Physical Therapy After PRP Injection

Physical therapists delve into the science of healing every single day. PT services are often helpful adjuncts to medical healing techniques such as tendon repair, cortisone injections, joint replacement, etc. When it comes to platelet-rich plasma (PRP) injections and other regenerative medicine techniques, it’s still a relatively new and exciting frontier with varied opinions. You can learn more about the details of PRP and see our Q&A with Dr. Carl Balog, MD CLICK HERE.

In short, PRP is a portion of your own blood plasma that is highly concentrated with platelets using a centrifuge. It is then injected into injured musculoskeletal tissue (tendons, muscles, joints, ligaments) in order to speed healing by kicking the body’s natural processes into overdrive. This plays right into our goal as PTs: the body’s optimal healing and performance.

So, how can we help?

The brief answer is that research hasn’t caught up enough to give us a bulletproof formula, but we have a good idea of what direction we’re going. PTs have been treating these same conditions for decades, controlling inflammation, strengthening tissues, improving mobility, and decreasing pain. Perhaps most importantly, PTs work with each individual to customize a program that suits them best.

There are only a few studies exploring the use of PRP in conjunction with PT, and only a few more looking at PRP vs. PT for specific conditions. Here’s a rundown of some recent research, followed by the special considerations PTs need to make for patients post-PRP injection. (if you’d like to avoid the dry research summary, skip ahead to “REHAB CONSIDERATIONS”)

PRP AND Physical Therapy

• 2013 case-series concluding PT after PRP injection for patellar tendinopathy is promising and feasible.¹
• 2014 study showing that a single PRP injection combined with a rehab program was more successful than the rehab program alone.²
• 2015 case study showing PRP injection, manual therapy, and exercise were successful in treating a professional hockey player with inguinal disruption (sports hernia), returning him to action in 3.5 weeks. 4-8 weeks is a more typical return to sport timeline.³
• 2015 trial showing no benefit for a single PRP injection vs intensive physical therapy for acute hamstring injuries.⁴
• 2014 trial showing PRP injection with eccentric exercise and dry needling was superior to eccentric exercise and dry needling alone for patellar tendinopathy, but the positive effects dissipated over time.⁵
• 2010 trial showing no difference between PRP and saline injections in those with chronic Achilles tendinopathy that were all also treated with eccentric exercise.⁶

PRP VS Physical Therapy

• 2015 trial on patients with chronic partial supraspinatus tears. Those that underwent PT had greater ROM and pain improvements than those with PRP injections. However, those with PRP injections showed greater functional improvement on a questionnaire.⁷
• 2015 trial showed that PRP injection was safe and effective for short-term treatment of knee osteoarthritis symptoms. It was more effective than exercise and TENS for some outcomes.⁸

There are other studies showing that PRP injections can have positive effects on things like ROM, pain, and increase growth factors in the blood.^9,10 These are positive effects that could potentially help improve a patient’s tolerance to PT treatment. There is also a systematic review from 2012 that takes into account multiple studies and determines that throughout the literature, PRP has been shown to be safe when applied properly.¹¹ When considering that most research studies have their limitations and this is still an emerging research area, it is important to keep in mind that detail.

REHAB CONSIDERATIONS

In short, PRP and PT are still a promising combo, we are just waiting for the research community to give us a definitive verdict on an effective formula and the conditions that will benefit.

Beyond the research above, here are some considerations for post-PRP injection physical therapy, consolidated from several sources with experience.^{12, 13, 14, 15} As with most conditions, each physician may have differing preferences and protocols from what is listed below.

