KEN MAUTNER, MD EMORY SPORTS MEDICINE FEBRUARY 12, 2009 Tendon Injuries: New Treatments For an Old...

KEN MAUTNER, MDEMORY SPORTS

MEDICINEFEBRUARY 12, 2009

Tendon Injuries: New Treatments For an Old Problem

Tendon Injury – Terms

Tendinitis– Implying inflammatory

pathology

Tendinosis– Implying degenerative

pathology w/o inflammatory component

Tendinopathy– No implication for pathology

Tendon Structure

TropocollagenTriple Helix Structure

Tendon Analogy

The Tendinopathy Cycle

http://www.clinicalsportsmedicine.com/articles/common_tendinopathies.htm

Tendinosis

Microscopic– Collagen

degeneration– Fibrosis– Neovascularization– LACK of

inflammation

Normal

Tendinosis

J.D. Rees et al, Rheumatology May 2006

Traditional Treatments Rest Immobilization NSAIDS Physical Therapy/ biomechanics Possible CSI RTP when pain free/ functional

But is tissue healed?

If symptoms persist Surgery

What is ideal way to treat tendinopathy?

LACK OF EVIDENCE FOR TRADITIONAL TREATMENTS

Evolving algorithm Pathology specific conservative treatments

NSAIDS only if inflammatory Immobilization only if necessary Eccentrics exercises for tendinosis

Regenerative intervention Percutaneous needle tenotomy PRP PRP with adipose tissue BMAC Cultured stem cells

What is ideal way to treat tendinopathy?

TIMING OF INTERVENTION AND TYPE OF INTERVENTION NEEDS MORE EVIDENCE

Evolution of Regenerative Injections for treating chronic tendinopathy

Proliferative therapy (prolotherapy) was first described in the 1930’s and represents first form of regenerative medicine

Theory is that irritant solutions (most often dextrose) along with needling of soft tissues stimulates an inflammatory reaction which initiates a healing cascade for injured soft tissues.

This technique has been employed for chronic enthesopathies and ligamentous injuries/laxity.

Percutaneous Tenotomy (PNT)

Release of tissue by repetitive needling of a tendon insertion will induce inflammation, a release of growth factors which leads to fibroblast proliferation and ultimately healing

First use of PRP in US was in 1987 following open heart surgery

Periodontal and wound healing were early successful clinical applications of PRP

Benchwork research has clearly demonstrated proliferation of GF’s with supraphysiologic amount of platelets

Prior to human use, considerable use and success in Equine (horse) racing with tendon regeneration using PRP

Evolution of platelets for healing soft tissue injuries

Rapid growth of ultrasound use in MSK medicine

Ease of obtaining and using Platelets without the need for OR/ ASC

Unsuccessful traditional treatmentments of tendonopathy/chronic soft tissue injuries

Motivated patient population (athletes) that will do anything to get back sooner/ stronger

Early pilot studies/ case series showing remarkable success of procedure and the ability to “fix” an injury without surgery What’s the downside?

The “perfect storm” for clinical application of platelets in MSK injuries

Why Platelets?

Why do we need to concentrate platelets?

Studies have shown accelerated would healing requires at least 4x-5x platelet concentration

An exponential increase in cell proliferation occurs as platelet concentration increases from 2.5x to 5x-10x baseline levels

Much lower volume needed to get high levels of platelets to area

PRP Procedure

Tendon Healing

PRP for chronic lateral epicondylosis

Allan Mishra et al, AJSM, 2006140 pts evaluated for lateral epicondylosis20 had refractory pain an avg. of 15 months

later15 in treatment group, 5 in bupivicaine control

groupIntervention

– Injection w/ autologous PRP once into common extensor tendon followed by gradual increase in rehab program through 4 weeks after which full activity allowed

Outcome– A 46%, 60% and 81% improvement in VAS pain scores

at 1, 2 and 6 months respectively in tx group– 3/5 in bupivicaine group withdrew/ sought other tx– At final F/U (12-38 months) 93% pain free (<10/100

