Knee Surgery, Sports Traumatology, Arthroscopy (2023) 31:1940–1952

https://doi.org/10.1007/s00167-022-07223-9

SHOULDER

Platelet‑rich plasma does not improve clinical results in patients

with rotator cuff disorders but reduces the retear rate. A systematic
review and meta‑analysis
Pietro Feltri1   · Giorgia Carlotta Gonalba1 · Angelo Boffa2 · Christian Candrian1,3 · Alessandra Menon4,5,6 ·
Pietro Simone Randelli4,5,7 · Giuseppe Filardo1,3,8

Received: 19 July 2022 / Accepted: 4 November 2022 / Published online: 11 December 2022
© The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2022

Abstract
Purpose  To assess whether the use of Platelet-rich plasma (PRP) produces a clinical benefit in patients with rotator cuff
disorders, treated either conservatively or surgically.
Methods  A systematic review was performed according to PRISMA guidelines on three databases (PubMed, Cochrane
Library, Web of Science) to identify randomised controlled trials (RCTs) on the use of PRP in patients with rotator cuff dis-
orders, treated either conservatively or surgically. A meta-analysis was performed on articles reporting results for Constant,
UCLA, VAS, SST scores and retear rate. The RoB 2.0 and the modified Coleman Methodology Score were used to assess
methodological quality.
Results  A total of 36 RCTs (20 surgical, 16 conservative) were included, for a total of 2,443 patients. Conservative treatment
showed high heterogeneity and no clear consensus in favour of PRP. The meta-analysis of the studies with surgical treatment
showed no benefit in using PRP in any of the clinical outcomes, either at the short or medium/long-term follow-up. However,
the retear rate was lower with PRP augmentation (p < 0.001). The overall quality of the studies was moderate to high, with
the surgical studies presenting a lower risk of bias than the conservative studies.
Conclusion  The use of PRP as augmentation in rotator cuff surgical repair significantly reduces the retear rate. However, no
benefits were documented in terms of clinical outcomes. PRP application through injection in patients treated conservatively
also failed to present any clear advantage. While there are many studies in the literature with several RCTs of moderate
to high quality, the high heterogeneity of products and studies remains a significant limitation to fully understanding PRP
potential in this field.
Level of evidence  Level I.

Keywords  PRP · Platelet-rich plasma · Rotator cuff disorders · Tendinopathy

6
* Pietro Feltri Scuola di Specializzazione in Statistica Sanitaria e Biometria,
pietro.feltri@eoc.ch Department of Clinical Sciences and Community Health,
Università degli Studi di Milano, Via Della Commenda 19,
1
Service of Orthopaedics and Traumatology, Department 20122 Milan, Italy
of Surgery, EOC, Lugano, Switzerland 7
Research Center for Adult and Pediatric Rheumatic
2
Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Diseases (RECAP‑RD), Department of Biomedical Sciences
Ortopedico Rizzoli, Via Pupilli 1, 40136 Bologna, Italy for Health, Università degli Studi di Milano, Via Mangiagalli
3 31, 20133 Milan, Italy
Faculty of Biomedical Sciences, Università della Svizzera
8
Italiana, Via Buffi 13, 6900 Lugano, Switzerland Applied and Translational Research (ATR) Center,
4 IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10,
Laboratory of Applied Biomechanics, Department
40137 Bologna, Italy
of Biomedical Sciences for Health, Università degli Studi di
Milano, Via Mangiagalli 31, 20133 Milan, Italy
5
Clinica Ortopedica, ASST Centro Specialistico Ortopedico
Traumatologico Gaetano Pini-CTO, Piazza Cardinal Ferrari
1, U.O.C. 1°, 20122 Milan, Italy