• Weeks 1-2: Rest or immobilization of the injured tissue. Minimal stress ROM activities may be permitted.
• Week 2-3: PT treatment begins 2-3x per week. Start with light exercise, including eccentric exercises for tendon injuries. Isometrics, passive stretching, and modalities. High repetitions and low/no resistance. It is important to stress the injured tissue in a controlled manner in order to stimulate further healing. Begin cycling (bike, arm cycle, elliptical) or other minimal impact cardio exercises.
• Weeks 3-6: Progress exercise program gradually in order to avoid re-injuring the tissue. Pain is used as a guide for exercise progression and pushing through pain is not advised. By 6 weeks, patient will hopefully have attained full strength, no pain with typical activities, full ROM, and appropriate proprioception (balance, control of the limb).
• Weeks 6+: Your physician will monitor your healing and indicate if further injections are needed. Once the tissue is healed, your physical therapist will help facilitate a program that helps you return to sport or your typical functions. This program will consist of strengthening, sport/job specific movements, training for neuromuscular control, stability, and addressing any other factors that may be risks for re-injury. Work in multiple planes with increased resistance and repetition. Work toward dynamic neuromuscular control and functional/sport-specific activities. Increase velocity and impact gradually.

Stride Strong Physical Therapy is on the forefront of research in this area. We are here to help you answer any of your questions about PRP injections and subsequent physical therapy.

By: Dr. John Paul Fairhart, PT, DPT

1. Ark MV, Akker-Scheek IVD, Meijer L, Zwerver J. An exercise-based physical therapy program for patients with patellar tendinopathy after platelet-rich plasma injection. Physical Therapy in Sport. 2013;14(2):124-130.
2. Hamid MSA, Ali MRM, Yusof A, George J, Lee LPC. Platelet-Rich Plasma Injections for the Treatment of Hamstring Injuries. The American Journal of Sports Medicine. 2014;42(10):2410-2418.
3. St Onge E, MacIntyre IG, Galea AM. Multidisciplinary approach to non-surgical management of inguinal disruption in a professional hockey player treated with platelet-rich plasma, manual therapy and exercise: a case report. J Can Chiropr Assoc. 2015;59(4):390-7.
4. Hamilton B, Tol JL, Almusa E, et al. Platelet-rich plasma does not enhance return to play in hamstring injuries: a randomised controlled trial. British Journal of Sports Medicine. 2015;49(14):943-950.
5. Dragoo JL, Wasterlain AS, Braun HJ, et al. Platelet-rich plasma as a treatment for patellar tendinopathy: a double-blind, randomized controlled trial. Am J Sports Med. 2014 Mar;42(3):610-8.
6. de Vos RJ,Weir A,van Schie HT, et al. Platelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial. JAMA. 2010 Jan 13;303(2):144-9.
7. Ilhanli I, Guder N, Gul M. Platelet-Rich Plasma Treatment With Physical Therapy in Chronic Partial Supraspinatus Tears. Iranian Red Crescent Medical Journal. 2015;17(9).
8. Angoorani H, Mazaherinezhad A, Marjomaki O, Younespour S. Treatment of knee osteoarthritis with platelet-rich plasma in comparison with transcutaneous electrical nerve stimulation plus exercise: a randomized clinical trial. Med J Islam Repub Iran. 2015 Jun 27;29:223.
9. Hamilton B, Tol JL, Knez W, Chalabi H. Exercise and the platelet activator calcium chloride both influence the growth factor content of platelet-rich plasma (PRP): overlooked biochemical factors that could influence PRP treatment. British Journal of Sports Medicine. 2013;49(14):957-960.
10. Li F-X, Li Y, Qiao C-W, Zhu J, Chen J, Zhang P-Y. Topical use of platelet-rich plasma can improve the clinical outcomes after total knee arthroplasty: A systematic review and meta-analysis of 1316 patients. International Journal of Surgery. 2017;38:109-116.
11. Ziltener JL, Allet L, Sclison P, Grosclaude M (2012) How Effective are Injections of Platelet-Rich Plasma (PRP) for the Treatment of Sports Injuries: a Critical Review of the Literature. J Sport Medic Doping Studies. 2:003.
12. Description of a standardized rehabilitation program based on sub-maximal eccentric following a platelet-rich plasma infiltration for jumper’s knee
13. platelet-rich plasma rehabilitation guidelines
14. Platelet Rich Plasma Post Treatment Instructions