Platelet-Rich Plasma as an Adjunct to Rehabilitation for Partial Rotator Cuff Tears in Recreational Athletes: A Comparative Study

Introduction

Rotator cuff tears (RCTs), which are responsible for up to 40% of shoulder joint disorders, are frequently linked to discomfort and a reduction in physical activity ^[1,2]. Patients diagnosed with rotator cuff tendinopathy suffer from a significant deterioration in their quality of life owing to functional limitation, decreased range of motion, and an inability to perform several actions that require overhead motions ^[3]. Among athletes, prevalence rates of RCTs have been reported to be as high as 40% in the dominant shoulder ^[4]. In a study highlighting the burden of the disease in athletes, rotator cuff-related injuries accounted for 39% of gradual onset shoulder pain, of which 59% resulted in time loss from sport ^[5]. Furthermore, it has been reported that the incidence of RCTs is higher in throwing athletes, with tears involving the articular portion of the tendon ^[6]. Based on their extent, these tears are classified into two categories: Full-thickness tears and partial-thickness tears ^[7,8,9]. Partial-thickness RCTs (PTRCTs) are a frequent type of shoulder injury, affecting around 4% of people under 40 years old, 26% of those over 60, and 20% of the general asymptomatic population ^[10]. The treatment of choice for younger individuals with acute symptomatic partial or full-thickness injuries that cause significant functional impairment is often surgical intervention. Conversely, conservative management is generally advised for the treatment of cases that involve partial injuries or tendon degeneration that affects <50% of the tendon thickness ^[8,9,11,12]. These techniques encompass corticosteroid injections, non-steroidal anti-inflammatory drugs, pain relief medications, activity modification, and physical therapy (PT) ^[12,13,14]. Surgical intervention is typically warranted in patients who do not respond to conservative treatment after 3–6 months and in younger individuals with complete traumatic tears. Numerous systematic reviews in recent years have established the efficacy of PT in the treatment of rotator cuff diseases ^{[15,16,17,18]}. Alongside PT intended to alleviate symptoms, numerous invasive techniques have also been studied as an adjunct ^[19]. Over the previous two decades, there has been a growing interest in biological treatments that augment the repair and function of wounded tendons and muscles, as well as provide better pain relief. The utilization of platelet-rich plasma (PRP), an autologous blood product that is obtained by centrifuging a patient’s own blood to obtain a concentrated number of platelets, is one such approach ^[20]. PRP is identified by its platelet concentration, which surpasses the body’s typical physiological levels. Inflammation, angiogenesis, cell proliferation, and stem cell migration are among the numerous biological processes in which platelets are critically involved ^[21]. As platelets release growth factors that promote tissue repair and regeneration, these mechanisms are essential for the initiation of tissue healing ^[22,23]. Tendons typically have an inadequate blood supply, which prevents the torn or degenerated tissues from receiving the necessary nutrients to facilitate repair. Consequently, their regeneration capacity is restricted. The injured site is supplied with restorative growth factors through PRP injection, which are challenging to access due to inadequate blood supply ^[24]. Over the past decade, there has been a growing body of evidence examining the efficacy of PRP in improving structural healing and clinical outcomes in RCTs. However, to our knowledge, no study has specifically evaluated its impact on return-to-sport (RTS) rates in recreational athletes, which remains a critical gap in the literature. The present study aimed to compare the outcomes of two treatment approaches – PT alone versus PRP combined with PT – in patients with traumatic partial RCTs over a 6-month follow-up. In addition, we sought to document and compare RTS rates between the two treatment groups.

Materials and Methods

Results

The demographic analysis showed no significant differences in gender or age between the groups, ensuring unbiased outcomes. Gender distribution was similar, with 28.6% females and 71.4% males in the Control group, compared to 24.2% females and 75.8% males in the PRP group (P = 0.702). The average age was slightly higher in the Control group (38.71 ± 7.13 years) than in the PRP group (36.87 ± 7.49 years), but this difference was not significant (P = 0.334) (Table 2).