13
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Knee Surgery, Sports Traumatology, Arthroscopy (2023) 31:1940–1952 1941
Introduction
 Due to the considerable socio-economical burden of these
disorders [13, 34], numerous therapeutic options have been
proposed over the years, ranging from conservative strat-
egies, including anti-inflammatory drugs [59], physical
therapy [61] and corticosteroid or hyaluronic acid injec-
tions, to surgical approaches, such as tendon sutures, auto-
grafts, allografts, or prostheses [29]. However, these treat-
ments are not always effective, often resulting in symptom
persistence or surgical failure. This is likely due to the
frequent degenerative nature of rotator cuff disorders and
the intrinsic poor healing potential of the tendon tissue, as
these tendons are poorly vascularised [48]. Consequently,
research efforts have focused on improving the treatment
of rotator cuff pathologies, with the aim of increasing the
biological potential of rotator cuff tendon healing. [30, 53]
In this scenario, the use of platelet-rich plasma (PRP)
has gained major interest in the treatment of rotator cuff
disorders, thanks to its safety and simple preparation
technique [24]. PRP contains a high concentration of
bioactive molecules, stored in platelet α-granules, which
are involved in the healing process [45]. Numerous pre-
clinical studies have shown the positive effects of PRP on
tendon healing, favouring collagen deposition, tendon vas-
cularisation, and cell recruitment, development and mor-
phogenesis [3, 26, 38]. The unique nature of PRP makes
this product applicable both as a conservative treatment,
by a simple injective approach, and as a biological aug-
mentation during surgical procedures in the form of a gel
allowing the secretion of its bioactive molecules in situ
[55]. Several clinical studies have investigated the use of
PRP in both the conservative and surgical treatment of
rotator cuff disorders [16]. However, results are still con-
troversial and there are no clear indications of the potential
of PRP applications in clinical practice.
The aim of this systematic review and meta-analysis is
to document the efficacy of PRP application in terms of
functional improvement, pain reduction, and retear rate
in both the conservative and surgical treatment of rotator
cuff disorders.
Materials and methods
Literature search and selection criteria
A review protocol was developed based on the Pre-
ferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) statement (www.​prisma-​state​
ment.​org), which was then registered in the PROSPERO
International Prospective Register of Systematic Reviews
(CRD42021260538). A comprehensive literature search
was performed on 1 January 1 2022 in the bibliographic
databases PubMed, Web of Science, and Cochrane Library,
with no time limitation and without any filter. The fol-
lowing research terms were used: (PRP OR “platelet rich
plasma” OR “plasma rich in growth factors” OR PRGF
OR “platelet derived growth factor” OR “platelet derived”
OR “platelet gel” OR “platelet concentrate” OR PRF OR
“platelet rich fibrin” OR ACP OR “autologous conditioned
plasma” OR APS OR “autologous protein solution” OR
“platelet lysate” OR “platelet supernatant”) AND (“rota-
tor cuff”). Inclusion criteria were: randomised controlled
trials (RCTs); and full-length English-language articles
that reported clinical and pain outcomes on the use of PRP
for the conservative or surgical treatment of rotator cuff
disorders. Pre-clinical studies, non-RCTs, articles written
in other languages, congress abstracts, and review articles
were excluded. A flowchart of the study selection process
for qualitative and quantitative data synthesis is reported
in Fig. 1.
Study selection and data extraction
Two independent reviewers (GCG and PF) screened all the
titles and abstracts. After this first screening, the articles that
met the inclusion criteria were assessed for full-text eligibil-
ity and excluded if they met any one of the exclusion criteria.
In addition, the reference lists from the selected papers and
previously-published relevant reviews were also screened.
In case of disagreement between the two reviewers, a third
reviewer (AB) was consulted. An electronic table for data
extraction was created before the study using Excel (Micro-
soft). The following data were extracted: title, first author,
year of publication, journal, population characteristics (age,
sex, BMI), type of lesion, tendon(s) involved, PRP charac-
teristics, repair technique, follow-up, functional outcomes,
pain scores, and retear rate. A meta-analysis of comparable
outcomes was then performed. To ensure highly-reliable
results, meta-analyses were performed only if there were at
least five studies for each specific outcome. Subsequently,
all the outcomes were divided, according to the time they
were assessed, into short-term (≤ 6.5 months of follow-up)
or long-term (≥ 12 months). Conservatively and surgically
treated patients were considered separately.
Assessment of risk of bias and quality of evidence
The modified Coleman Methodology Score (CMS) was used
to assess the methodological quality of the included studies
[9], whereas assessment of the risk of bias was performed
using the Cochrane Collaboration Risk of Bias (RoB) 2.0
tool [51] and completed independently by two authors (GCG
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1942
Fig. 1  Flow diagram based on PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines reporting the study selection pro-
cess
and PF) for all outcomes. A third author (AB) resolved any
discrepancies. The CMS includes 11 criteria and it is divided
into two parts, with a maximum of 60 and 40 points given
for each part, for a total of 100 points; the higher the score,
the lower the probability that the outcomes are caused by
chance, biases, or confounding factors. The outcome “num-
ber of surgical procedures” was specified with an internal
consensus so that PRP application during rotator cuff repair
was not counted as an additional procedure. Considering the
