Elsevier

Journal of Ultrasound

Volume 15, Issue 4, December 2012, Pages 260-266
Journal of Ultrasound

Ultrasound-guided injection of platelet-rich plasma in chronic Achilles and patellar tendinopathy

https://doi.org/10.1016/j.jus.2012.09.006Get rights and content

Abstract

Purpose

The efficacy of platelet-rich plasma (PRP) in the treatment and healing of chronic tendinopathy through stimulation of cell proliferation and total collagen production has been demonstrated by both in vitro and in vivo studies. The aim of this study is to evaluate the effectiveness of ultrasound (US)-guided autologous PRP injections in patellar and Achilles tendinopathy.

Materials and methods

Autologous PRP was injected under US-guidance into the Achilles and patellar tendons (30 Achilles tendons, 28 patellar tendons) in 48 prospectively selected patients (30 males, 18 females, mean age 38 ± 16 years, range 20–61 years). All patients were previously evaluated according to the Victoria Institute of Sport Assessment (VISA) scale, which assessed pain and activity level, and they all underwent US of the tendon before treatment and at follow-up after 20 days and 6 months. Statistical analysis was performed with Chi-square and Wilcoxon tests.

Results

20 days after PRP injection the patients presented a non-significant improvement of clinical symptoms. At the 6-month follow-up VISA score increased from a mean value of 57–75.5 (p < .01). US evaluation revealed a reduction of hypoechoic areas in 26 tendons (p < .01) associated with a widespread improvement of fibrillar echotexture of the tendon and reduced hypervascularity at power Doppler.

Conclusion

PRP injection in patellar and Achilles tendinopathy results in a significant and lasting improvement of clinical symptoms and leads to recovery of the tendon matrix potentially helping to prevent degenerative lesions. US-guidance allows PRP injection into the tendon with great accuracy.

Sommario

Scopo

Il plasma ricco di piastrine (PRP), provocando un iperafflusso di citochine nel sito di iniezione si è dimostrato efficace, sia in vitro che in studi clinici in vivo, come promotore della rigenerazione tissutale.

Lo scopo di questo studio è quello di valutare l’efficacia dell’iniezione ecoguidata di PRP autologo nel trattamento delle tendinopatie croniche del rotuleo e dell’achilleo.

Materiali e metodi

Il PRP autologo è stato iniettato sotto guida ecografica in tendini rotulei e achillei (30 tendini di Achille, 28 tendini rotulei) di 48 pazienti selezionati in modo prospettico (30 maschi, 18 femmine, età media 38 ± 16 anni, range 20–61 anni). Tutti i pazienti erano stati precedentemente valutati mediante questionario Victoria Institute of Sport di valutazione (VISA) in cui si analizza il punteggio del dolore e il livello di attività.

È stata poi eseguita una valutazione ecografica dei tendini mirata a valutarne l’ecostruttura e vascolarizzazione. La valutazione statistica dei dati ottenuti è stata eseguita mediante i test del Chi-quadrato e di Wilcoxon.

Risultati

Venti giorni dopo l’iniezione di PRP è stato rilevato un miglioramento dei sintomi clinici non significativo. Il punteggio VISA è migliorato da una base di 57 a 75,5 a 6 mesi (p < .01). La valutazione ecografica ha rilevato una riduzione delle aree ipoecogene tendinee in 26 tendini a 6 mesi (p < 0,01) con un generale miglioramento dell’ecostruttura fibrillare tendinea e riduzione dell’ipervascolarizzazione al power Doppler.

Conclusione

La terapia infiltrativa con PRP per il trattamento della tendinopatia rotulea e achillea si è rivelata efficace, determinando un miglioramento significativo e duraturo dei sintomi clinici e permettendo un recupero della fisiologica struttura tendinea. La guida ecografica permette inoltre di iniettare il PRP all'interno del tendine con elevata precisione.

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)

  • L.G. Josza et al.

    Human tendons. anatomy, physiology, and pathology

    (1997)
  • J.L. Cook et al.

    Prospective imaging study of asymptomatic patellar tendinopathy in elite junior basketball players

    J Ultrasound Med

    (2000)
  • J.A. Kettunen et al.

    Long-term prognosis for jumper’s knee in male athletes: a prospective follow-up study

    Am J Sports Med

    (2002)
  • D. Kader et al.

    Achilles tendinopathy: some aspects of basic science and clinical management

    Br J Sports Med

    (2002)
  • L.M. Sconfienza et al.

    Sonoelastography in the evaluation of painful achilles tendon in amateur athletes

    Clin Exp Rheumatol

    (2010)
  • M. Paavola et al.

    Long-term prognosis of patients with achilles tendinopathy. An observational 8-year follow-up study

    Am J Sports Med

    (2000)
  • K.H. Peers et al.

    Patellar tendinopathy in athletes: current diagnostic and therapeutic recommendations

    Sport Med

    (2005)
  • R.J. de Vos et al.

    Autologous growth factor injections in chronic tendinopathy: a systematic review

    Br Med Bull

    (2010)
  • E. Anitua et al.

    Autologus platelets as a source of proteins for healing and tissue regeneration

    Thromb Haemost

    (2004)
  • P.A. Everts et al.

    Is the use of autologous platelet-rich plasma gels in gynecologic, cardiac, and general, reconstructive surgery beneficial?

    Curr Pharm Biotechnol

    (2012)
  • U. Sheth et al.

    Efficacy of autologous platelet-rich plasma use for orthopaedic indications: a meta-analysis

    J Bone Jt Surg Am

    (2012)
  • Y. Sariguney et al.

    Effect of platelet-rich plasma on peripheral nerve regeneration

    J Reconstr Microsurg

    (2008)
  • M. Magra et al.

    Nonsteroidal antiinflammatory drugs in tendinopathy: friend or foe

    Clin J Sport Med

    (2006)
  • M. Sànchez et al.

    Plasma rich in growth factors to treat an articular cartilage avulsion: a case report

    Med Sci Sports Exerc

    (2003)
  • J.M. Robinson et al.

    The VISA-A questionnaire: a valid and reliable index of the clinical severity of achilles tendinopathy

    Br J Sports Med

    (2001)
  • Cited by (98)

    • PRP ankle and foot injections

      2024, Revue du Rhumatisme (Edition Francaise)
    • The use of PRP in treatment of Achilles Tendinopathy: A systematic review of literature. Study design: Systematic review of literature

      2020, Annals of Medicine and Surgery
      Citation 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).

    View all citing articles on Scopus

    Oral communication prize winner at the 23rd SIUMB Congress in Rome 2011.

    View full text