effects. However, one of the teams reported the
PRP production

using citrate dextrose

achievement of satisfactory results in small and medium-size

autologous thrombin

3 ml PRP not activated

Table IV. Use of PRP in animal models with muscle lesions.

lesions. In this way, authors suggest the use in bigger-sized

lesions, since the different methods commercially available may
lead to more efficient preparations [90–92].
10 minutes

Despite the discrepancies between the results obtained by

different research groups, the rationale for the use of PRP in
muscle lesions is substantiated by the release of growth factors
linked to acceleration of tissue recovery, once it acts in
proliferation of muscle precursors, vascularization improvement,
reduction of infectious processes and symptoms of pain, leading
to functional improvement and rapid return to sports activities. It
is known that the PRP appears to act better on the regeneration
Tibialis anterior muscles of

phase, through the action of IGF which stimulates muscle cells to

Sprague Dawley men
Rotator cuff (430 mm,

proliferate and form muscle tissue free from fibrous scar tissue
associated with relapses. Another important aspect is based on the
anteroposterior)

hypothesis that PRP can have no therapeutic effect when applied

Grade II lesions

Muscle trains

in the first 24 hours after injury [93].

Lesion site

The extensive description of conflicting results in the literature

(Table IV) makes clear the need for additional studies that should
be strictly standardized in relation to the size and location of the
 DOI: 10.3109/09537104.2014.881991
lesion, age of the patients studied, methodology used to obtain the
PRP, leukocyte and platelet count in order to obtain a product
having adequate physiological concentrations of growth factors
and other bioactive factors related to muscle recovery, searching
for routine clinical application of a therapy highly effective and, at
the same time, minimally invasive.
Tendinous lesions
Tendon is a durable and flexible tissue, anchored to the bone by
a mineral resistant connection. However, due to the fact that this
tissue is subject to much mechanical loading and stress, there is
great risk of tendinopathies, chronic tendons injuries, since the
continuous effort may cause successive lesions of the collagen
fibers [55]. The tissue of tendons is not very well vascularized, the
metabolic rate and oxigen consumption are low, so it regenerates
slowly, in the variable manner and with risk of reinjury. Therefore,
scars may impair tendons function and increase the risk of
repeated injuries, as well as chronic inflammation and pain [8].
Tendinous lesions outstand among musculoskeletal lesions,
Platelets Downloaded from informahealthcare.com by University of Otago on 09/11/14
and impact both practitioners of intense physical activities, as
well as inactive people [95, 96]. It is estimated that these lesions
represent from 30 to 50% over all lesions related to sports [97].
In this context, and by taking into account the pieces of evidence
that tendinitis is an intrinsic degenerative disorder, PRP has been
widely used in the treatment of Achilles tendon, elbow, rotator
cuff and patellar lesions [98]. The use of PRP as therapeutic
strategy in tendon injuries has been especially considered in
patients with chronic inflammation, over 12 months and refrac-
tory to previous treatments [99].
For personal use only.
Concomitant with the applied research, PRP has generated
interesting results also in vitro models for the purpose of tendon
repair. At the cellular level, tendons are formed mostly by
tenocytes, cells responsible for the maintenance and tissue repair.
In this regard, in vitro studies related to the action of PRP on
tenocytes have shown results of great importance and clinical
interest. There is evidence in the literature suggesting an increased
in tenocytes proliferation inder action of the PRP, and this effect is
dose dependent. Still, although controversial, there are results that
indicate the ability of PRP to act on the expression of collagen
(COL1 and COL3) by tenocytes in order to contribute to the quality
of the repair [100]. One important exception, however, must be
emphasized, as in vitro models are not capable of mimicking the
microenvironment of chronic inflammatory tendinopathy and thus
it is not possible to draw conclusions categorical, since the
laboratory response may be different from the clinical reality.
Animal models, similar to the in vitro tests are not able to
provide the identical condition to human tendinopathy. However,
the results indicate interesting therapeutic properties of PRP on
tendon lesions surgically induced when there is comparison with
control groups [100]. When PRP is used in acute tendon injuries,
the repair process happens faster and the organization of
fibroblasts and collagen bundles is optimized in relation to
controls without administration of PRP in equine model [101],
murine [102] and cunicular [103]. However, in most of the studies
reported, there are few data and cytological investigations of the
PRP employed, and thus impediment of therapeutic elucidation.
Further, the treatment is carried out in animal models in the acute
phase in contrast, therefore, to most clinical cases.
Mishra and Pavelko [65] published the first study in human
patients using PRP in the treatment of tendinosis, or chronic
tendinitis of the elbow. From the 140 evaluated patients, only
20 with a background of failure with non-surgical treatments
underwent the experiment, and five were used as a control group
(treated with bupivacaine). Within 8 weeks after one application
of PRP, there was an improvement in 60% of the treated patients,
PRP: Methodologies and clinical applications 7
and within 6 months, 81% of patients felt better, and this
improvement reached 93% two years afterwards, without compli-
cation. Among patients treated with PRP was possible to observe
a return of daily activities (99%) and of sports activities (94%).
However, the authors did not consider the variation in the duration
of pain and neither the age of the patients to assess outcomes
between treated and control groups. Still, the work presents a
reduced number of control patients (n ¼ 5), and 60% of these
(n ¼ 3) were excluded from the study, becoming impossible a
statistical analysis [76].
Another relevant site of tendinopathy, lesions in the rotator cuff
are among the most common disorder of shoulders and usually
need surgical intervention, due to the inexistence of therapeutic
agents which enable the cure of the tendon. The treatment of
14 patients with partial thickiness rotator cuff and a background of
failure in the answer to conventional treatments involving steroids,
physiotherapy and non-steroid anti-inflammatories, were assessed
as to the possible answer to PRP. Within 8 weeks, 12 patients
involved in the study achieved significant improvement of pain,
strength and muscle resistance [104].
A study proposed by Sánchez et al. [105], pointed out the
potential of PRP in the treatment of tendinous lesions. In said
study, six athletes having Achilles tendon lesions underwent the
conventional surgery combined with PRP (called by the author