13
Knee Surgery, Sports Traumatology, Arthroscopy (2023) 31:1940–1952
different domains that could be a source of bias, all the stud-
ies were classified as either having a low risk of bias, some
concerns of bias, or a high risk of bias. RoB 2.0 is designed
to identify a fixed set of bias domains, focusing on different
aspects of trial design, conduct and reporting. Within each
domain, a series of questions ask for information on features
of the trial that are relevant to the risk of bias. A proposed
judgement about the risk of bias arising from each domain
is then generated by an algorithm, based on answers to the
Knee Surgery, Sports Traumatology, Arthroscopy (2023) 31:1940–1952 1943
signalling questions. The risk of bias can be judged as ‘Low',
'Some concerns’, or ‘High’.
Statistical analysis
Statistical analysis was performed using Excel (Microsoft,
USA). All continuous data were expressed in terms of mean
and standard deviation, or median and 25th-75th percentiles,
whereas categorical data were expressed as frequency and
percentages. The Kolmogorov–Smirnov test was performed
to test the normality of continuous variables. The Levene
test was performed to assess the homogeneity of variances.
The ANOVA test was performed to assess the between-
group differences of continuous, normally-distributed, and
homoscedastic data, otherwise, the Mann–Whitney test was
used. The ANOVA test followed by the Scheffè post hoc
pairwise comparison was also used to assess the among-
groups differences of continuous, normally distributed, and
homoscedastic data, otherwise the Kruskal–Wallis test fol-
lowed by the Mann Whitney test with the Bonferroni cor-
rection for multiple comparisons was used. The Spearman
Rank Correlation was used to assess the correlation between
continuous data and the Kendall tau correlation for the cor-
relation between ordinal data. The Pearson chi-square exact
test was performed to investigate relationships between
grouping variables and the Fisher chi-square exact test to
investigate relationships between dichotomous variables.
For all analyses, the significance level was set at a p-value
lower than 0.05.
Results
Included studies
A total of 36 RCTs studies were included (Table 1— Con-
servative Studies, Table 2—Surgical Studies). Two of these
studies [39, 40] evaluated the same population, the new-
est one being the 10-year update of the first study. Hence,
these two were treated as a single study and their results
were merged. The papers were published between 2011 and
2021, with an increasing number of studies regarding con-
servatively treated patients in the last years (Fig. 2). Geo-
graphical distribution of the studies is presented in Fig. 3.
A total of 2443 patients (991 males, 1190 females, and 265
unknown – the majority of whom surgically treated) were
included, with a mean age of 54.3 ± 0.1 years and a mean
follow-up of 16.2 ± 9.2 months. Sixteen cohorts of patients
were affected by only full-thickness tears, three only par-
tial-thickness tears, four mixed full and partial tears, and
the others with mixed combinations of tendinosis/tears/
impingement/bursitis.
Conservative studies
Sixteen studies [2, 4, 7, 11, 19–21, 25, 28, 35, 41, 43, 44, 46,
47, 54] compared conservative treatment using PRP injec-
tions vs corticosteroid (CS) (nine studies), saline (three),
exercise (two), prolotherapy (two), physical therapy (one),
dry needling (one), sodium hyaluronate (SH) (one), and
lidocaine (one). Three of these studies had more than two
groups: two studies had three arms (PRP, SH, and saline
in one study; PRP, prolotherapy, and corticosteroids in the
other); and one study had four arms (PRP, prolotherapy,
corticosteroids, and lidocaine). Ten studies about conserva-
tive treatment performed a single injection, four studies
performed two injections (three with a 1-month interval,
one with a 2-week interval), one study performed three
injections, and one study performed four injections (once
a week for three and four weeks, respectively). The PRP
volume ranged from 1 to 6 ml, with two studies using fro-
zen PRP and two studies activating it (calcium chloride or
gluconate). Finally, only two studies described their PRP
as “leukocyte-poor” and four studies reported the platelets
concentration (ranging from 900 × ­103/µl to 1096 × ­103/µl).
With regard to the tendons involved, nine studies included
only the supraspinatus tendon, one study specified that dif-
ferent tendons were injured, while six studies did not men-
tion which tendons were involved.
Surgical studies
Twenty publications (19 cohorts of patients) [6, 10, 12, 14,
15, 17, 22, 23, 32, 33, 37, 39, 40, 42, 49, 57, 58, 60, 62, 63]
analysed the benefits of PRP augmentation in arthroscopic
surgical procedures, comparing surgical repair + PRP to sur-
gical repair alone, except in one study where saline + ropi-
vacaine was used in the control group and one study that
used saline alone. The administration method of PRP was by
injection in 14 cohorts of patients, whilst by gel/membrane
in the other five. In 16 studies the procedure was intraop-
erative: in 11 studies an injection was administered, three
of which were gel and two were membranes; in one study,
a single injection was performed 10–14 days after surgery,
while in two studies two injections were performed at seven
and 14 days after surgery. The volume of PRP administered
was very heterogeneous, ranging from 2 to 20 ml, and six
studies did not report the PRP volume. All studies used fresh
PRP, with 10 studies activating it (calcium chloride in nine
studies, autologous clotting factors in one). Five studies used
leukocyte-poor PRP, four used leukocyte-rich PRP, and the
others did not provide any information in this regard. Only
eight studies reported the platelet concentration (ranging
from 400 × ­103/µl to 1096 × ­103/µl). As regards the tendons
involved, in eight studies only the supraspinatus tendon was
injured, compared to multiple tendons in eight other studies;
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1944