VAS)– No complications, no one got worse

PRP vs Steroid Injection for Lateral Epicondylitis

Peerbooms et al, AJSM, February 2010Double blind RCT with 1 year follow up

of 100 ptsNo Ultrasound guidance was usedSuccess defined as >25% reduction in

VAS or DASH scoreRESULTS

At 1 yr, 49% of CSI group and 73% in PRP group were successful (p<.001)

PRP lateral epicondylosis- Case #1

Long axis view Short axis view

BEFORE AFTER

Elbow case #1– 2.5 months later

Elbow PRP Case #2

BEFORE AFTER (3 months)

PRP for Achilles Tendinosis

de Vos et al, JAMA, January 13, 2010 First double blind, placebo controlled, RCT on PRP 54 randomized patients age 18 to 70 with chronic

(at least 2 mo) achilles tendon pain 2 to 7 cm above calcaneus

Either 6cc PRP or Saline was injected with US guidance into achilles tendon

Rehab for both groups involved rest and then after 2 weeks, started on 12 week daily (180 repetitions) eccentric exercise program

No sports for at least 4 weeks and then only if pain <=3/10

f/u qestionnaire at weeks 6,12,24


de Vos et al, JAMA, January 13, 2010 RESULTS

After 24 weeks, no statistical difference between the 2 groups

Both groups improved > 20 pts on VISA-A scores (0-100)

No adverse events in either group (ruptures/ infections)

CONCLUSIONS Both groups improved

Needle? Saline? Placebo? Eccentric Exercises? Only 1 treatment done Small Sample Size Eccentric exercises may have worsened outcomes

Certainly this confounded the results


Gaweda K et all . Treatment of Achilles Tendinopathy with Platelet-Rich Plasma, International J. of Sports Medicine, 2010

14 patients (15 tendons), prospective study Avg. 6 months symptoms (range 3-10 months) 3 cc PRP injected under US guidance Rehab –PWB x 3 days, PROM x 2 wks, then active ROM,

stretching from 2-6 wks, then >6wks, full load active exercises

Results Tendon thickness decreased in 13/15 tendons by 6 months Intrasubstance tears reduced from 11/15 to 1/15 at 6 mo.

Initial 6weeks 3 months 6 months 18 months

AOFAS 24 44 66 92 96

VISA-A 55 72 84 96 96

Longitudinal achilles Short axis achilles

Achilles Tendon Pain

BEFORE AFTER

Achilles PRP Injection8 months later

Preliminary Results of PRP Surveyfor chronic tendinopathyDATA COLLECTION STILL ONGOING

Multi-center study146 patients sent questionnaire (as of oct.

1) 94 responded (64%) 71/ 94 (76%) were isolated treatments for

tendinopathy 22/67 (33%) tendons received a 2nd PRP injection

(all within 4 months of the first injection)All retrospective data analyzed with

following questions: VAS score –pre and post Overall improvement

Not at all, slightly, moderately, mostly, completely Overall satisfaction

Distribution of tendons (responders only)

19 -- Common extensor tendon at lateral epicondyle

15 -- Patella Tendon10 – Rotator cuff6 – Gluteus medius/ minimus6 – Achilles tendons4 – Common flexor tendon at medial

epicondyle3 -- Hamstring

Pain Score pre and post PRPtendons only

Before PRP6+ months post

PRP

012345678

VAS

VAS

➤ 68% Reduction in VAS

7.4

2.4

Overall Improvement

No. of patients N= 710

5

10

15

20

25

30

Not at allSlightlyModeratelyMostlycompletely

79% reported moderate to complete improvement

– 50%- 100% relief of symptoms59 % reported mostly to complete improvement

-- 75-100% relief of symptoms

Overall Improvement

late

ral e

pico

ndylos

is (n

=19

)

pate

lla te

ndon

osis (n

=15

)

RTC te

ndin

osis (n

=10

)0

10

20

30

40

50

Not at allSlightlyModeratelyMostlycompletely

95% moderate to complete improvement

Percentage



Overall satisfaction with PRP procedure

87%

13%

Satisfied with procedure

Not Satisifed with Pro-cedure

87%

13%

Would rec. to family or friend

Would not rec. to fam-ily or friend

DATA COLLECTION STILL ONGOING

Conclusion

Tendon injuries have had poor clinical success with traditional treatments

Some will improve on there own, but will the tendon regain its normal architecture/ strength?