<H3>Before intervention

• The Shapiro–Wilk test at baseline for the two groups revealed that the QuickDASH score for PRP+PT, the ASES score for the PT and PRP+PT groups, and the Constant score for PT and PRP+PT showed normal distribution. The QuickDASH score for PRP+PT, VAS score for PT, and PRP+PT groups showed non-parametric distribution (Table 3).

• Pre-intervention between-group analysis revealed that the mean ASES and Constant scores in the PT group were significantly greater than in the PRP+PT group, indicating the PT group had better shoulder function and improved ability to perform daily activities (Table 3).

• The Mann–Whitney test revealed that the median QuickDASH and VAS scores before intervention were significantly higher in the PRP+PT group than in the PT group, indicating greater functional disability and higher pain levels at baseline among patients in the PRP+PT group (Table 4).

Discussion

PTRCTs are complex problems in athletes and are multifactorial, more so in a throwing athlete, where the act of overhead throwing may place a significant amount of stress on the glenohumeral joint, requiring the rotator cuff muscles to overcome these forces to stabilize the glenohumeral joint ^[25]. The management of PTRCTs in athletes remains controversial, particularly during the competitive season, when surgical repair can result in substantial time lost from sport ^[26]. PRP has emerged as a promising treatment option for musculoskeletal disorders in recent years; however, there is still no consensus on its optimal application in the management of rotator cuff pathology. Most studies on the treatment of PTRCTs have explained surgical techniques or outcomes; few studies have evaluated the clinical outcomes and RTS rates of two commonly employed management strategies for PTRCTs: Rehabilitation alone and rehabilitation combined with orthobiologicals. In the present study, we intended to evaluate the efficacy of adding PRP to a standardized rehabilitation program when compared to exclusive rehabilitation for treatment of PTRCT. We observed notable differences in outcomes between the PT group and the PRP+PT group. We found that PRP injections combined with PT outperformed exclusive PT in improving shoulder function, reducing disability, and alleviating pain in patients with traumatic partial RCTs. Furthermore, the PRP+PT group demonstrated higher rates of return to sport compared with the PT group, thereby strengthening the evidence for PRP as a valuable adjunct in the treatment of athletes with RCTs.

The study revealed that the PRP+PT group demonstrated significantly better outcomes compared to the PT group across multiple measures. It was noted that 6 months after the intervention, the QuickDASH scores were significantly lower in the PRP+PT group when compared to the PT group after adjustment for baseline values, reflecting superior gains in shoulder function, reduction in pain during daily activities, and improved ability to perform overhead and sport-related tasks. Similarly, after adjusting for baseline values, ASES scores showed a more pronounced improvement in the PRP+PT group, indicating greater recovery of shoulder function even though this group started with lower baseline scores when compared to the PT group. In terms of CMSs, after adjusting for baseline values, the PRP+PT group demonstrated greater improvements in pain relief, strength, and range of motion, underscoring superior functional recovery compared to the PT group. However, VAS scores did not show a statistically significant difference between the two groups after adjustment for baseline values, possibly because pain intensity is a more subjective measure with limited sensitivity to change, and functional improvements achieved through PRP and rehabilitation may not always parallel reductions in perceived pain. These findings collectively underscore the enhanced effectiveness of PRP injections combined with physiotherapy in improving shoulder function and alleviating pain.

The group receiving the PRP injections with PT exhibited significantly worse baseline scores (QuickDASH, ASES, and Constant-Murley) when compared to the group receiving PT. This aligns with the findings by Ilhanli et al., who emphasized the use of PRP for patients with chronic partial supraspinatus tears, a population often presenting with more severe baseline symptoms. This suggests that PRP may be particularly useful for patients with more significant functional deficits ^[27].