13
Table 1  Details of the conservative studies
First author, year Country Pts Age Follow-up Type of injury Tendon Comparator Method of Volume Coleman
(PRP-ctrl) (months) administra- of PRP
tion (ml)

Rha et al. 2012 Korea 20–39 53 6 Tendinosis or partial thickness tear Supraspinatus Dry needling Injection 3 74
Kesikburun et al. 2013 Turkey 20–20 53 12 Tendinosis or partial or full-thick- N/A Saline Injection 5 91
ness tear
Ilhanli et al. 2015 Iran 35–35 59 12 Partial thickness tear Supraspinatus Physical therapy Injection 6 70
Shams et al. 2016 Egypt 20–20 52 6 Partial thickness tear Supraspinatus CS Injection 2–2.5 69
Nejati et al. 2017 Iran 31–31 53.2 6 Tendinopathy or partial thickness Supraspinatus Exercise Injection 4 73
tear
Cai et al. 2018 China 50–250 39.7 12 Partial thickness tear Supraspinatus Sodium hyaluronate; saline Injection 2 87
Barreto et al. 2019 Brazil 26–25 53 6 Subacromial impingement N/A CS Injection 3 74
Ibrahim et al. 2019 Egypt 15–15 44 2 Tendinosis, partial or full-thick- Supra/infraspi- CS Injection 4 67
ness tear natus/sub-
scapularis
Sari et al. 2019 Turkey 33–96 52.1 3 Tendinosis or partial thickness tear N/A Prolotherapy; CS; lidocaine Injection 5 68
Schwitzguebel et al. 2019 Switzerland 42–42 48 19.5 Partial or full-thickness tear Supraspinatus Saline Injection 2 89
Centeno et al. 2020* USA 14–11 47.5 12 Partial or full-thickness tear Supraspinatus Exercise Injection 1–2 85
Jo et al. 2020 Korea 30–30 54 6 Tendinosis, partial or full-thick- N/A CS Injection 4 79
ness tear
Kwong et al. 2020 Canada 50–54 49.5 12 Tendinosis or partial thickness tear Supraspinatus CS Injection 5 81
Sabaah et al. 2020 Egypt 20–40 43 3 Tendinosis, tendinitis, bursitis, N/A Prolotherapy; CS Injection 5 82
tenosynovitis, partial thickness
tear
Thepsoparn et al. 2021 Thailand 16–16 57 6 Partial thickness tear Supraspinatus CS Injection 5 80
Dadgostar et al. 2021 Iran 30–28 55.5 3 Tendinosis or partial thickness tear N/A CS Injection 2×3 77

Pts patients, PRP platelet rich plasma, CS corticosteroids, M male, F: female, N/A: not assessable, ctrl control group
*The injected solution was as follows: 60% of bone marrow concentrate, 20% of PRP and 20% of platelet lysate
Knee Surgery, Sports Traumatology, Arthroscopy (2023) 31:1940–1952
 Table 2  Details of the surgical studies
First author, year Country Pts Age Follow-up Type of injury Tendon Comparator Repair technique Method of Volume Coleman
(PRP- ctrl) (months) administra- of PRP
tion (ml)

Castricini et al. Italy 45–43 55.3 16 Full-thickness tear Supraspinatus Repair without Double-row Membrane N/A 88
2011 treatment
Randelli et al. 2011 Italy 26–27 61 24 Full-thickness tear Supraspinatus and/ Repair without Single-row, with Injection 6 81
or infraspinatus treatment acromioplasty
and/or subscapu-
laris
Gumina et al. 2012 Italy 40–40 61.5 13 Full-thickness tear Supraspinatus Repair without Single-row Membrane N/A 90
treatment
Jo et al. 2013 Korea 24–24 63 16.5 Full-thickness tear Supraspinatus and/ Repair without Double-row, with Gel 3×3 79
or infraspinatus treatment acromioplasty
and/or subscapu-
laris
Ruiz-Moneo et al. Spain 32–31 56 12 Full-thickness tear Supraspinatus and/ Repair without Double-row Injection N/A 81
2013 or infraspinatus treatment
Weber et al. 2013 USA 30–30 62 12 Full-thickness tear N/A Repair without Single-row, with Gel N/A 62
treatment acromioplasty
Knee Surgery, Sports Traumatology, Arthroscopy (2023) 31:1940–1952