as a platelet-rich fibrin matrix), and an improvement in the cure
and functional recovery were achieved, in comparison with the
control group.
In another study which entailed the use of PRP in chronic
tendinopathy of no-insertion of the tendon calcaneus, with
a background of previous and unsuccessful treatments, achieved
a significant clinical improvement, which was further confirmed
by ultrasonography studies. After 18 months, all patients showed
an improvement in acute symptoms, increase in the vasculariza-
tion and in the diameter of areas previously noted as having
fibrillary interruption. The authors reported the increase of the
PRP vascular activity to its involvement with surrounding tissues
related to the tendinous cicatrization. The significant functional
improvement, the lack of complications followed by functional
improvement and satisfaction of patients are pointed out by the
author as encouraging initiatives for the use of said therapy [106].
The use of PRP in patellar tendon during the reconstruction of the
anterior cruciate ligament, also points out the benefits of therapy,
and it has shown significant reduction of the size of the lesions
and pain during the post-surgery period [107]. Different studies
do not present uniformity of results and procedures, thus it is
necessary to make further randomized trials with larger numbers
of patients, in order to enable a consensus or methodological
reference, allowing conclusions more consistent about the use of
PRP on tendon injuries. Table V presents some works using of
PRP in different types of tendon injuries.
As seen in Table V, there are a different number or even
conflicting parameters in regard to the preparation, quality,
dosage and interval of injection of PRP in various clinical studies
in tendon injuries. Thus, the analysis of therapeutic results
becomes complex, since there may also the involvement of several
cell types such as lymphocytes and neutrophils, in accordance
with the methodology used to obtain the PRP. Furthermore,
inflammatory cytokines with short lifetime, released after plate-
let activation, may start an acute inflammatory response in
compromised tendinous fibers, causing a proliferative phase
synthesis of collagen, essential for tendon repair [108]. Another
flagrant methodological distinction between the different clinical
protocols refers to the previous activation of PRP, while in other
studies the PRP is injected without previous activation.
Another interesting fact refers to the discrepancy of clinical
outcomes. Clinical responses range from significantly positive in
 Platelets Downloaded from informahealthcare.com by University of Otago on 09/11/14
Table V. Clinical studies with the use of PRP in patients with tendinopathies.
Lesion site PRP production
Achilles tendon, no more Whole blood and trisodium citrate cen-
than 2 weeks after trifuged at 460 g for 8 minutes. One
rupture milliliter above the erythrocyte fraction
activated with calcium chloride.
Achilles tendon, chronic Whole blood (54 ml) and citrate centri-
tendinopathy fuged for 15 minutes, non-activated
PRP
Achilles tendon, chronic Whole blood processed in accordance
tendinopathy with the kit adopted for obtaining the
non-activated PRP
Achilles tendon, chronic Whole blood processed in accordance
tendinopathy with the kit adopted for obtaining the
non-activated PRP
Rotator cuff Whole blood (54 ml) and citrate dextrose
solution (6 ml) centrifuged for 15
minutes at 3200 rpm. PPP centrifuged
for 2 minutes at 2000 rpm. PRP
activated with autologous thrombin.
Rotator cuff Whole blood (9 ml) and trisodium citrate
centrifuged for 6 minutes at 1100 rpm.
The plasma was centrifuged for 25
minutes at 4500g. PRP activated with
calcium chloride.
Rotator cuff Whole blood (9 ml) centrifuged in two
steps. PRP activated with calcium
chloride
Rotator cuff Whole blood (54 ml) and citrate (6 ml)
centrifuged for 15 minutes at
3200 rpm, 6 ml of non-activated PRP
Elbow, epicondylitis Whole blood (55 ml) and sodium citrate
processed in accordance with the kit
adopted for obtaining the non-activated
PRP
Elbow, epicondylitis Whole blood (27 ml) and sodium citrate
(3 ml) processed according to the kit
adopted for obtaining non-activated
PRP
Elbow, epicondylitis Whole blood (510 ml) and sodium citrate
centrifuged for 15 minutes at 2000g.
Non-activated PRP (1.5 ml) obtained
from the buffy coat.
For personal use only.
Therapeutic (treated group)
Six athletes, open suture surgery
followed by intratendineous
injection of activated PRP
(4 ml)
Twenty seven patients randomized,
intratendineous injection of
non-activated PRP (4 ml)
Ten patients, intratendineous
injection of non-activated PRP
(6 ml)
Fourteen patients, intratendineous
injection of non-activated PRP
(3 ml)
Twenty six patients submitted to
arthroscopy, intratendineous
injection of activated PRP
(6 ml)
Forty three patients, application of
PRP clot during arthroscopy
Forty patients, application of PRP
clot associated with suture
during arthroscopy
Twenty patients, intratendineous
injection of PRP (5 ml)
Fifteen patients, intratendineous
injection of PRP (2–3 ml)
Fifty patients, intratendineous
injection of 1 ml of corticoster-
oids and bupivacaine
Eighty patients, two intratendi-
neous injections of PRP (1.5 ml)
with an interval of 1 month
8
Therapeutic (control group) Outcome References
Six athletes, open suture The treated group showed significant [104]
surgery improvement, absence of complica-
tions and faster return to physical
activities when compared to the con-
trol group
L. F. Marques et al.
Twenty seven patients ran- There was no significant difference [109]
domized, intratendi- between the groups with respect to
neous injection of saline pain relief and return to physical
(4 ml) activities
– Minimal functional improvement without [110]
changing the magnetic resonance
imaging
– Functional improvement, pain reduction, [106]
positive change to examination by
Doppler ultrasonography
Twenty seven patients sub- Pain reduction and significant functional [111]
mitted to arthroscopy improvement in short-term treated
group. In long term (46 months) there
was no difference between groups.
There was no difference in magnetic
resonance imaging.
Forty five patients, There was no significant difference [90]
arthroscopy between the groups in relation to
Constant Shoulder Score or changes in
magnetic resonance imaging.
Thirty nine patients, arth- There was no significant difference in [92]
roscopy (suture surgery) improvement between the groups
Twenty patients, intratendi- There was no significant difference in [112]
neous injection of saline pain reduction, functional improve-
(5 ml) ment and quality of life between
groups
Five patients, intratendi- Constant and significant improvement in [76]
neous injection of bupi- pain in the treated group compared
vacaine (2–3 ml) with the control group
Forty nine patients, intra- Reduction of pain and significant func- [113]
tendineous injection of tional improvement in the treated
1 ml of corticosteroids group compared to the control
and bupivacaine
Seventy patients, two intra- Similar functional improvement in treated [114]
tendineous injections of and control groups
blood (1.5 ml) with an
interval of 1 month
Platelets, Early Online: 1–13