The PRP+PT group showed significantly greater improvements in functionality measures such as QuickDASH, ASES, and CMSs, indicating that PRP injections enhance the effectiveness of PT. These findings align with the conclusions of Rha et al., who found PRP to be safe and effective in improving shoulder function ^[28]. Similarly, Cai et al. demonstrated that PRP in combination with sodium hyaluronate produced superior clinical outcomes compared to either treatment alone, supporting the idea of combined approaches leading to enhanced recovery ^[29].

The greater improvement in CMSs (pain, strength, and range of motion) in the PRP+PT group also reflects findings from Sari and Eroglu (2020), who observed that PRP outperformed corticosteroid injections in enhancing rotator cuff lesion recovery ^[30].

Both groups demonstrated a reduction in VAS scores over the follow-up period, but improvement was not statistically significant (P = 0.568). This result contrasts with findings from Ibrahim et al., who reported superior pain relief with PRP compared to corticosteroids and may suggest variability in outcomes based on patient populations or methodological differences ^[31]. Furthermore, Mautner et al. found that 75% of patients showed VAS pain score improvement, with 95% reporting no pain at rest and 68% no pain during activities ^[32], consistent with the findings of Ibrahim et al. Similarly, Wesner et al. also confirmed significant improvements in pain and disability in PRP-treated patients ^[33]. The lack of a significant difference in VAS scores between the groups may be attributed to the fact that all participants underwent structured physiotherapy, which is known to provide substantial pain relief in rotator cuff–related injuries. This finding underscores that rehabilitation remains the cornerstone of first-line management in partial RCTs, with biologic adjuncts such as PRP potentially offering additional benefits in functional recovery and return to sport rather than in pain relief alone.

Adding PRP to standard rehabilitation may represent a valuable option for athletes with partial RCTs, particularly during the competitive season when surgical management could result in substantial time loss from sport ^[26]. From an ethical and anti-doping standpoint, the use of PRP is permitted in sports; however, the administration of isolated growth factors in concentrated form is prohibited ^[34]. Physicians should remain mindful of this distinction. In this context, PRP provides sports medicine practitioners with a safe and legitimate adjunctive tool for managing PTRCTs in athletes. Importantly, our study demonstrated higher RTS rates in the PRP+PT group compared to the PT-only group, reinforcing the potential role of PRP as an adjunctive therapy. Collectively, these findings highlight the clinical relevance of incorporating PRP into rehabilitation strategies, particularly for athletes seeking timely return to play.

We acknowledge the limitations in our study. A key concern is that group allocation was based on patient preference rather than randomization, which introduces the possibility of selection bias into the research. However, our primary intention was to compare the outcomes of two available treatment options in a real-world clinical setting. Randomizing participants would have required withholding their choice of treatment, which could pose an ethical dilemma, particularly in athletes making decisions about their careers and RTS timelines. Second, long-term follow-up was not conducted, limiting our ability to assess the durability of functional improvements and RTS outcomes beyond 6 months. Future studies should incorporate objective imaging modalities and extended follow-up periods to better understand the efficacy of PRP treatment, particularly among athletes, and to evaluate its impact on tendon healing and sustained RTS performance.

Conclusion

Autologous PRP injections for the treatment of rotator cuff disease are safe, and combining PRP injections with PT is more effective in improving strength, shoulder function, reducing disability, and allowing greater return-to-sport rates when compared to exclusive PT, in young patients with partial RCTs. These results support the use of PRP as a valuable adjunct to PT in the treatment of partial RCTs.

Clinical Message

In young recreational athletes with partial RCTs, PRP used as an adjunct to a structured rehabilitation program may improve shoulder function and increase RTS rates compared with rehabilitation alone. PRP can therefore be considered a useful non-operative treatment option for athletes seeking to optimize recovery and return to sporting activity.

References

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About the Authors

• 

  Ayyappan V Nair

• 

  Shishir Mysore

• 

  Aravind Rajan

• 

  Harikanth Reddy

• 

  M Priyamvada

• 

  Prince Shanavas Khan