Malavolta et al. Brazil 39–36 54.6 24 Full-thickness tear Supraspinatus Repair without Single-row Injection 2 × 10 91
2014 treatment
Jo et al. 2015 Korea 37–37 60.5 13 Subacromial Supraspinatus and/ Repair without Double-row Gel 3×3 80
impingement, or infraspinatus treatment
partial or full- and/or subscapu-
thickness tear laris
Wang et al. 2015 Australia 30–30 59 4 Full-thickness tear Supraspinatus Repair without Double-row Injection 2–4 89
treatment
D'Ambrosi et al. Italy 20–20 59.9 6 Full-thickness tear Supraspinatus Repair without Single-row Injection 16 82
2016 treatment
Flury et al. 2016 Switzerland 60–60 58.4 24 N/A Supraspinatus and/ Repair + Saline with Double-row Injection 4 94
or infraspinatus 1% ropivacaine
and/or subscapu-
laris
Holtby et al. 2016 Canada 41–41 59 6 Partial and full- N/A Repair without Single and double- Injection 7 88
thickness tear treatment row, with acro-
mioplasty
Pandey et al. 2016 India 54–56 54 24 Full-thickness tear Supraspinatus or Repair without Single-row Injection 8 89
infraspinatus treatment
Zhang et al. 2016 China 30–30 57 12 Full-thickness tear N/A Repair without Double-row Injection N/A 70
treatment
Zumstein et al. 2016 France 17–18 65.3 14.5 Full-thickness tear Supraspinatus and/ Repair without Double-row Gel N/A 68
or infraspinatus treatment

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1946 Knee Surgery, Sports Traumatology, Arthroscopy (2023) 31:1940–1952

Coleman

92

94

84

87

81
Volume
of PRP

2 × 10
(ml)

2–4

6
administra-
Method of

Injection

Injection

Injection

Injection
tion

Gel

Single and double-

Repair technique

Fig. 2  Studies trend over the years, presenting the yearly distribution

Single-row, with

Single-row, with
acromioplasty

acromioplasty
of the papers that reported PRP application in rotator cuff pathologies
Double-row

Double-row

row

three studies, on the other hand, did not mention which ten-
dons were involved.

Results of conservatively treated patients

Reapir + Saline
Repair without

Repair without

Repair without

Repair without
Comparator

treatment

treatment

treatment

treatment

Data from the studies presenting conservative treatment was

not suitable for meta-analysis due to its heterogeneity. Four-
teen studies analysed pain, using either the Visual Analog
Scale (VAS), Shoulder Pain and Disability Index (SPADI),
Supraspinatus and/

Supraspinatus and/

and/or subscapu-
or infraspinatus

or infraspinatus

or Numeric Pain Scale (NPS), and reported conflicting

Supraspinatus

Supraspinatus

Supraspinatus

results. More specifically, seven studies reported better pain

management with PRP (5 studies vs CS, 1 vs saline, and
Tendon

laris

Pts: patients, PRP platelet rich plasma, M male, F female, N/A not assessable, ctrl control group

1 vs dry needling), but only in the short-term in two stud-

ies (both vs CS), in the long-term in one study (vs CS),
and at 3–6 months, but not at one month, in another study
Full-thickness tear

Full-thickness tear

Full-thickness tear

Full-thickness tear

Full-thickness tear

(vs saline). Four studies found no difference between PRP

Type of injury

and the control group (saline, placebo and CS) either in the
short or the long-term, four studies reported more favour-
able results in the control group (vs physical therapy, pro-
lotherapy, CS and exercise) and two of the studies reported
this outcome only in the short-term (vs CS and exercise).
Age Follow-up
(months)

Fifteen studies evaluated functional outcomes using the

120

Disability of Hand and Shoulder (DASH), Western Ontario

59.6 42

54.7 60

52.7 24

61.3 24

Rotator Cuff Index (WORC), American Shoulder Elbow

71

Surgeons Score (ASES), Single Assessment Numeric Eval-

uation (SANE), Shoulder Disability Questionnaire (SDQ),
(PRP- ctrl)

