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PRP may provide relief to patients with Achilles tendinopathy

Issue: September 2011

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KEYSTONE, Colo. — Platelet-rich plasma injection may be a viable option for patients with mid-portion Achilles tendinopathy who have failed conservative treatment, according to a presenter at the 2011 Annual Meeting of the American Orthopaedic Foot and Ankle Society.

“PRP [platelet-rich plasma] is a potential alternative to surgery for Achilles tendinopathy, but no definitive conclusions can be drawn at this time” Christopher D. Murawski, said during his presentation.

Retrospective review

Murawski and his colleagues retrospectively reviewed 32 patients with chronic mid-portion tendinopathy who underwent PRP injection between August 2009 and February 2010. The patients failed 3 months of conservative treatment that consisted of rest, physical therapy or bracing, according to the study abstract. Following injection, patients used a controlled ankle motion (CAM) walker for 2 weeks and underwent physical therapy with functional isometric training for 2 months.

The investigators assessed the patients using the Foot and Ankle Outcome Score (FAOS) before and after PRP injection, and patients completed SF-12 questionnaires 6 months after PRP injection. An MRI was taken of each patient pre-injection and at 6 months post-injection.

Correlations

The researchers found that the PRP injections were successful in treating Achilles tendinopathy, with 25 of 32 patients noting complete resolution of symptoms. In addition, the study showed that pre-injection foot and ankle scores improved from 51 points to 87 points at 6 months post-injection. The investigators discovered that pre-injection SF-12 scores increased from 68 points to 91 points. However, seven patients reported worsening symptoms and underwent surgery.

“There was no correlation between patient symptoms and either age or in the appearance of MRI,” Murawski said.

Because the post-injection MRI findings did not correlate with symptoms, Murawski warned, this could be “a harbinger for return of symptoms in the long run.”

“There is however compelling basic science evidence, including one study out of the University of Pittsburgh, to suggest that PRP may have a positive effect on tendon stem cells. We’re looking into this further with a prospective, randomized multi-center clinical trial,” Murawski said. In addition, the study showed no link between gender and patient outcomes.

“It is important to stress this is provisional data from a pilot study and that the randomized-controlled trial will provide evidence as to whether PRP should be used in treating Achilles tendinosis or not,” cautioned senior author John G. Kennedy, MD, FRCS (Orth). – by Renee Blisard

Reference:

• Murawski CD, Newman H, Kennedy JG. Platelet-rich plasma injection for the treatment of chronic mid-substance Achilles tendinopathy. Paper #19. Presented at the 2011 Annual Meeting of the American Orthopaedic Foot & Ankle Society. July 14-16. Keystone, Colo.

• John G. Kennedy, MD, FRCS (Orth), can be reached at the Hospital for Special Surgery, 523 E. 72nd St., New York, NY 10021; 646-797-8880; email: kennedyj@hss.edu.
• Disclosure: Murawski has no relevant financial disclosures.

Achilles tendinosis is a common orthopedic condition. Most cases of Achilles tendinosis resolve with conservative therapy as indicated in this study. The patients who do not respond to this initial treatment, around 25%, are a challenge to treat and may very well benefit from injection therapy.

It does seem reasonable that the increase in growth factor initiated by PRP may attract macrophages and fibroblasts, and help with the repair of damaged tissue. However, there is no science to indicate the exact quantity or number of injections that are required. Furthermore, since the pathopyhysiology of tendinosis is not fully understood, and improvement with injection therapy appears to improve with time, an MRI exam at 6 months post-injection may be arbitrary. The clinical improvement in this difficult group of patients is, however, impressive.

— Carol C. Frey, MD
Orthopedics Today Foot & Ankle Section Editor
Assistant Clinical Professor of Orthopedic Surgery
University of California Manhattan Beach, Calif.
Disclosure: She has no relevant financial disclosures.