MODERATE RECOMMENDATION One high-quality RCT (Paget 2023) compared two platelet-rich plasma (PRP) injections to saline with 12-month follow-up.13 Saline was superior to PRP at 1.5 months (AOFAS, VAS Pain), 3 and 6.5 months (EQ-5D QOL), and 12 months (patient satisfaction). No significant differences between PRP and saline for AOS Total, SF-36, FAOS subscales, or AAS Total at any time point. No sustained benefit of PRP through 12 months.
Benefits/Harms: No demonstrated benefit over saline. PRP requires blood draw and centrifugation (additional time/discomfort). Generally well-tolerated with no serious adverse events but creates false expectations given lack of efficacy.
Cost Effectiveness/Resource Utilization: PRP costs a patient an out-of-pocket expense of $500-1500+ per injection plus blood draw and preparation costs. Complete lack of efficacy versus placebo represents very poor resource utilization.
Acceptability: Despite popularity of "regenerative" treatments, ankle-specific evidence does not support use. High out-of-pocket cost limits accessibility. Patients should be counseled that high-quality evidence demonstrates no benefit over placebo.
Feasibility: Requires specialized equipment and technical expertise, increasingly available but feasibility does not override lack of efficacy.
Future Research: Investigation of specific PRP formulations (leukocyte-rich vs. poor, concentration levels), patient subgroups, different injection protocols, mechanistic studies, economic analyses, comparison to other treatments, and longer-term outcomes.