Elbow, epicondylitis
Elbow, epicondylitis
Knee, patellar tendinopathy
Knee, patellar tendinosis
Knee, patellar tendinopathy
Knee, patellar tendinosis
Knee, patellar tendinopathy
Platelets Downloaded from informahealthcare.com by University of Otago on 09/11/14
Whole blood and anticoagulant centri-
fuged for 15 minutes at 3200 rpm, non-
activated PRP
Whole blood (30 ml) and ACD-A anti-
coagulant centrifuged for 15 minutes at
3200 rpm, non-activated PRP
Whole blood (27 ml) and citrate dextrose
solution (3 ml) processed in accord-
ance with the kit adopted for obtaining
the non-activated PRP
Whole blood (150 ml) and sodium citrate
(21 ml), centrifuged for 15 minutes at
1800 rpm. Plasma centrifuged for 10
minutes at 3500 rpm. Non-activated
PRP (20 ml).
Whole blood (150 ml) and sodium citrate
(21 ml), centrifuged for 15 minutes at
1800 rpm. Plasma centrifuged for 10
minutes at 3500 rpm. Non-activated
PRP (20 ml).
Whole blood (450 ml) fractionated in
portion erythrocyte and PPP, PRP
activated with autologous thrombin
and calcium chloride.
Whole blood (150 ml) centrifuged for 6
minutes at 1480 rpm. Plasma centri-
fuged for 15 minutes at 3400 rpm,
generating 20 ml of PRP, PRP activa-
tion of calcium chloride.
For personal use only.
Fourteen patients, intratendineous
injections of PRP (3 ml)
For 116 patients, intratendineous
injections of PRP (2–3 ml)
Eight patients (6 athletes), intra-
tendineous injection of PRP
(3 ml)
Twenty athletes, 3 intratendineous
injections of PRP (5 ml) every
15 days
Fifteen athletes, 3 intratendineous
injections of PRP (5 ml) every
15 days
Twelve patients, reconstruction of
the anterior cruciate ligament
with implant of PRP gel (20–
40 ml)
Forty three patients, 3 intratendi-
neous injections of PRP (5 ml)
every 15 days
Fourteen patients, intraten- Significant pain reduction in the short- [115]
dineous injections of term treated group. In long term (43
blood (3 ml) months), there was no difference
between groups
For 114 patients, intraten- Functional improvement and reduction of [116]
dineous injections of pain superior in the treated group.
bupivacaine (2–3 ml) Significant differences in favor of the
treated group in alternating periods.
– Functional improvement and positive [117]
DOI: 10.3109/09537104.2014.881991
change in the magnetic resonance
imaging. Total return to sports 12
weeks after injection.
– Significant reduction of pain and stiff- [65]
ness, functional improvement and
return to activities at 6 months after
treatment
Sixteen patients, physio- Functional improvement, significant [118]
therapy treatment reduction of pain compared to the
control group in the short term.
Increased improvement in 6 months
when physiotherapy was inserted in the
PRP group.
Fifteen patients, recon- Functional improvement and reduction of [107]
struction of the anterior pain higher in the group treated (short
cruciate ligament term). No significant difference in the
long term (6 months) between groups
– Stability of functional improvement, pain [119]
reduction, return to activities, patient
satisfaction
PRP: Methodologies and clinical applications
9
 10 L. F. Marques et al.
the short and/or long-term, positive but not significant in the short
and/or long term, or the results are similar when compared to
control groups. Chronic tendinopathy, who comprise the majority
of clinical studies have pathologies cell subtypes that range over
time and thus the PRP could be beneficial and contribute to the
morphological and functional improvement in some of these
stages, but not in others.
Finally, the tendency observed in the literature, as well as
clinical experience on the treatment of tendinopathy with PRP,
support the importance of the combined treatment. In this sense,
physical therapy and a program of activities after injection of
PRP, adopted in most studies, demonstrate better results in tendon
lesions and should be considered for this type of clinical
application.
Conclusion
In the past twenty years, PRP application has proved to be a safe
and effective in experimental animals models and in the clinical
treatment of human patients. Its therapeutic use in regenerative
Platelets Downloaded from informahealthcare.com by University of Otago on 09/11/14
medicine has reported favorable effects in connection with safety,
and a simple methodology of preparation. Another important
advantage relates to the low cost of obtaining the preparations of
PRP. Nonetheless, the implementation of its therapeutic use as a
clinical alternative has been impaired, or even made unfeasible,
for a series of aspects related with the insufficient description of
the adopted procedures, the large variability of the studies in
regard to platelet quality and concentration, small sample and lack
of control groups. Therefore, new research are required, with
greater accuracy and experimental refinement, employing a larger
For personal use only.
numbers of patients, randomization of samples, standardization of
