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Three Part Question

In [Adult professional footballers]
IS [a rehabilitation programme plus PRP injection] BETTER THAN [a rehabilitation programme alone for a speedier return to play]?

Clinical Scenario

A 27 year old professional footballer sustains a structural right hamstring injury during a match. A visiting club official says that in his country, PRP injections are used to bring a quicker return to field based activities (including match play) in addition to a traditional rehabilitation protocol. You decide to find evidence to support his view.

Search Strategy

Cochrane database for systematic reviews
Medline
CINAHL
AMED

1.Hamstring
2.Muscle injury
3.Semimembranosis
4.Semitendinosis
5.Biceps femoris
6.Posterior thigh pain
7.1 OR 2 OR 3 OR 4 OR 5 OR 6
8.Rehabilitation
9.Exercise
10.Activity
11.Function
12.Physiotherapy
13.Physical therapy
14.8 OR 9 OR 10 OR 11 OR 12 OR 13
15.PRP injections
16.PRP
17.Platelet rich plasma
18.15 OR 15 OR 17
19.7 AND 14 AND 18
20.Limited to English Language
21.Limited to human species.

Search Outcome

14 papers were found.
2 were not RCTs
1 was a narrative review
1 was an animal study
1 was an RCT in 2016 but not on the hamstrings specifically.
9 papers were relevant to the 3 part question.
1 systematic review with meta-analysis had all previous studies included in its results.
There were no new studies since this review.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Pas HIMFL, Reurink G, Tol JL, Weir A, Winters M, Moan MH. 2015 Netherlands	10 RCTs (526 participants) with hamstring injury	systematic review with meta-analysis	1. Hazard Ratio (HR) for Return to Play	1. HR = 1.03 (95% CI 0.87 to 1.22; Z=0.35, p=0.73)	The quality of the RCTs reviewed range from fair to excellent using Downs and Black criteria. Of 10 included studies in this review, there were only two good or excellent quality RCTs with low risk of bias identified.
			2. HR for low risk of bias studies only	2. HR = 1.00 (95% CI 0.85 to 1.19), Z=0.04, p=0.97
			3. Relative Risk (RR) 6 months re injury	3. RR = 0.88 (95% CI 0.45 to 1.71, Z=0.39, p=0.70)

Comment(s)

The most recent systematic review published(Pas et al 2015) was an update of their 2012 paper. Since this review there had been an increase in good quality RCTs on PRP in acute hamstring injury. We have focused on studies which added PRP to a standard rehabilitation programme.

Clinical Bottom Line

Currently, there is no evidence that after an acute hamstring injury, adding a PRP injection to a lengthening and loading rehabilitation programme will quicken the return to play.

References

1. Pas HIMFL, Reurink G, Tol JL, Weir A, Winters M, Moan MH. Efficacy of rehabilitation (lengthening) exercises, platelet-rich plasma injections, and other conservative interventions in acute hamstring injuries: an updated systematic review and meta-analysis British Journal of Sports Medicine 2015;49: 1197-1205