Ultrasound-guided injection of platelet-rich plasma in chronic Achilles and patellar tendinopathy☆
Introduction
Chronic musculoskeletal diseases are the most common cause of severe long-term pain and physical disability [1]. Patellar tendinopathy (a degeneration of the tendon enthesis caused by a repetitive and/or chronic overloading that exceeds the adaptive capacity of the tendon) and Achilles tendinopathy (a degenerative tendinous disorder that commonly involves the hypovascular area located from 2 to 6 cm above the calcaneal insertion) are commonly considered the result of multiple micro-tears that do not heal because of poor tendon vascularity [2], [3]. Histological features in the early stages of the disease are focal areas of asymptomatic intratendineous damage without signs of inflammation [4], [5]. Histological appearance of degenerative damage begins and progresses long before onset of symptoms. This delay causes late therapeutic approaches to be less successful [6], [7]. Patellar tendinopathy, in which degeneration is located at the proximal enthesis, is also known as jumper's knee. This disease mostly affects young athletes and is associated with running, jumping, soccer, and volleyball [5]. Prevalence has been estimated to approx. 40%–50% among professional volleyball players and 35%–40% among basketball players. Some intrinsic factors (e.g. gender, age and overweight) and extrinsic factors (e.g. functional overload and training errors) play an important role in the development of chronic tendinopathy [5], [6], [7], [8], [9].
Achilles tendinopathy is a common condition in the adult population. In 59% of patients it is related to sports activities, and 53% of them are runners [10], [11]. At present, patients affected by jumper's knee and Achilles tendinopathy are primarily treated with rest, ice packs, physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs) and steroid injections, although there is no evidence of the effectiveness of these therapies [10], [11], [12], [13].
New theories of tendon regeneration have been focused on the role of platelets and the development of different therapeutic strategies in the treatment of chronic tendinopathy [14]. Platelets are involved in the mechanism of thrombus formation and participate in the healing process by removing necrotic tissues and stimulating regeneration and healing of the tissues [15], [16]. Platelet-rich plasma (PRP) with a high concentration of platelets has been used in cardiac, maxillofacial, plastic, neuro, and orthopedic surgery [17], [18], [19]. More recently, PRP injections have been used to treat muscle, tendon, and cartilage injuries [20], [21].
In this preliminary study, we evaluated the effectiveness of ultrasound (US)-guided intratendineous administration of PRP to treat jumper's knee and Achilles tendinopathy in a population of young athletes.
Section snippets
Patients
Institutional Review Board approval and patients' informed consent were obtained.
A total of 28 patellar tendons in 24 patients (14 men, 10 women) and 30 Achilles tendons in 24 patients (16 men, 8 women) were prospectively evaluated. Patients affected by patellar tendinopathy (group 1) were aged between 21 and 56 years (mean age 37.4 years), while the age of patients affected by Achilles tendinopathy (group 2) ranged from 20 to 61 years (mean age 38.6 years). All patients practiced sports at the
Results
No peri- and post-procedural complications were observed.
Discussion
Patellar tendinopathy and Achilles tendinopathy are common conditions in elite and amateur athletes as a result of overuse during sports activity. In both cases, repetitive overloading of the tendon stimulates the local release of cytokines resulting in an impaired reparative process [26], [27], [28].
Several treating options are available for these conditions [4], [29]. Physiotherapy and steroid injections have proved to have no long-term efficacy [30], [31]. Shock waves may be effective but
Conclusions
The present study shows that US-guided treatment of jumper's knee and Achilles tendinopathy using PRP is feasible as it is an effective and minimally invasive treatment option. Further randomized controlled studies performed on a larger sample size are warranted to confirm these preliminary results.
Conflict of interest
The authors have no conflict of interest to declare.
References (50)
- et al.
Effects of administration of trasforming growth factor (TGF)-beta1 and anti-TGF-beta1 antibody on the mechanical properties of the stress-shielded patellar tendon
J Biomech
(2006) - et al.
The VISA score: an index of severity of symptoms in patients with jumper's knee (patellar tendinosis). Victorian Institute of Sport Tendon Study Group
J Sci Med Sport
(1998) - et al.
Autologous preparations rich in growth factors promote proliferation and induce VEGF and HGF productions by human tendon cells in culture
J Orthop Res
(2005) - et al.
Platelet-rich plasma: new clinical application: a pilot study for treatment of jumper’s knee
Injury
(2009) - et al.
Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States
Arthritis Rheum
(1998) - et al.
Patellar tendon ultrasonography in asymptomatic active athletes reveals hypoechoic regions: a study of 320 tendons. Victorian Institute of Sport Tendon Study Group
Clin J Sport Med
(1998) - et al.
Quantitative assessment of blood vessels of the human achilles tendon: an immunohistochemical cadaver study
Arch Orthop Trauma Surg
(2003) - et al.
Achilles tendinopathy: aetiology and management
J R Soc Med
(2004) - et al.
Performance characteristics of volleyball players with patellar tendinopathy
Am J Sports Med
(2003) - et al.
Mid-portion achilles tendinopathy: why painful? An evidence-based philosophy
Knee Surg Sports Traumatol Arthrosc
(2011)
Human tendons. anatomy, physiology, and pathology
Prospective imaging study of asymptomatic patellar tendinopathy in elite junior basketball players
J Ultrasound Med
Long-term prognosis for jumper’s knee in male athletes: a prospective follow-up study
Am J Sports Med
Achilles tendinopathy: some aspects of basic science and clinical management
Br J Sports Med
Sonoelastography in the evaluation of painful achilles tendon in amateur athletes
Clin Exp Rheumatol
Long-term prognosis of patients with achilles tendinopathy. An observational 8-year follow-up study
Am J Sports Med
Patellar tendinopathy in athletes: current diagnostic and therapeutic recommendations
Sport Med
Autologous growth factor injections in chronic tendinopathy: a systematic review
Br Med Bull
Autologus platelets as a source of proteins for healing and tissue regeneration
Thromb Haemost
Is the use of autologous platelet-rich plasma gels in gynecologic, cardiac, and general, reconstructive surgery beneficial?
Curr Pharm Biotechnol
Efficacy of autologous platelet-rich plasma use for orthopaedic indications: a meta-analysis
J Bone Jt Surg Am
Effect of platelet-rich plasma on peripheral nerve regeneration
J Reconstr Microsurg
Nonsteroidal antiinflammatory drugs in tendinopathy: friend or foe
Clin J Sport Med
Plasma rich in growth factors to treat an articular cartilage avulsion: a case report
Med Sci Sports Exerc
The VISA-A questionnaire: a valid and reliable index of the clinical severity of achilles tendinopathy
Br J Sports Med
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2020, Annals of Medicine and SurgeryCitation Excerpt :The VISA-A score following PRP usage was substantially higher compared to research using intense eccentric calf training (Murphy et al., 2019 [20]) and thus PRP can be a more successful treatment. Comparing outcome results from the radiological evaluation showed some changes in the thickness of tendon with decrease vascularity as reported by (Boesen et al., 2017 [9]; de Vos et al., 2010 [12]; De Jonge et al., [13] and Ferrero et al., 2012 [17]). Despite this, work by Albano et al., 2017 [8] and Krogh et al., 2016 [11] which showed a slight increase in tendon thickness after 3 months follow up (Table 3).
Challenges and opportunities of medicines for treating tendon inflammation and fibrosis: A comprehensive and mechanistic review
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Oral communication prize winner at the 23rd SIUMB Congress in Rome 2011.