Despite its long provenance back to the early Greek and Roman physicians [
6] Sports Medicine is a relative newcomer to the professionalisation of western medicine [
44]. Moreover, established members of the sports medicine and leading international bodies consistently underwrite their activities as being “evidence-based”. Yet we have noted above the problems for PRP in this regard. Consider, then, the following remarks of one clinician at a leading club. He makes reference to a controversial and indeed notorious (amongst many sports medicine practitioners) treatment undertaken by a practitioner in Belgrade, Mariana Kocavecic, apparently a trained pharmacologist, who provided treatments using a gel incorporating material from horse placenta. Several high- profile players are known to have availed themselves of her services. The clinician indicates the kind of latitude he is prepared to accede in order to secure a speedy return to play:
So, to be honest, if there was somebody next door who was doing horse placenta and the player insisted on it, as long as it wasn’t doing any harm I personally wouldn’t have any problem with it. The simple reason for that is if the player is that fixed in their head that’s always going to be at the back of their mind “oh yeah, but if I had the horse placenta…” So, to try and rationalise it to them and to try and explain to them would be very difficult (Participant 14, Sports physician).
Set against such latitude one could expect few qualms about PRP use. The general evidence-based criticism of PRP may be thought of, in effect, as a criticism of the field more generally. A more pointed criticism came from another surgeon/researcher who remarked:
We did a cohort study which we thought demonstrated that there was possibly some efficacy of doing blood injections for patellar tendinopathy and there have been quite a few papers written on the subject of blood and PRP since. And there’s a lot of papers that don’t show much benefit as I’m sure you’re aware […], but it got to the point where PRP was being injected into everything. I’d heard surgeons from Spain saying they just put it in the knee after surgery. Well, isn’t there quite a lot of blood in the knee? […] So there’s an awful lot of snake oil out there, and I’m quite cynical about it. I resist getting trapped into this sort of arms race that you see particularly in elite sport. I think elite sport almost drives it to some extent (Participant 25, Orthopaedic Surgeon).
The notion that clinicians in the field of sports medicine are engaged in a kind of competition to return athletes to play, coming as it does from a recognised figure, will be troubling to the professional bodies in the field. Yet it is far from clear that it applies in the case of PRP. It is of the utmost importance to note that most of the participants in our study were all well aware of the lack of robust evidence base for PRP. Their use of it was not naive, nor did they think it was some miracle cure. Their rationales varied, however, from the need to control the treatment of their players, to a paternalist concern for athlete welfare, and even the notion that the use of PRP was (akin to) a placebo “treatment”. Here is one very experienced leading football doctor talking of the need for control:
If I have a player and I am offering him a treatment for something which is a problem that he has, in some respects, what it does is it stops him going and getting a treatment from somewhere else because he hasn’t been offered it by me. And I would rather control the degree of mismanagement (Participant 23, Sports Physician).
One can think then, that this is a carefully thought out harm minimisation strategy. In an attempt both to explain and justify PRP against the evidentiary background this physiotherapist remarked about the need to prevent players from seeking alternative treatments and/or places of treatment where the interventions sought might jeopardise player welfare:
What we use these placebo things for is […] to buy ourselves the healing time that we know we need. If I don’t do anything for the player they become frustrated […] It is unacceptable treatment in the eyes of the athlete, in the agents, and everyone else. They will go and seek alternative treatments with that. So, we will then lose. Under the control situation we will do something and […] the mainstay that we tend to do is PRP […] I can’t be having players, behind my back, going to these places, I want to control it. So, we brought it in-house. We sent [our sports physicians] to get the training […] to look at the literature to discuss the various techniques and how we are doing it and what we are doing with it. So, we try to follow as much evidence-based as we can and we’re using the PRP because we consider it safe. We haven’t had any adverse reactions in our knees or any of those issues with it [Participant 11, Sports Physiotherapist].
A joint rationale can be constructed thus: we can control the use of PRP ‘in house’, and it is safe, even if we are uncertain as to its efficacy. This rationale is set against a multitude of players going to (at least) two very well-known surgeons in Germany and Spain. The latter, Dr Ramon Cugat, was referred to in interviews colloquially as the ‘Godfather of PRP’. The former, Dr Hans Wilhelm Muller Wolfhart, gained considerable exposure as the head of sports medicine for Bayern Munich, and also the German national football team (along with many other high profile stars from other sports). But the justification for control is extended into harm
prevention territory:
I tell you what it’s really done, it’s done a couple of things for us. We will use it in the knee joint, for example. So, the player stops asking for anti-inflammatories because we tell him it’s pointless doing the two because they are going to work against each other. So, suddenly, this dependency and this absolute crush on having to have them, this culture of just pumping, stops. We’ve cut down our anti-inflammatory usage by, it must be, about two thirds, completely gone. So this pre-match “give me an anti-inflammatory, gimme, gimme” has gone (Participant 11, Sports Physiotherapist).
These remarks rendered the most complex justification for the use of PRP. Elements of this rationale were offered by many of the clinical participants in the study in a less sophisticated form. It is multi-layered. It can be analysed under five categories: control of patient care; harm/risk minimisation; player/agent emollient; deceptive; paternalistic. That indeed is a casuistic, though some might argue astute, management of the clinical encounter. Set against player and agent agitation and ignorance, the clinician seeks to achieve the shared outcome—optimal return to play, while managing risks. It is not, in ethical terms however, respectful of autonomy since it represents a level of deception, or at least a lack of full information, for the player-patient. Should this trouble us?
The idea that where a treatment is perceived as being successful it will actively facilitate better patient outcomes—whether objectively or not—is referred to by several other sports medicine professionals, such as this physiotherapist lead of a club’s sports medicine department. But he links it to some ‘shady’ commercial practices by sports medicine companies:
And the players bring them in because they will get tapped up by a company who say “we’ll give you 10 grand [i.e. £10 000], you go and tell all the other guys because we need two or three and once we’ve got that then it will just spiral out, the kids will want them, everyone will want them.” So, fortunately, I’m quite conservative, traditional in that sense rather than I’d like something that’s got more evidence base to it than that. […],if your player really believes in the process of what’s going on, I think the outcomes of that procedure are a lot better and your compliance is a lot better (Participant 11, Sports Physiotherapist).
Now it is clear for many medical interventions that the “buy-in” from the patient to the treatment and their subsequent compliance with rehabilitation protocols is a major factor in successful outcomes. Several participants referred to the use of PRP as if it were a placebo (given their lack of confidence in its efficacy, or their awareness of the patchy evidence base), or where what was enhancing recovery was a “placebo effect” brought about by the patient’s belief system. When pushed on this point, one of the most senior of the medical team participants in terms of experience and status remarked:
That’s where the art of medicine comes in […] we have patients with overload injuries or they are over-trained, maybe, and you’d like to take them out for three months and that’s a lifetime for them. Then, you have to put on something that you do to avert their attention and to get them to do something other than their usual use […] I think this goes on in every aspect of medicine, I think because there are so many things that we think we know but we don’t’ know […] Any clinician will use placebo as part of their medication, so to speak. Any experienced physician (Participant 10, Sports Surgeon).
This is the most explicit defense of PRP as placebo by any of our participants. And this highly regarded clinician expresses a view that the doctor legitimately may deceive the athlete patient in order to arrive at the shared outcome. Nevertheless, questions are raised regarding the extent to which the autonomy of the patient is being bypassed in order to achieve the best outcomes for them. This merits further exploration, beyond the scope of the paper.