methodological procedures, as well as the definition of a
consensus to establish more precisely the clinical conditions for
which the PRP should be properly and precisely employed.
Declaration of interest
The authors report no conflicts of interest. The authors thank Fundação
para o Desenvolvimento da Unesp (FUNDUNESP), Prefeitura Municipal
de Assis and CIVAP/Saúde (Assis, SP) for the financial support. T.S. is
financially supported by Coordenação de Aperfeiçoamento de Pessoal de
Nı́vel Superior (CAPES).
References
1. Schultz GS, Sibbald RG, Falanga V, Ayello E A, Dowsett C, Harding
K, Romanelli M, Stacey MC, Teot L, Vanscheidt W. Wound bed
preparation: A systematic approach to wound management. Wound
Repair Regen 2003;11(Suppl. 1):S1–S28.
2. Foster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo SA.
Platelet-rich plasma: From basic science to clinical applications. Am
J Sports Med 2009;37:2259–2272.
3. Bennett NT, Schultz GS. Growth factors and wound healing:
Biochemical properties of growth factors and their receptors. Am J
Surg 1993;165:728–737.
4. Cohen S, Levi-Montalcini R. A nerve growth-stimulating factor
isolated from snake venom. Proc Nat Acad Sci USA 1956;42:571–
574.
5. Cohen S. Isolation of a mouse submaxillary gland protein
accelerating incisor eruption and eyelid opening in the new-born
animal. J Biol Chem 1962;237:1555–1562.
6. Raines EW, Ross R. Platelet-derived growth factor. I. High yield
purification and evidence for multiple forms. J Biol Chem 1982;257:
5154–5160.
7. Bowen-Pope DF, Ross R. Platelet-derived growth factor. II. Specific
binding to cultured cells. J Biol Chem 1982;257:5161–5171.
8. Engebretsen L, Steffen K, Alsousou J, Anitua E, Bachl N, Devilee R,
Everts P, Hamilton B, Huard J, Jenoure P, et al. IOC consensus paper
on the use of platelet-rich plasma in sports medicine. Br J Sports
Med 2010;44:1072–1081.
Platelets, Early Online: 1–13
9. Kevy SV, Jacobson MS. Comparison of methods for point of care
preparation of autologous platelet gel. J Extra Corpor Technol 2004;
36:28–35.
10. El-Sharkawy H, Kantarci A, Deady J, Hasturk H, Liu H, Alshahat
M, Van Dyke TE. Platelet-rich plasma: Growth factors and pro- and
anti-inflammatory properties. J Periodontol 2007;78:661–669.
11. Galliera E, Corsi MM, Banfi G. Platelet rich plasma therapy:
Inflammatory molecules involved in tissue healing. J Biol Regul
Homeost Agents 2012;26:35S–42S.
12. Ferrari M, Zia S, Valbonesi M, Henriquet F, Venere G, Spagnolo S,
Grasso MA, Panzani I. A new technique for hemodilution,
preparation of autologous platelet-rich plasma and intraoperative
blood salvage in cardiac surgery. Int J Artif Organs 1987;10:47–50.
13. Wang HL, Avila G. Platelet-rich plasma: Myth or reality? Eur J
Dent 2007;1:192–194.
14. Vendramin FS, Franco D, Franco TR. Methods to obtain autolo-
gous platelet-rich plasma gel. Ver Bras Cir Plast 2009;24:212–218.
15. Oliveira-Filho MA, Almeida LE, Pereira JA, Nassif PAN, Czeczko
NG, Hume MH, Silva MBG. Platelet-rich plasma in rabbits:
Introduction of one experimental animal model. ABCD Arq Bras
Cir Dig 2008;21:175–179.
16. Bames GL, Kostenuik PJ, Gerstenfeld LC, Einhorn TA. Growth
factor regulation of fracture repair. J Bone Miner Res 1999;78:
1272–1286.
17. Pierce GF, Mustoe TA, Altrock BW, Deuel TF, Thomason A. Role
of platelet-derived growth factor in wound healing. J Cell Biochem
1991;45:319–326.
18. Rosier RN, O’Keef RJ, Hicks DG. The potential role of
transforming growth factor beta in fracture healing. Clin Orthop
1998;355:S294–S300.
19. Wang JS. Basic fibroblastic growth factor for simulation of bone
formation in osteoinductive or conductive implants. Acta Orthop
Scand 1996;269:1–33.
20. Friesel RE, Maciag T. Molecular mechanisms of angiogenesis:
Fibroblast growth factor signal transduction. FASEB J 1995;9:
919–925.
21. Canalis E, McCarthy TL, Centrella M. Effects of platelet-derived
gorwth factor on bone formation in vitro. J Cell Physiol 1989;140:
530–537.
22. Steenfos HH. Growth factors and wound healing. Scand J Plast
Reconstr Hand Surg 1994;28:95–105.
23. Rhee JS, Black M, Schubert U, Fischer S, Morgenstern E, Hammes
HP, Preissner KT. The functional role of blood platelet components
in angiogenesis. Thromb Haemost 2004;92:394–402.
24. Marx RE. 1999. Platelet rich plasma: A source of multiple
autologous growth factors for bone grafts. In: Lynch SE, Genco RJ,
Marx RE, editors. Tissue engineering. Aplications in maxillofacial
surgery and periodontics. Illinois: Quintessence Editores. pp
71–82.
25. Marx RE, Carlson ER, Eichstaedt RM, Schimmele SR, Strauss JE,
Georgeff KR. Platelet-rich plasma: Growth factor enhancement for
bone grafts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
1998;85:638–646.
26. Fufa D, Shealy B, Jacobson M, Kevy S, Murray MM. Activation of
platelet-rich plasma using soluble type I collagen. J Oral
Maxillofac Surg 2008;66:684–690.
27. Vendramini FS, Franco D, Schamall RF, Franco TR. Use of
autologous platelet-rich plasma (PRP) in skin grafts in rabbits. Ver
