Ross Hauser, MD, Danielle Matias, PA-C, Demi Foster, APRN
- PRP treatment takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets from your blood into your knee.
- Your blood platelets contain growth and healing factors. When concentrated through simple centrifuging, your blood plasma becomes “rich” in healing factors, thus the name Platelet RICH plasma.
- Platelet-Rich Plasma (PRP) and cortisone injections are both used to treat knee osteoarthritis, but they are different treatment methods. Cortisone (or steroid) acts as an anti-inflammatory and can give quick, short-term relief. PRP can provide long-lasting pain relief and helps improve function. The research is below.
A January 2024 paper in the journal Annals of Medicine and Surgery (1) reviewed the data of 42 research trials involving 3696 patients. The finding suggests that “PRP is an effective treatment for knee osteoarthritis when compared with hyaluronic acid, corticosteroid and placebo.”
What the researchers here in this paper was to offer a suggestion that PRP could be an alternative to cortisone. They write: “The recent evidence based clinical practice guidelines from the American Academy of Orthopaedic Surgeons (AAOS) on appropriate use criteria for the management of knee osteoarthritis provided treatment recommendations for specific patient scenarios. In the majority of cases, PRP was rated as “Rarely Appropriate,” while intra-articular corticosteroid was considered ‘Appropriate.’
In an effort to provide symptomatic relief and postpone surgery, intra-articular corticosteroid injections are frequently prescribed prior to secondary care referral (Surgical recommendation.) While these injections have shown temporary improvement in pain scores among osteoarthritic patients, they are also associated with side effects. Thus, our findings have the potential to provide valuable decision support in favor of PRP for the development of future guidelines.”
Two groups of patients, one group gets PRP for knee pain the other group gets cortisone for knee pain. How did this comparison work out?
In this study from The Journal of Sports Medicine and Physical Fitness, (2) a comparison is made between the effects of a one-time injection of PRP and corticosteroid (a cortisone shot) for the patients suffering from osteoarthritis.
- Patients suffering from Grade II or Grade III knee osteoarthritis were randomly divided into two groups: intraarticular injection of PRP and cortisone.
- Forty-one participants (48 knees) were involved in the research (66.7% women, with an average age of 61).
Compared to the group treated with corticosteroid, PRP showed significant results for:
- pain relief
- being symptom-free
- activities of daily living and quality of life
This study demonstrated that one shot of PRP injection, decreased joint pain more and longer-term, alleviated the symptoms and enhanced the activity of daily living and quality of life in short-term duration in comparison with the corticosteroid.
In an October 2020 study (3) also comparing PRP and corticosteroid, similar findings were recorded. PRP results were better over time and the lack of side-effects should be considered if debating between one treatment or the other.
- PRP is a concentrated platelet solution made with autologous (your own) blood, it is a safe treatment for clinical use.
- Studies have shown that the intra-articular administration of PRP can increase the quality of life even after 1 year of treatment.
- In this study, the researchers found “more significant values for improvement in comparison with corticosteroids, especially in the long-term (180 days).”
- Both PRP and corticosteroid improved the functional and pain status in 30 and 180 days, but patients who had the PRP treatment showed a greater pain improvement.
- The PRP group showed a reduction in pain and better functional status functional at 180 days after treatment.
The Platelet-Rich Plasma group showed the lowest radiographic progression (of knee degeneration) at 52 weeks of follow-up.
Doctors writing in the journal Clinical rehabilitation (4) published an April 2022 double blinded randomized controlled trial comparison study in which they assessed the one year effectiveness of one injection of platelet-rich plasma, one injection of triamcinolone hexacetonide, or one injection of saline solution injection in patients knee osteoarthritis.
Using various questionnaires to measure outcomes in pain reduction, functional increases, stiffness and quality of life, the researchers found one injection of Triamcinolone Hexacetonide was superior in the percentage of improvement in pain, function and stiffness, the Platelet-Rich Plasma patients had superior results to the Saline group. The Platelet-Rich Plasma group showed the lowest radiographic progression at 52 weeks of follow-up. What the researchers suggest is that MRI imaging at the beginning of the one year period and at the end of the one year period showed the PRP injection people had less progression of their knee osteoarthritis.
Short-term results vs. Long-term-results
A September 2022 paper in the journal Cureus (5) showed results of a double-blind randomized controlled trial including 29 patients (58 knees) with radiologically confirmed mild-to-moderate bilateral knee osteoarthritis. The patients were divided randomly to receive an intra-articular PRP injection into one knee and a methylprednisolone injection with a local anesthetic into the contralateral knee. Their results: “Corticosteroids and PRP were both effective in improving pain, stiffness, and function at all time points, before the treatment and at six weeks, three months, and six months, with maximal improvements at six weeks and three months. PRP scored slightly better than steroid injections at six months; nevertheless, there was no statistically significant difference between corticosteroids and PRP injections.”
A February 2023 paper in the Annals of medicine and surgery (6) suggests “PRP and corticosteroid intra-articular injections both are safe and effective treatments in knee osteoarthritis for alleviating pain, and improving symptoms. It seems that PRP injections have prolonged and shown better improvement in some studies. However, the results do not prefer one method over the other.”
A July 2020 study in the Journal of orthopaedic surgery and research (7) found “a single PRP or corticosteroid intra-articular injections is safe and improves the short-term scores of pain and the knee function in patients affected by mild to moderate symptomatic knee OA (with no significant differences between the groups). PRP demonstrated a statistically significant improvement over corticosteroid in a 1-year follow-up.”
Cortisone is a one-shot treatment, PRP should not be given the same way. This is when PRP does not work for knee pain.