University of California Los Angeles (UCLA) Shoulder

30–30

39–36

28–44

48–49

17–21

Score, Simple Shoulder Test (SST), and SPADI measure-

Pts

ment tools. The results were conflicting: eight studies (9

arms) reported better results for the PRP group (5 studies
Australia
Country

vs CS, and 1 study vs SH, saline, physical therapy, and dry

Brazil

USA

Italy
UK

needling, respectively), although in some cases the results

were better only in the short-term (2 studies, both vs CS), in
Table 2  (continued)

Randelli et al. 2021

the long-term (1 study vs CS), or only in one of the multiple

Walsh et al., 2018

Snow et al., 2020

First author, year

Ebert et al. 2017

Malavolta et al.

functional scores used (1 study vs CS). Four studies showed

no difference between PRP and the control groups (2 studies
vs CS, 1 study vs placebo and 1 vs saline), and three stud-
2018

ies found better results in the control groups (1 vs exercise,

13
Knee Surgery, Sports Traumatology, Arthroscopy (2023) 31:1940–1952 1947
Fig. 3  World distribution of the published paper, divided for countries, with a distinction between surgical and conservative studies
1 vs prolotherapy, and 1 vs CS), although the study vs CS
reported better results only in the short-term. With regard
to the range of motion (ROM), in one study no difference
was found (vs CS), in one study the results were better in
the control group only in some domains (vs exercise), and
in two studies the results were better in the control groups
(vs prolotherapy and vs physical therapy).
Results of surgically treated patients
Of the 20 studies presenting surgically-treated patients
included in the review, 19 studies were suitable for the meta-
analysis. The two studies with the same cohort of patients
were treated as a single study, as stated above. The outcome
measures were: Constant score (10 studies), UCLA score (6
studies), VAS (6 studies), SST (5 studies), and retear rate
after arthroscopic repair (17 studies). A meta-analysis on
covariates, such as the specific rotator cuff tendon involved,
leukocyte-rich/poor PRP and the use of different formula-
tions (gel, injection), was not feasible since too few studies
provided the necessary data.
Constant score: Both the patients who received PRP in
addition to arthroscopic tendon repair as well as the control
group reported a significant improvement at the short-term
follow-up (weighted mean difference -WMD 30.0, 95% CI
20.5–39.5, p < 0.001, and WMD 28.1, 95% CI 19.5–36.7,
p < 0.001, respectively) and the long-term follow-up (WMD
37.1, 95% CI 27.4–46.8, p < 0.001, and WMD 37.5, 95% CI
24.8–50.3, p < 0.001, respectively). No difference was noted
between PRP and the control group either at the short-term
or the long-term follow-up (n.s.).
UCLA score: Both the patients who received PRP in
addition to arthroscopic tendon repair as well as the control
group reported a significant improvement at the short-term
follow-up (WMD 18.8, 95% CI 12.2–25.4, p < 0.001, and
WMD 18.8, 95% CI 12.2–25.4, p < 0.001). No difference
was noted between PRP and the control group (n.s.).
VAS: Both the patients who received PRP in addition
to arthroscopic tendon repair as well as the control group
reported a significant improvement at the short-term follow-
up (WMD -4.5, 95% CI -6.4 – -2.6, p < 0.001, and WMD
-4.1, 95% CI -5.8 – -2.4, p < 0.001) and the long-term fol-
low-up (WMD − 4.9, 95% CI − 6.8–− 3.1, p < 0.001, and
WMD − 4.8, 95% CI − 6.5–− 3.1, p < 0.001, respectively).
No difference was noted between PRP and the control group
either at the short-term or the long-term follow-up (n.s.).
SST score: Both the patients who received PRP in addi-
tion to arthroscopic tendon repair as well as the control
group reported a significant improvement at the short-term
follow-up (WMD 5.6, 95% CI 4.5–6.8, p < 0.001, and WMD
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1948
5.8, 95% CI 5.0–6.5, p < 0.001, respectively). No difference
was noted between PRP and the control group (n.s.).
Retear rate: The mean follow-up of the studies evaluat-
ing the retear rate was 25.9 ± 28.8 months, and the mini-
mum was four months. The patients who received PRP had
a retear rate of 6.8% ± 1.6% (95% CI 3.6%—9.9%), while
in the control group the retear rate was 13.5% ± 2.6% (95%
CI 8.5%—18.6%). A statistically-significant difference
(p < 0.001) was documented between the two groups favour-
ing PRP augmentation (Fig. 4).
Risk of bias and quality of evidence
According to the modified CMS tool, the quality of the studies
ranged from 70 to 94 points, (83.5 ± 4.9 in the surgical studies
and 77 ± 2.1 in the conservative studies), thus the overall qual-
ity was judged as moderate to high (Table 1—Conservative
Studies, Table 2—Surgical Studies). All studies reported a
clearly-stated aim and appropriate end-points, while the major-
ity were poor from the perspective of an unbiased assessment
Fig. 4  Forest Plot of the retear rate, with the statistical presentation of
the meta-analysis
13
Knee Surgery, Sports Traumatology, Arthroscopy (2023) 31:1940–1952
of the study end-point and a prospective calculation of the
study size. Comparing surgical and conservative studies, the
former scored better in the study size and follow-up duration.
With regard to the risk of bias, the RoB 2.0 tool reported that
13 studies (36.1% of all studies: 50.0% of the surgical and