Bras Cir Plást 2010;25:4–10.
28. Tate KS, Crane DM. Platelet rich plasma grafts in musculoskeletal
medicine. J Prolother 2010;2:371–376.
29. Everts PA, Knape JT, Weibrich G, Schonberger JPAM, Hoffmann
JJHL, Overdevest EP, Box HA, van Zundert A. Platelet-rich plasma
and platelet gel: A review. JECT 2006;38:174–187.
30. Crane D, Everts PA. Platelet rich plasma (PRP) matrix grafts. PPM
2008;8:12–27.
31. Creaney L, Hamilton B. Growth factor delivery methods in the
management of sports injuries: The state of play. Br J Sports Med
2007;10:1–16.
32. Longo UG, Loppini M, Berton A, Spiezia F, Maffulli N, Denaro V.
Tissue engineered strategies for skeletal muscle injury. Stem Cell
Int 2012:175038.
33. Schepull T, Kvist J, Norrman H, Trinks M, Berlin G, Aspenberg P.
Autologous platelets have no effect on the healing of human
Achilles tendon ruptures a randomized single-blind study. Am J
Sports Med 2011;39:38–47.
 DOI: 10.3109/09537104.2014.881991
34. Dugrillon A, Eichler H, Kern S, Kluter H. Autologous concentrated
platelet-rich plasma (cPRP) for local application in bone regener-
ation. Int J Oral Maxillofac Surg 2002;31:615–619.
35. Giannoudis PV, Dinopoulos H, Tsiridis E. Bone substitutes:
An update. Injury 2005;36:S20–S27.
36. Schuckert KH, Jopp S, Osadnik M. Modern bone regeneration
instead of bone transplantation: A combination of recombinant
human bone morphogenetic protein-2 and platelet-rich plasma for
the vertical augmentation of the maxillary bone—A single case
report. Tissue Eng Part C Methods 2010;16:1335–1346.
37. Bhumiratana S, Vunjak-Novakovic G. Concise review:
Personalized human bone grafts for reconstructing head and face.
Stem Cells Transl Med 2012;1:64–69.
38. Tayapongsak P, O’Brien DA, Monteiro CB. Autologous fibrin
adhesive in mandibular econstruction with particulate cancellous
bone and marrow. J Oral Maxillofac Surg 1994;52:161–166.
39. Whitman DH, Berry RL, Green DM. Platelet gel: An autologous
alternative to fibrin glue with applications in oral and maxillofacial
surgery. J Oral Maxillofac Surg 1997;55:1294–1298.
40. Batista MA, Leivas TP, Rodrigues CJ, Arenas GCF, Belitardo DR,
Guarniero R. Comparison between the effects of platelet-rich
plasma and bone marrow concentrate on defect consolidation in the
rabbit tibia. Clinics 2011;66:1787–1792.
Platelets Downloaded from informahealthcare.com by University of Otago on 09/11/14
41. Creeper F, Lichanska AM, Marshall RI, Seymour GJ, Ivanovski S.
The effect of platelet rich plasma on osteoblast and periodontal
ligament cell migration, proliferation and differentiation.
J Periodontal Res 2009;44:258–265.
42. Pieri F, Lucarelli E, Corinaldesi G, Fini M, Aldini NN, Giardino R,
Donati D, Marchetti C. Effect of mesenchymal stem cells and
platelet-rich plasma on the healing of standardized bone defects in
the alveolar ridge: A comparative histomorphometric study in
minipigs. J Oral Maxillofac Surg 2009;67:265–272.
43. Markopoulou CE, Markopoulos P, Dereka XE, Pepelassi E, Vrotsos
IA. Effect of homologous PRP on proliferation of human period-
For personal use only.
ontally affected osteoblasts. In vitro preliminary study. Report of a
case. J Musculoskelet Neuronal Interact 2009;9:167–172.
44. Kim, ES, Kim JJ, Park FJ. Angiogenic factor-enriched platelet-rich
plasma enhances in vivo bone formation around alloplastic graft
material. J Adv Prosthodont 2010;2:7–13.
45. Arvidson K, Abdallah BM, Applegate LA, Baldini N, Cenni E,
Gomez-Barrena E, Granchi D, Kassem M, Konttinen YT, Mustafa
K, et al. Bone regeneration and stem cells. J Cell Mol Med 2011;
15:718–746.
46. Kanthan SR, Kavitha G, Addi S, Choon DSK, Kamarul T. Platelet-
rich plasma (PRP) enhances bone healing in non-united critical-
sized defects: A preliminary study involving rabbit models. Injury
2011;42:782–789.
47. Nassan MA, Gobran HG, Saad AY, Abdelaal AM. Evaluation of
intra-osseous defects regeneration treated by platelet rich plasma
using silver-stained nucleolar organizer regions (AgNORs). J Am
Sci 2012;8:301–307.
48. Jensen TB, Rahbek O, Overgaard S, Søballe K. Platelet rich plasma
and fresh frozen bone allograft as enhancement of implant fixation:
An experimental study in dogs. J Orthop Res 2004;22:653–658.
49. Roldán JC, Jepsen S, Miller J, Freitag S, Rueger DC, Açil Y,
Terheyden H. Bone formation in the presence of platelet-rich
plasma vs. bone morphogenetic protein-7. Bone 2004;34:80–90.
50. Yamada Y, Ueda M, Hibi H, Nagasaka T. Translational research for
injectable tissue-engineered bone regeneration using mesenchymal
stem cells and platelet-rich plasma: From basic research to clinical
case study. Cell Transplant 2004;13:343–355.
51. Borrelli V, Sterpetti AV, Coluccia P, Randone B, Cavallaro A,
Santoro D’Angelo L, Cucina A. Bimodal concentration-dependent
effect of thrombin on endothelial cell proliferation and growth
factor release in culture. J Surg Res 2001;100:154–160.
52. Karp JM, Tanaka TS, Zohar R, Sodek J, Shoichet MS, Davies JE,
Stanford WL. Thrombin mediated migration of osteogenic cells.
