July 25, 2021
PRP and achilles tendinopathy

PRP and Achilles Tendinopathy

Achilles tendinopathy is a common cause of heel pain, affecting 5-10% of runners and athletes.[1]Lysholm J, Wiklander J. Injuries in runners. Am J Sports Med. 1987 Mar-Apr;15(2):168-71 It is an overuse injury which is often chronic in nature. The diagnosis is easily made on the clinical exam but can be confirmed with US or MRI. Treatment typically revolves around activity modification, physical therapy, heel lifts and medications. Of those, physical therapy emphasizing eccentric exercises and stretching appear to be the most important. Up to 25% of patients still experience symptoms up to 8 years after onset, making it a very stubborn disease.[2]Paavola M, Kannus P, Paakkala T, Pasanen M, Järvinen M. Long-term prognosis of patients with achilles tendinopathy: an observational 8-year follow-up study. Am J Sports Med 2000;28:634–642.

Case Vignette

You are initiating treatment on a 21 year old runner with achilles tendinitis. There was no trauma. Plantarflexion is intact but painful, even in the office. Which of the following would be the most appropriate initial treatment for this patient?

A) Heel lift, topical nitroglycerin

B) Physical therapy, US guided corticosteroid injection

C) NSAIDS, US guided PRP injection

D) Activity modification, physical therapy

Injection therapies are sometimes considered and utilized. Potential injectants include prolotherapy, hydrodilation (high volume), corticosteroids (not recommended) and platelet-rich plasma (PRP). PRP is a regenerative therapy which involves using a centrifuge to isolate the plasma in a patient’s blood and inject it into or around pathologic tissue. PRP involves injecting concentrated pro-inflammatory markers and cytokines around the diseased tendon to promote healing.[3]Moraes, Vinícius Y., et al. “Platelet‐rich therapies for musculoskeletal soft tissue injuries.” Cochrane Database of Systematic Reviews 4 (2014).

The study

The authors asked “In adults with painful midportion Achilles tendinopathy lasting longer than 3 months, does a single injection of platelet-rich plasma result in better function when compared with a sham injection 6 months after treatment?”
the stages and pathogenesis of tendonitis

Image 1. The pathogenesis of tendinopathy[4]Fu, SC., Rolf, C., Cheuk, YC. et al. Deciphering the pathogenesis of tendinopathy: a three-stages process. BMC Sports Sci Med Rehabil 2, 30 (2010).

They created a double blinded, multicenter randomized clinical trial that included 240 people from 24 sites assigned to either a platelet-rich plasma injection or a sham injection between April 2016 and February 2020. Participants were adults with achilles tendinopathy greater than 3 months confirmed by MRI or US. Ultimately, 121 participants received PRP while 119 received the sham injections. The outcome of interest was Victorian Institute of Sport Assessment-Achilles (VISA-A) score which provides a composite score assessing pain, function and activity.
They found no difference between VISA-A scores for the PRP group (54.4) vs the sham injection group (53.4) (adjusted mean difference, −2.7 [95% CI, −8.8 to 3.3]). They also found no benefits for secondary outcomes of change in VISA-A score at 3-month follow-up or the EQ-5D-5L (health related questionaiire) and pain at 2 weeks, 3 months, and 6 months. PRP patients had slightly more adverse events with injection site discomfort (97 vs 73 patients) and swelling (56 vs 52 patients) but not bruising (48 vs 49 patients).

The Bottom Line

Ultimately, they found no benefit for PRP in this large, double blind, RCT and the PRP patients had slightly more adverse events. This is consistent with a previous RCT by Devos et al and a systematic review by Sadoghi et al.[5]de Vos RJ, Weir A, van Schie HT, et al. Platelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial. JAMA 2010;303:144–149[6]Sadoghi P, Rosso C, Valderrabano V, Leithner A, Vavken P. The role of platelets in the treatment of achilles tendon injuries. J Orthop Res 2013;31:111–118 I would argue this pretty much closes the door on PRP for achilles tendinopathy. For other diseases of the achilles, namely partial and complete tears, there may still be a role.

Case Conclusion

Best answer is D. The runner should discontinue or cut back on running volume and begin physical therapy. The emphasis should be on stretching and eccentric exercises. A slow return to play/ sport can begin if the symptoms resolve. NSAIDS are reasonable initially, but PRP doesn’t help and corticosteroid injections should be avoided. Both heel lift and topical nitroglycerin can be useful in refractory cases, but should not be initiated early in the treatment course.

Alfredson H, Pietilä T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 1998;26:360–366.

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