18.8% of the conservative studies) were to be considered at
“low risk of bias”, 14 studies (38.9% of all studies: 25.0% of
the surgical and 50.0% of the conservative studies) with “some
concerns for bias”, and 9 studies (25.0% of all studies: 25.0%
of the surgical and 31.2% of the conservative studies) at “high
risk of bias” (See Fig. 5 and 6 for more details.
Discussion
The main finding of this systematic review and meta-analysis
is that the augmentation of PRP during arthroscopic repair
procedures for rotator cuff disorders reduces the retear rate
Fig. 5  Risk of Bias of the surgical studies (on the left) where "−"
indicates a high risk of bias, "+" indicates a low risk of bias, and "?"
indicates an unclear risk of bias
Knee Surgery, Sports Traumatology, Arthroscopy (2023) 31:1940–1952 1949
Fig. 6  Risk of Bias of the conservative studies (on the right), assessed
through the Cochrane Collaboration Risk of Bias 2.0 tool
compared to surgical approaches alone, although no ben-
efits were documented in terms of clinical outcomes. The
literature analysis also underlined an increased application
of PRP in conservative management. However, there is a
high heterogeneity in the conservative use of PRP for rotator
cuff disorders, and no clear advantages were found in terms
of pain relief, function improvement, and imaging findings
or range of movement (ROM) for PRP-treated patients.
Considerable effort has been focused on the improve-
ment of rotator cuff disorders treatment strategies in the
last decades, with the aim of reducing pain and optimis-
ing the outcome. In light of this, increasing attention has
been dedicated to regenerative medicine, whose purpose is
to improve the healing potential of tendons and stimulate
tissue regeneration [45]. Of all the orthobiologic options,
this is particularly true for PRP, thanks to the ease of its
use and its unique composition [24, 24]. Nowadays, PRP is
increasingly being applied in clinical practice for rotator cuff
disorders. The current systematic review and meta-analysis
summarise the evidence of PRP potential for rotator cuff
disorders available by investigating both its surgical and
conservative applications.
For the “surgical augmentation studies” [6, 10, 12, 14,
15, 17, 22, 23, 32, 33, 37, 39, 40, 42, 49, 57, 58, 60, 62,
63], all the RCTs included in the meta-analysis found that
the addition of PRP to the surgical procedure (arthroscopic
rotator cuff repair) led to a statistically-significant functional
improvement at the short- and medium-long follow-up com-
pared to the baseline, without achieving better results than
the control groups for any of the retrieved scores. It is to
be noted that in all but one of the retrieved studies [14],
the control group was standard arthroscopic repair without
the addition of any other therapy, thus the controls were
homogeneous. These results support the previous literature
analysis of Cai et al. [5], while they are in contrast with the
meta-analysis of Chen et al. [8]. The reason for this apparent
incoherency is to be found in the smaller number of studies
and patients included in the previous review, and in the fact
that Chen et al. [8] attempted the analysis also when only
two or three studies were available, thus resulting in poorly
reliable results. Moreover, also the results of Chen et al. [8]
did not fully support the superiority of PRP for functional
outcomes, since they found no difference in terms of the
ASES score. They also concluded that although they found a
statistically-significant difference, none of the analysed stud-
ies highlighted a clinically-significant difference between
PRP and the control groups. The analysis of Chen et al. [8],
as well as the one performed by Hurley et al. [18], also sug-
gested a short-term benefit of PRP in terms of pain improve-
ment. However, as for functional outcomes, these analyses
included a lower number of studies and patients. The current
meta-analysis on a larger number of studies did not con-
firm this effect. Moreover, the previously-published works
[8, 18] mainly reported pain improvement in the short-term
only, which further questions the benefit of PRP use as a
pain reliever compared to other less expensive solutions (i.e.
standard pain killers or other conservative strategies).
The meta-analysis on the application of PRP during sur-
gery may call the previously-suggested clinical benefits of
PRP augmentation into question, but it provides solid evi-
dence on the positive effect of another important outcome of
rotator cuff surgery: PRP can reduce the risk of retear after
arthroscopic repair. On a large dataset, this result confirms
previous literature findings, suggesting a lower retear rate for
PRP-treated patients [4, 8, 18]. This result could lead to a
lower re-admission rate and risk of failure, although the cor-
relation between retear and clinical outcome after surgery is
elusive. Moreover, the cost-effectiveness of using PRP only
to reduce retears is questionable and ought to be analysed
by a thorough cost-effectiveness analysis, since the work of
Vavken et al. [56] demonstrated that PRP treatment, despite
its biological effects on tendon healing, at its current cost,
is not cost-effective in the arthroscopic repair of small- and
medium-sized tears. Further studies should clarify the real
13

