Your PRP Didn’t Work. Now What?

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Platelet rich plasma, or PRP, is becoming well known these days, with many professional athletes using it to return to play faster and with many weekend warriors following their lead. But for some, there is either an early impression that the PRP injection didn’t work, or their PRP actually fails to help resolve the problem. Why does this happen and what’s next?

What Is PRP?

PRP stands for platelet rich plasma. This is a concentrate of the patient’s own blood platelets in their own serum (1). Platelets are fragments of cells that clot the blood and then release helpful growth factors to stimulate repair. You can think of PRP like concentrated espresso shots for the local cells to kick them into gear.

The first thing to understand is that few physicians possess the technical expertise to prepare PRP manually in their offices (every Regenexx Network Provider does). Hence, most doctors purchase automated centrifuges to reduce complexity and costs. These are push button machines that utilizer kits that the doctor buys. What this typically means is that all the doctors know about the PRP is where to put the kit and where the “On” button is located on the machine.

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What Are the Types of PRP Injections?

Believe it or not, there are many types of PRP out there. From the patient’s perspective, this falls into three categories (2):

  1. Red PRP: This is literally red in color and often concentrated to lower levels. This is the first type of PRP available with many of the older machines sold to doctors. It’s rich in white blood cells, so it generally causes more inflammation and reaction when injected (3). Many doctors believe that red PRP may be less effective for most orthopedic applications because of these extra white blood cells. Having said that, there may be a few conditions where red PRP is the best way to go (4).
  2. Lower Concentration Amber PRP: This is amber in color and concentrated to lower levels (fewer platelets). This is a newer PRP type that is usually poor in red and white blood cells. This is also called “Pure PRP.” This causes less of a tissue reaction and less swelling when injected (3). Many doctors consider this type to be ideal for injecting into tendons and ligaments.
  3. Higher Concentration Amber PRP: This is also amber, but with more platelets. Few automated machines that doctors purchase can produce this higher concentration amber PRP, so this type is less common. Our research has shown that this type of PRP is ideal in joints and is best used to treat arthritis (5).

What Are PRP Injections Used to Treat?

  1. Tendinopathy: irritated and degenerated tendons (6)
  2. Small tendon or ligament tears (7)
  3. Arthritis: a joint that has begun to lose cartilage and develop bone spurs (8)

Why Does PRP Fail?

In our extensive clinical experience, sometimes PRP shots are just a bad fit for the problem being treated. For example, PRP can produce great results when used to treat mild knee arthritis, but can often fail when used to treat moderate or severe arthritis.

For the latter more severe variety, we’ve noticed that better results can be obtained with high concentration amber PRP or stem cells. Other problems that may be too severe for PRP include bigger tendon or ligament tears. These again may respond to stem cell injections. If they’re massive tears, they may require surgery.

Another reason PRP may fail is due to the wrong type used for the problem. Regrettably, once a doctor makes an investment in a specific automated machine that produces a specific PRP type, that’s all he or she usually has to use.

However, the broad scope of patient problems aren’t one sized fits all. For example, older patients have less potent platelets and may need much higher concentrations injected. Another example is that red PRP may not be the best fit for problems like knee arthritis (9). Regenexx providers can custom tailor PRP preparations to best match the patient and the condition.

PRP failure may also result from a doctor who is inexperienced in using the technology. For example, many physicians who inject toxic anesthetics like Marcaine/Bupivicaine, or harmful high dose steroids, may continue to use these noxious drug chemicals with PRP, counteracting much of its healing effects.

Lastly, PRP should only be injected under imaging guidance like ultrasound and/or fluoroscopy to ensure that the platelets are getting to the exact spots where they’re needed. Unfortunately, many older physicians and surgeons have never been trained in the proper use of guidance technologies, leaving them to perform blind injections that are likely to miss the mark.

The upshot? PRP is great stuff and it usually works well when the right type is used for the right problem. However, like any medical technology, it can fail. If PRP didn’t work for you, see if you might need a different type, a more experienced provider, or another technology that packs more punch, like the Regenexx patented stem cell protocol.



(1) Alsousou J, Thompson M, Hulley P, Noble A, Willett K.. The biology of platelet-rich plasma and its application in trauma and orthopaedic surgery. J Bone Joint Surg Br. 2009 Aug;91(8):987-96. doi:10.1302/0301-620X.91B8.22546

(2) Mautner K, Malanga GA, Smith J, Shiple B, Ibrahim V, Sampson S, Bowen JE. A call for a standard classification system for future biologic research: the rationale for new PRP nomenclature. PM R. 2015 Apr;7(4 Suppl):S53-S59. doi:10.1016/j.pmrj.2015.02.005

(3) Braun HJ, Kim HJ, Chu CR, Dragoo JL. The effect of platelet-rich plasma formulations and blood products on human synoviocytes: implications for intra-articular injury and therapy. Am J Sports Med. 2014;42(5):1204–1210. doi:10.1177/0363546514525593

(4) Yaşar Şirin D1, Yılmaz İ, İsyar M, Öznam K, Mahiroğulları M. Does leukocyte-poor or leukocyte-rich platelet-rich plasma applied with biopolymers have superiority to conventional platelet-rich plasma applications on chondrocyte proliferation? Eklem Hastalik Cerrahisi. 2017 Dec;28(3):142-51. doi:10.5606/ehc.2017.55186

(5) Berger DR, Centeno CJ, Steinmetz NJ. Platelet lysates from aged donors promote human tenocyte proliferation and migration in a concentration-dependent manner. Bone Joint Res. 2019;8(1):32–40. Published 2019 Feb 2. doi:10.1302/2046-3758.81.BJR-2018-0164.R1

(6) (13) Wang Y, Han C, Hao J, Ren Y, Wang J. Efficacy of platelet-rich plasma injections for treating Achilles tendonitis : Systematic review of high-quality randomized controlled trials. Orthopade. 2019 Sep;48(9):784-791. doi:10.1007/s00132-019-03711-y

(7) Sengodan VC, Kurian S, Ramasamy R. Treatment of Partial Rotator Cuff Tear with Ultrasound-guided Platelet-rich Plasma. J Clin Imaging Sci. 2017;7:32. Published 2017 Aug 14. doi:10.4103/jcis.JCIS_26_17

(8)Xing D, Wang B, Zhang W, Yang Z, Hou Y1,2, Chen Y, Lin J. Intra-articular platelet-rich plasma injections for knee osteoarthritis: An overview of systematic reviews and risk of bias considerations. Int J Rheum Dis. 2017 Nov;20(11):1612-1630. doi:10.1111/1756-185X.13233

(9) Riboh JC, Saltzman BM, Yanke AB, Fortier L, Cole BJ. Effect of Leukocyte Concentration on the Efficacy of Platelet-Rich Plasma in the Treatment of Knee Osteoarthritis. Am J Sports Med. 2016 Mar;44(3):792-800. doi:10.1177/0363546515580787

Chris Centeno, MD is a specialist in regenerative medicine and the new field of Interventional Orthopedics. Centeno pioneered orthopedic stem cell procedures in 2005 and is responsible for a large amount of the published research on stem cell use for orthopedic applications. View Profile

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NOTE: This blog post provides general information to help the reader better understand regenerative medicine, musculoskeletal health, and related subjects. All content provided in this blog, website, or any linked materials, including text, graphics, images, patient profiles, outcomes, and information, are not intended and should not be considered or used as a substitute for medical advice, diagnosis, or treatment. Please always consult with a professional and certified healthcare provider to discuss if a treatment is right for you.