Bone 2005;37:337–348.
53. Gruber R, Karreth F, Kandler B, Fuerst G, Rot A, Fischer MB,
Watzek G. Platelet-released supernatants increase migration and
proliferation, and decrease osteogenic differentiation of bone
marrow-derived mesenchymal progenitor cells under in vitro
conditions. Platelets 2004;15:29–35.
54. Croci AT, Camargo OPD, Bitar G, Pereira SLB, Moreira M. Effect
of plasma concentrate on bone defects induced in mice fêmurs via
PRP: Methodologies and clinical applications 11
stimulation of bone formation: An experimental study. Acta Ortop
Bras 2003;11:230–239.
55. Leong DKC, Benedict BCLT, Chew KTL. Autologous growth
factors: A biological treatment in sports medicine. Proc Singapore
Healthc 2010;19:229–236.
56. Tay AG, Farhadi J, Suetterlin R. Cell yield, proliferation, and
postexpansion differentiation capacity of human ear, nasal, and rib
chondrocytes. Tissue Eng 2004;10:762–770.
57. Mizuta H, Kudo S, Nakamura E, Otsuka Y, Takagi K, Hiraki Y.
Active proliferation of mesenchymal cells prior to the chondro-
genic repair response in rabbit full-thickness defects of articular
cartilage. Osteoarthr Cartil 2004;12:586–596.
58. Akeda K, An HS, Okuma M, Attawia M, Miyamoto K, Thonar
EJM, Lenz ME, Sah RL, Masuda K. Platelet-rich plasma stimulates
porcine articular chondrocyets and matrix biosynthesis. Osteoarthr
Cartil 2006;14:1272–1280.
59. Krüger JP, Hondke S, Endres M, Pruss A, Siclari A, Kaps C.
Human platelet-rich plasma stimulates migration and chondrogenic
differentiation of human subchondral progenitor cells. J Orthop Res
2012;30:845–852.
60. van Buul GM, Koevoet WL, Kops N, Bos PK, Verhaar JA, Weinans
H, Bernsen MR, van Osch GJ. Platelet-rich plasma releasate
inhibits inflammatory processes in osteoarthritic chondrocytes. Am
J Sports Med 2011;39:2362–2370.
61. Sanchez MS, Azofra J, Anitua E, Andı́a I, Padilla S, Santisteban J,
Mujika I. Plasma rich in growth factors to treat an articular
cartilage avulsion: A case report. Med Sci Sports Exerc 2003;35:
1648–1652.
62. Everts PA, Devilee RJ, Brown Mahoney C, Eeftinck-Schattenkerk
M, Box HA, Knape, JT, van Zundert A. Platelet gel and fibrin
sealant reduce allogenic blood transfusions in total knee arthro-
plasty. Acta Anaesthesiol Scand 2006;50:593–599.
63. Berghoff WJ, Pietrzak WS, Rhodes RD. Platelet-rich plasma
application during closure following total knee arthroplasty.
Orthopedics 2006;29:590–598.
64. Gardner MJ, Demetrakopoulos D, Klepchick PR, Mooar PA. The
efficacy of autologous platelet gel in pain control and blood loss in
total knee arthroplasty: An analisys of the hemoglobin, narcotic
requirement and range of motion. Int Orthop 2007;31:309–313.
65. Kon E, Filardo G, Delcogliano M, Presti ML, Russo A, Bondi A,
Di Martino A, Cenacchi A, Fornasari PM, Marcacci M. Platelet-
rich plasma: New clinical application: A pilot study for treatment
of jumper’s knee. Injury 2009;40:598–603.
66. Kon E, Buda R, Filardo G, Di Martino A, Timoncini A, Cenacchi
A, Fornasari PM, Giannini S, Marcacci M. Platelet-rich plasma:
Intra-articular knee injections produced favorable results on
degenerative cartilage lesions. Knee Surg Sports Traumatol
Arthrosc 2010;18:472–479.
67. Mei-Dan O, Carmont MR, Laver L, Mann G, Maffulli N, Nyska M.
Platelet-rich plasma or hyaluronate in the management of
osteochondral lesions of the talus. Am J Sports Med 2012;40:
534–541.
68. Spaková T, Rosocha J, Lacko M, Harvanová D, Gharaibeh A.
Treatment of knee joint osteoarthritis with autologous platelet-rich
plasma in comparison with hyaluronic acid. Am J Phys Med
Rehabil 2012;91:411–417.
69. Radice F, Yánez R, Gutiérrez V, Rosales J, Pinedo M, Coda S.
Comparison of magnetic resonance imaging findings in anterior
cruciate ligament grafts with and without autologous platelet-
derived growth factors. Arthroscopy 2010;26:50–57.
70. Murray MM, Spindler KP, Abreu E, Muller JA, Nedder A, Kelly
M, Frino J, Zurakowski D, Valenza M, Snyder BD, et al. Collagen-
platelet rich plasma hydrogel enhances primary repair of the
porcine anterior cruciate ligament. J Orthop Res 2007;25:81–91.
71. Nin JRV, Gasque GM, Azcárate AV, Beola JDA, Gonzalez MH.
Has platelet-rich plasma any role in anterior cruciate ligament
allograft healing? Arthroscopy 2009;25:1206–1213.
72. Murray MM, Palmer M, Abreu E, Spindler KP, Zurakowski D,
Fleming BC. Platelet-rich plasma alone is not sufficient to enhance
suture repair of the ACL in skeletally immature animals: An in vivo
study. J Orthop Res 2009;27:639–645.
73. Rupreht M, Jevtič V, Serša I, Vogrin M, Jevšek M. Evaluation of
the tibialtunnel after intraoperatively administered platelet-rich
plasma gel during anterior cruciate ligament reconstruction using
diffusion weighted and dynamic contrast-enhanced MRI. J Magn
Reson Imaging 2013;37:928–935.
 12 L. F. Marques et al.
74. Wu W, Chen F, Liu Y, Ma Q, Mao T. Autologous injectable tissue-
engineered cartilage by using platelet-rich plasma: Experimental
study in a rabbit model. J Oral Maxillofac Surg 2007;65:
1951–1957.
75. Saito M, Takahashi KA, Arai Y, Inoue A, Sakao K, Tonomura H,
Honjo K, Nakagawa S, Inoue H, Tabata Y, et al. Intraarticular
administration of platelet-rich plasma with biodegradable gelatin
hydrogel microspheres prevents osteoarthritis progression in the
rabbit knee. Clin Exp Rheumatol 2009;27:201–207.
76. Gotterbarm T, Richter W, Jung M, Bernardi VS, Mainil-Varlet P,
Yamashita T. An in vivo study of a growth factor enha, cell free,
two layered collagen-tricalcium phosphate in deep osteochondral
defects. Biomaterials 2006;27:3387–3395.
77. Mishra A, Pavelko T. Treatment of chronic elbow tendinosis
with buffered platelet-rich plasma. Am J Sports Med 2006;34:
1774–1778.
78. Sun Y, Feng Y, Zhang CQ, Chen SB, Cheng XG. The regenerative
effect of platelet-rich plasma on healing in large osteochondral
defects. Int Orthop 2010;34:589–597.
79. Wahlström O, Linder CH, Ansell A, Kalén A, Söderström M,
Magnusson P. Acidic preparations of lysed platelets upregulate
proliferative pathways in osteoblast-like cells as demonstrated by
genome-wide microarray analysis. Platelets 2011;22:452–460.
Platelets Downloaded from informahealthcare.com by University of Otago on 09/11/14
80. Filardo G, Kon E, Buda R, Timoncini A, Di Martino A, Cenacchi
A, Fornasari PM, Giannini S, Marcacci M. Platelet-rich plasma
intra-articular knee injections for the treatment of degenerative
cartilage lesions and osteoarthritis. Knee Surg Sports Traumatol
Arthrosc 2011;19:528–535.
81. Shi M, Ishikawa M, Kamei N, Nakasa T, Adachi N, Deie M,
Asahara T, Ochi M. Acceleration of skeletal muscle regeneration in
a rat skeletal muscle injury model by local injection of human
peripheral blood-derived CD133-positive cells. Stem Cells 2009;
27:949–960.
82. De Carli A, Volpi P, Pelosini I, Ferretti A, Melegati G, Mossa L,
For personal use only.
Tornese D, de Girolamo L, Scarpignato C. New therapeutic
approaches for management of sport-induced muscle strains. Adv
Ther 2009;26:1072–1083.
83. Hamilton BH, Best TM. Platelet-enriched plasma and muscle strain
injuries: Challenges imposed by the burden of proof. Clin J Sport
Med 2011;21:31–36.
84. Hammond JW, Hinton RY, Curl LA, Muriel JM, Lovering RM. Use
of autologous PRP to treat muscle injuries. Am J Sports Med 2009;
37:1135–1142.
85. Kasemkijwattana C, Menetrey J, Bosch P, Somogyi G, Moreland
MS, Fu FH, Buranapanitkit B, Watkins SS, Huard J. Use of growth
factors to improve muscle healing after strain injury. Clin Orthop
Relat Res 2000;370:272–285.
86. Musaro A, McCullagh KJ, Paul A, Houghton L, Dobrowolny G,
Molinaro M, Barton ER, Sweeney HL, Rosenthal N. Localized
IGF-1 transgene expression sustains hypertrophy and regeneration
in senescent skeletal muscle. Nat Genet 2001;27:195–200.
87. Alsousou J, Thompson M, Hulley P, Noble A, Willett K. The
biology of platelet-rich plasma and its application in trauma and
orthopaedic surgery: A review of the literature. J Bone Joint Surg B
2009;91:987–996.
88. Wright-Carpenter T, Klein P, Schaferhoff P, Appell HJ, Mir LM,
Wehling P. Treatment of muscle injuries by local administration of
autologous conditioned serum: A pilot study on sportsmen with
muscle strains. Int J Sports Med 2004;25:588–593.
89. Cugat R, Carrillo JM, Serra I, Soler C. 2006. Articular cartilage
defects reconstruction by plasma rich growth factors. Basic science,
clinical repair and reconstruction of articular cartilage defects:
Current status and prospects. Bologna, Italy: Timeo Editore. pp
801–807.
90. Castricini R, Longo UG, De Benedetto M, Panfoli N, Pirani P, Zini
R, Maffulli N, Denaro V. Platelet-rich plasma augmentation for
arthroscopic rotator cuff repair a randomized controlled trial. Am J
Sports Med 2011;39:258–265.
91. Jo CH, Kim JE, Yoon KS, Lee JH, Kang SB, Lee JH, Han HS,
Rhee SH, Shin S. Does platelet-rich plasma accelerate recovery
after rotator cuff repair? A prospective cohort study. Am J Sports
Med 2011;39:2082–2090.
92. Rodeo SA, Delos D, Williams RJ, Adler RS, Pearle A, Warren RF.
The effect of platelet-rich fibrin matrix on rotator cuff tendon
healing a prospective, randomized clinical study. Am J Sports Med
2012;40:1234–1241.
Platelets, Early Online: 1–13
93. Tinsley BA, Ferreira JV, Dukas AG, Mazzocca AD. Platelet-rich
plasma nonoperative injection therapy—a review of indications
and evidence. Oper Tech Sports Med 2012;20:192–200.
94. Bernuzzi G, Petraglia F, Pedrini MF, De Filippo M, Pogliacomi F,
Verdano MA, Costantino C. Use of platelet-rich plasma in the
care of sports injuries: Our experience with ultrasound-guided
injection. Blood Transfus 2013. doi: 10.2450/2013.0293-12.
95. Maffulli N, Wong J, Almekinders LC. Types and epidemiology of
tendinopathy. Clin Sports Med 2003;22:675–692.
96. Alfredson H. Chronic midportion Achilles tendinopathy: An
update on research and treatment. Clin Sports Med 2003;22:
727–741.
97. Järvinen TA, Kannus P, Maffulli N, Khan KM. Achilles tendon
disorders: Etiology and epidemiology. Foot Ankle Clin 2005;10:
255–266.