Biological agents such as PRP may offer a way to cure chronic tendon pain Techniques will be refined

over next several years

Open Surgery

Arthroscopy

US-guided Regenerative Procedures

[email protected]

# of patients

cc’s +Conc. Of PRP

Acti-vator

buffering agent/ Anesthetic

US guid-ance

Rehab / RTP

De VosAchilles

54(27 in tx group)

4cc none Sodium Bicarb/Marcaine

yes 7 days protected activity, 7 days stretching ;12 weeks eccentricsRTP after 4 wks if pain <3

GawedaAchilles

14(15 tendons)

3cc none NoneUnsure

yes PWB 3d, PROMx2wks, AROM, stretching wks 2-6, then full load active exercise

PeerboomsLat Epic.

100(51 in tx group)

3cc none Sodium Bicarb/Marcaine with epi

No 24 hrs limited mobility, 2 wks stretching, then eccentricsRTP after 4 wks as symptoms allow

MishraLat. Epi

20 (15 in tx group)

5cc539%

none Sodium Bicarb/Marcaine

No Same as above

KonPatella Tendon

20 20cc/3tx600%

10% CaCl

NoneUnsure

No 24 hrs limited mobility, rest btwn injection 1st and 2nd , stretching between 2nd and 3rd and after 3rd RTP allowed 1 month after 3rd injection (2 months after 1st)

FilardoPatella Tendon

15 20cc/3tx600%

10% CaCl

NoneUnsure

No Same as above

Rehabilitation after PRP

Days 0- 3 Ice allowed for first 24 hrs only as needed (20 min at a time) Protected weight bearing for lower extremity procedures (walking boot) Rest from all use of affected extremity beyond necessary daily activities Take tylenol or hydrocodone as needed (avoid anti-inflammatory

(NSAID’S) medications, e.g. ibuprofen, aspirin) Days 4-14

Wean out of boot/ splint Light biking or pool work allowed (stay below pain) Take Tylenol as needed (avoid NSAID’S)

Weeks 2-4 Continue bike/pool work Resume formal physical therapy/ rehabilitation to include:

Light stretching Soft tissue work (including CFM, ASTYM, Graston, ART) Heating/ ultrasound modalities Core work/ strengthen adjacent body parts

• Shoulder and scapulo-thoracic work for elbow procedures• Hip/ core work for knee and foot/ankle procedure

May walk lightly for exercise on treadmill/ flat ground if no increase in pain

Rehabilitation after PRP

Weeks 4-8 Advance formal physical therapy/ rehabilitation:

Eccentric exercises – start with light weight Re- Introduce strengthening exercise Lower extremity closed kinetic chain exercises allowed with light weights/body

weight Continue light aerobic/ weight bearing exercise (if little to no pain present) Start slow and do no more than every other day initially with small increases

each time if no increase symptoms. Months 2-6

Advance formal physical therapy/ rehabilitation: Increase strengthening activities (esp. eccentrics) introduce dynamic stabilization and integrated musculoskeletal activities

Increase aerobic activities slowly May start to resume sport specific activities ONLY IF PAIN IS MINIMAL with

these activities Start out with no more than every other day and increase amount of activity

slowly each time if activity does not cause pain and no increase pain after activity is done

Progress sporting activities as tolerated to full return to play!! If additional procedures are done, the rehabilitation starts over with the

additional procedure

KEN MAUTNER, MD EMORY SPORTS MEDICINE FEBRUARY 12, 2009 Tendon Injuries: New Treatments For an Old...

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