1950
implications of the documented lower retear rate in terms
of long-term clinical benefit when managing these patients.
The application of PRP in conservative studies was also
studied. In this case, a meta-analysis was not feasible due to
the high heterogeneity of the included studies, nonetheless
important findings could still be highlighted. With regard
to functional outcomes, the majority of the retrieved stud-
ies reported conflicting results, with several advocating sig-
nificant improvement over control (sometimes for just a few
months), while others denied such a finding [2, 19, 25, 35,
43, 46]. These results are in line with the review of Lin et al.
[31], but are in contrast with the results of Xiang et al. [61],
who concluded in favour of statistical and clinical improve-
ments in pain and function within 6 months of follow-up.
However, they also concluded by saying that the effect may
not last for longer. More importantly, the high heterogene-
ity of the studies questions the reliability of combining the
different findings, which could lead to misleading conclu-
sions. Further RCTs are needed, since the conservative stud-
ies available are not comparable, not only due to the differ-
ent scores used but also due to the different therapies used
as control groups. Clearly, comparing PRP with exercise
therapy, which is one of the standard treatments recognised
as being more effective for rotator cuff tendinopathy [50],
is different from comparing it to sham or saline injections.
The lack of adequate negative controls precludes the abil-
ity to conclude whether improvements were due to natural
disease evolution or non-operative PRP treatments. Further-
more, different conservative treatments, as well as follow-up
times and evaluation methods, all concur to the lack of clear
evidence on the potential and limitations of PRP applied for
rotator cuff disease treated conservatively.
The present work included only RCTs to ensure studies
of the highest quality possible, but there are still limitations,
nevertheless. Besides the aforementioned heterogeneity of
the control groups, the PRP formulations and kits used were
also highly heterogeneous, as the market provides numerous
possibilities in terms of activating systems, platelet counts,
white blood cells, growth factors, PRP volume, and injection
schedules. It would be of interest to perform a compara-
tive analysis on leukocyte-rich vs. leukocyte-poor PRP, a
debated aspect in the field [1], but the heterogeneity of the
included studies made such an analysis impossible. Moreo-
ver, many studies did not even include the characteristics of
the injected products, which is in contrast with recent recom-
mendations in this field, which strongly support the need to
document the properties of the delivered platelet concentrate
[27]. In addition, the types of patients and lesions differed,
and also in this case it was impossible to perform a sub-
analysis with the data available. Finally, less than 15% of
the included studies used non-injective PRP solutions (gel or
membrane), thus hindering the possibility of comparing dif-
ferent administration methods. Therefore, even though there
13
Knee Surgery, Sports Traumatology, Arthroscopy (2023) 31:1940–1952
are many studies in the literature addressing PRP use, each
type of application is supported by limited data. Future high-
level studies should explore specific products and delivery
methods, as well as different patient and lesion types, which
may benefit more from PRP use for rotator cuff disorders.
Conclusions
This systematic review and meta-analysis showed that
the use of PRP as an augmentation in rotator cuff repair
significantly reduces the retear rate, although no benefits
were documented in terms of clinical outcomes, either at
the short- or at medium/long-term follow-up. Moreover,
despite the increasing interest in the conservative treatment
of rotator cuff disorders, no clear advantages were shown
in favour of PRP injection. While there are many studies in
literature with several RCTs of moderate to high quality, the
high heterogeneity of the products and studies used remains
a significant limitation to fully understanding PRP potential
in this field.
Funding  No outside funding or grants directly related to the present
manuscript
Declarations 
Conflict of interest  The authors declare that there is no disclosure for
all the authors except for Dr. Menon and Prof. Randelli.
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