In the above research, we see that many people get a benefit from PRP treatment. One of the challenges doctors have with patients is that the patent thinks PRP is just like cortisone and the relief they want should be immediate. PRP is NOT just like cortisone. Cortisone has an immediate pain-reducing effect for many people, not all, because it is reducing pain brought on by chronic inflammation. Nothing is being healed. PRP brings healing through inflammation. When tissue is repaired, the inflammation goes away. Please read below for a direct comparison of cortisone injection and PRP and the PRP time frame of healing. You will see cortisone is short-term, PRP is long-term. Cortisone will eventually suppress the body’s natural healing mechanism and send you to knee replacement. PRP will rebuild and repair tissue in the knee and help you avoid a knee replacement or arthroscopic surgery.
The difference in the side-effects. PRP has little risk of side effects, cortisone greater chance of side effects.
A December 2020 study in the medical journal Radiology (8) offered “Considerations and Controversies,” in the offering of cortisone injections for patients with knee osteoarthritis. The considerations and controversies in part surrounded the known side-effects of cortisone injections. Here is what the researchers wrote:
“Current management of osteoarthritis is primarily focused on symptom control. Intra-articular corticosteroid injections are often used for pain management of hip and knee osteoarthritis in patients who have not responded to oral or topical analgesics.
Recent case series suggested that negative structural outcomes including accelerated osteoarthritis progression, subchondral insufficiency fracture, (stress fractures in the bone below the cartilage in the weight-bearing bones of the shin) complications of pre-existing osteonecrosis, and rapid joint destruction (including bone loss) may be observed in patients who received intra-articular corticosteroid injections.”
What these researchers were looking for was if there was a way that MRI or other imaging could predict which patients would be more prone to these side effects so they could avoid getting the cortisone injection. What they found was:
“As of today, there is no established recommendation or consensus regarding imaging, clinical, or laboratory markers before an intra-articular corticosteroid injection to screen for osteoarthritis-related imaging abnormalities.
Repeating radiographs before each subsequent intra-articular corticosteroid injection remains controversial. The true cause and natural history of these complications are unclear and require further study.“
In other words, it is currently too difficult to determine with imaging, who would be more prone to these side effects.
Comparisons of PRP, Cortisone and Hyaluronic Acid
A May 2022 paper published in the Journal of clinical medicine (9) evaluated the Platelet Rich Plasma (PRP) injections for safety and effectiveness in patients affected by knee osteoarthritis. The researchers noted that PRP has shown promising results in achieving pain reduction and better function in these patients.
In this study, one hundred and fifty-three patients from 40-81 years old received three consecutive PRP injections. The patients were then followed up to determine if the treatment helped them. The patients were evaluated before PRP injection, at one month, three months and six months after the treatment.
Results: A statistically significant functional ability and pain reduction was seen during the course of the study. While MRI demonstrated non-statistically significant improvement in cartilage thickness for both tibial plate and femoral plate and no radiographic changes could be seen in any patients.
The researchers concluded that the results of their study highlight that PRP injections represent a useful conservative treatment to reduce pain, improve quality of life and functional scores at the midterm of 6 months follow-up in patients with knee osteoarthritis. Patients with knee osteoarthrosis who received PRP intra-articular injections had the best overall success when compared to steroids, hyaluronic acid, and placebo at 3, 6, and 12-month follow-ups. All the scores referring to stiffness and physical functional showed an improvement overtime, agreeing with a previous study which pointed out a decrease in disability and an increase in the function total score, suggesting a positive influence of the treatment. “The results confirm the efficacy of the PRP injections (for knee osteoarthritis), also suggesting that decreasing pain was obtained already after one month after injection with best results observed after 6 months.
A March 2023 study in the journal Medicine (10) compared the data from 16 randomized controlled trials with a total of 1652 patients. Platelet-rich plasma (PRP) injection therapy had the highest likelihood of being the best intervention in reducing pain, stiffness, and improving function. In the VAS (0 – 10 Pain assessment) score group, PRP outperformed hyaluronic acid and corticosteroids. PRP also outperformed corticosteroids, ozone, and PRP + hyaluronic acid in self-reported symptom alleviation scores.
A March 2022 study in The American journal of sports medicine (11) comes from a combined effort of doctors at the Albert Einstein Hospital in Brazil and the Department of Orthopaedic Surgery, University of Pittsburgh Medical Center. In this paper forty previously published medical reviews with 3035 participants were included to assess the comparisons of PRP with hyaluronic acid, corticosteroid, and saline. The doctors believed that these injections are the most relevant comparisons with the most studies available.
- At six-month follow-up, PRP was as effective as and in some studies more effective than other therapies regarding pain, function, and stiffness. However, current evidence is of low or very low quality and is based on trials with high risk of bias and great heterogeneity (differences in how the studies were conducted) among them. No significant difference among treatments was found concerning major adverse events and treatment failure.
- Conclusion: “Although studies suggest that PRP may be more effective than or at least as effective as other modalities of nonsurgical treatment for knee osteoarthritis in terms of pain, function, and adverse events, serious limitations and methodological flaws are considerable in the current literature. Therefore, the authors are not able to make recommendations for clinical practice regarding PRP for knee osteoarthritis.”
In a study published in the American medical journal Arthroscopy, (12) medical university researchers suggested that PRP injections were more effective in the treatment of knee osteoarthritis, in terms of pain relief and self-reported function improvement at three, six, and twelve months follow-up, compared with other injection treatments. In this study, data was examined from 10 randomized controlled trials with a total of 1069 patients. The analysis showed that at 6 months post-injection, PRP and hyaluronic acid (HA) had similar effects with respect to pain relief and functional improvement. At 12 months post-injection, however, PRP was associated with significantly better pain relief and functional improvement than hyaluronic acid.
More articles
Other articles
Platelet Rich Plasma for Knee Osteoarthritis: When it works, when it does not work
References
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