98. Tate KS, Crane DM. Platelet rich plasma grafts in musculoskel-
etal medicine. J Prolother 2010;2:371–376.
99. Lopez-Gavito E, Gómez-Carlı́n LA, Parra-Téllez P, Vázquez-
Escamilla J. Platelet rich plasma for the management of
tendinopathy of the Achilles tendon and plantar fasciitis. Acta
Ortop Mex 2011;25:379–384.
100. Baksh N, Hannon CP, Murawski CD, Smyth NA, Kennedy JG.
Platelet-rich plasma in tendon models: A systematic review of
basic science literature. Arthroscopy 2013;29:596–607.
101. Bosch G, Moleman M, Barneveld A, van Weeren PR, van Schie
HT. The effect of platelet-rich plasma on the neovascularization
of surgically created equine superficial digital flexor tendon
lesions. Scand J Med Sci Sports 2011;21:554–561.
102. Spang JT, Tischer T, Salzmann GM, Winkler T, Burgkart R,
Wexel G, Imhoff AB. Platelet concentrate vs. saline in a rat
patellar tendon healing model. Knee Surg Sports Traumatol
Arthrosc 2011;19:495–502.
103. Lyras DN, Kazakos K, Tryfonidis M, Agrogiannis G, Botaitis S,
Kokka A, Drosos G, Tilkeridis K, Verettas D. Temporal and
spatial expression of TGF-b1 in an Achilles tendon section model
after application of platelet-rich plasma. Foot Ankle Surg 2010;
16:137–141.
104. Scarpone MA, Rabago DP, Zgierska A, Arbogast G, Snell E. PRP
as a treatment alternative for symptomatic rotator cuff tendino-
pathy for patients failing conservative treatment. Advances in
Blood Management Meeting Presentation 2005;35:245–251.
105. Sánchez M, Anitua E, Azofra J, Andı́a I, Padilla S, Mujika I.
Comparison of surgically repaired Achilles tendon tears
using platelet-rich fibrin matrices. Am J Sports Med 2007;35:
245–251.
106. Gaweda K, Tarczynska M, Krzyzanowski W. Treatment of
Achilles tendinopathy with platelet-rich plasma. Int J Sports
Med 2010;31:577–583.
107. de Almeida AM, Demange MK, Sobrado MF, Rodrigues MB,
Pedrinelli A, Hernandez AJ. Patellar tendon healing with platelet-
rich plasma: A prospective randomized controlled trial. Am J
Sports Med 2012;40:1282–1288.
108. Kaux JF, Crielaard JM. Platelet-rich plasma application in the
management of chronic tendinopathies. Acta Orthop Belg 2013;
79:10–15.
109. de Vos RJ, Weir A, van Schie HT, Bierma-Zeinstra SM, Verhaar
JA, Weinans H, Tol JL. Platelet-rich plasma injection for chronic
Achilles tendinopathy: A randomized controlled trial. JAMA
2010;303:144–149.
110. Owens Jr RF, Ginnetti J, Conti SF, Latona C. Clinical and
magnetic resonance imaging outcomes following platelet rich
plasma injection for chronic midsubstance Achilles tendinopathy.
Foot Ankle Int 2011;32:1032–1039.
111. Randelli P, Arrigoni P, Ragone V, Aliprandi A, Cabitza P. Platelet
rich plasma in arthroscopic rotator cuff repair: A prospective
RCT study, 2-year follow-up. J Shoulder Elbow Surg 2011;20:
518–528.
112. Kesikburun S, Tan AK, Yılmaz B, Yaşar E, Yazicioğlu K.
Platelet-rich plasma injections in the treatment of chronic rotator
cuff tendinopathy a randomized controlled trial with 1-year
follow-up. Am J Sports Med 2013;41:2609–2616.
113. Peerbooms JC, van Laar W, Faber F, Schuller HM, van der
Hoeven H, Gosens T. Use of platelet rich plasma to treat plantar
fasciitis: Design of a multicentre randomized controlled trial.
BMC Musculoskelet Disord 2010;11:69.
 DOI: 10.3109/09537104.2014.881991
114. Creaney L, Wallace A, Curtis M, Connell D. Growth factor-based
therapies provide additional benefit beyond physical therapy in
resistant elbow tendinopathy: A prospective, double-blind,
randomised trial of autologous blood injections versus platelet-
rich plasma injections. Br J Sports Med 2011;45:966–971.
115. Thanasas C, Papadimitriou G, Charalambidis C, Paraskevopoulos
I, Papanikolaou A. Platelet-rich plasma versus autologous whole
blood for the treatment of chronic lateral elbow epicondylitis: A
randomized controlled clinical trial. Am J Sports Med 2011;39:
2130–2134.
116. Mishra AK, Skrepnik NV, Edwards SG, Jones GL, Sampson S,
Vermillion DA, Ramsey ML, Karli DC, Rettig AC. Platelet-rich
plasma significantly improves clinical outcomes in patients with
chronic tennis elbow: A double-blind, prospective, multicenter,
Platelets Downloaded from informahealthcare.com by University of Otago on 09/11/14
For personal use only.
PRP: Methodologies and clinical applications 13
controlled trial of 230 patients. Am J Sports Med 2013. [Epub
ahead of Print]. doi: 10.1177/0363546513494359.
117. Volpi P, Mariconi L, Bait C, De Girolamo L, Schoenhuber H.
Treatment of chronic patellar tendinosis with buffered platelet
riche plasma: A preliminary study. Medicina Dello Sport 2007;60:
595–603.
118. Filardo G, Kon E, Della Villa S, Vincentelli F, Fornasari
PM, Marcacci M. Use of platelet-rich plasma for the
treatment of refractory jumper’s knee. Int Orthop 2010;34:
909–915.
119. Filardo G, Kon E, Di Matteo B, Pelotti P, Di Martino A,
Marcacci M. Platelet-rich plasma for the treatment of patellar
tendinopathy: Clinical and imaging findings at medium-term
follow-up. Int Orthop 2013;37:1583–1589.