AOSSM/AANA Specialty Day 2020-Biologics for the Cuff – What Does the Highest-Level Evidence Say

Biologics for the Cuff – What Does the Highest-Level Evidence Say_

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Dr. Brian J. Cole presents a comprehensive review of orthobiologics for tendon injuries, focusing primarily on platelet-rich plasma (PRP) and mesenchymal stem cells (MSCs) in the treatment of rotator cuff repairs (RCR) and other tendinopathies. Tendon injuries are prevalent, with millions affected by rotator cuff tears and high re-tear rates after surgery due to scar formation rather than true enthesis regeneration.<br /><br />Basic science shows that leukocyte-poor PRP (LP-PRP) promotes collagen synthesis and reduces inflammatory cytokines better than leukocyte-rich PRP, potentially aiding degenerative tendon healing. However, clinical studies of PRP in RCR show mixed results, influenced by factors such as PRP type, application method (notably at tendon-bone interface), tear size, and repair technique (double row repairs fare better). Overall, PRP may improve functional outcomes and reduce re-tears when optimally applied.<br /><br />MSCs ("medicinal signaling cells") possess recruitment, anti-inflammatory, anti-scarring, and regenerative properties. Studies report reduced MSC numbers at the tendon-bone interface in symptomatic tears, suggesting biological augmentation with bone marrow concentrate (BMC) or adipose MSCs during RCR might enhance healing. Level III studies show significantly lower re-tear rates and improved MRI outcomes with BMC augmentation.<br /><br />PRP use extends beyond RCR: for lateral epicondylitis and UCL injuries, evidence suggests PRP provides functional improvement and is generally safe, though comparisons to corticosteroids, anesthetics, or other therapies yield varied results. Similarly, PRP for patellar tendinitis shows some pain relief but no clear superiority over placebo or rehabilitation.<br /><br />PRP's benefit in Achilles tendon injuries and ACL graft healing remains unproven. Emerging biologics like amniotic tissue show promise in plantar fasciitis but require further study.<br /><br />In conclusion, while robust clinical data on MSCs are limited, PRP can be considered as an adjunct in RCR (especially small/medium tears, double row repair, solid PRP matrix applied at tendon-bone interface), lateral epicondylitis, UCL injuries, and patellar tendinitis. Further high-quality research is needed to optimize protocols and confirm efficacy across tendon pathologies.

Keywords

orthobiologics

platelet-rich plasma

PRP

mesenchymal stem cells

MSCs

rotator cuff repair

tendinopathy

bone marrow concentrate

lateral epicondylitis

patellar tendinitis