Achilles tendinopathy is a common disease among both athletes and in the general population in which the use of platelet-rich plasma has recently been increasing. Good evidence for the use of this autologous product in tendinopathy is limited, and data on longer-term results are lacking.
Purpose
To study the effects of a platelet-rich plasma injection in patients with chronic midportion Achilles tendinopathy at 1-year follow-up.
Study Design
Randomized controlled trial; Level of evidence, 1.
Methods
Fifty-four patients, aged 18 to 70 years, with chronic tendinopathy 2 to 7 cm proximal to the Achilles tendon insertion were randomized to receive either a blinded injection containing platelet-rich plasma or saline (placebo group) in addition to an eccentric training program. The main outcome was the validated Victorian Institute of Sports Assessment–Achilles score. Patient satisfaction was recorded and ultrasound examination performed at baseline and follow-up.
Results
The mean Victorian Institute of Sports Assessment–Achilles score improved in both the platelet-rich plasma group and the placebo group after 1 year. There was no significant difference in increase between both groups (adjusted between-group difference, 5.5; 95% confidence interval, –4.9 to 15.8, P = .292). In both groups, 59% of the patients were satisfied with the received treatment. Ultrasonographic tendon structure improved significantly in both groups but was not significantly different between groups (adjusted between-group difference, 1.2%; 95% confidence interval, –4.1 to 6.6, P = .647).
Conclusion
This randomized controlled trial showed no clinical and ultrasonographic superiority of platelet-rich plasma injection over a placebo injection in chronic Achilles tendinopathy at 1 year combined with an eccentric training program.
AlfredsonH, LorentzonR. Chronic tendon pain: no signs of chemical inflammation but high concentrations of the neurotransmitter glutamate. Implications for treatment? Curr Drug Targets.2002; 3(1): 43–54.
2.
AlfredsonH, OhbergL. Increased intratendinous vascularity in the early period after sclerosing injection treatment in Achilles tendinosis: a healing response?Knee Surg Sports Traumatol Arthrosc.2006; 14(4):399–401.
3.
AlfredsonH, PietilaT, JonssonP, LorentzonR. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med.1998; 26(3): 360–366.
4.
AndresBM, MurrellGA. Treatment of tendinopathy: what works, what does not, and what is on the horizon. Clin Orthop Relat Res.2008; 466(7): 1539–1554.
5.
AnituaE, SanchezM, NurdenATAutologous fibrin matrices: a potential source of biological mediators that modulate tendon cell activities. J Biomed Mater Res A.2006; 77(2): 285–293.
6.
AstromM, RausingA. Chronic Achilles tendinopathy: a survey of surgical and histopathologic findings. Clin Orthop Relat Res.1995; 316: 151–164
7.
BleakneyRR, WhiteLM. Imaging of the Achilles tendon. Foot Ankle Clin.2005; 10(2): 239–254.
8.
BrownR, OrchardJ, KinchingtonM, HooperA, NalderG. Aprotinin in the management of Achilles tendinopathy: a randomised controlled trial. Br J Sports Med.2006; 40(3): 275–279.
9.
CastriciniR, LongoUG, De BenedettoMPlatelet-rich plasma augmentation for arthroscopic rotator cuff repair: a randomized controlled trial. Am J Sports Med.2011; 39: 258–265
CreaneyL. Platelet-rich plasma for treatment of Achilles tendinopathy. JAMA.2010; 303(17):1696; author reply 1697-1698.
12.
de JongeS, de VosRJ, Van SchieHT, VerhaarJA, WeirA, TolJL. One-year follow-up of a randomised controlled trial on added splinting to eccentric exercises in chronic midportion Achilles tendinopathy. Br J Sports Med.2010; 44(9): 673–677.
13.
de MosM, van der WindtA, JahrHCan platelet-rich plasma enhance tendon repair? A cell culture study. Am J Sports Med.2008; 36(6): 1171–1178.
14.
de MosM, van ElB, DeGrootJAchilles tendinosis: changes in biochemical composition and collagen turnover rate. Am J Sports Med.2007; 35(9): 1549–1556.
15.
de VosRJ, van VeldhovenPL, MoenMH, WeirA, TolJL, MaffulliN. Autologous growth factor injections in chronic tendinopathy: a systematic review. Br Med Bull.2010; 95: 63–77
16.
de VosRJ, WeirA, TolJL, VerhaarJA, WeinansH, van SchieHT. No effects of PRP on ultrasonographic tendon structure and neovascu-larisation in chronic midportion Achilles tendinopathy. Br J Sports Med.2011; 45: 387–392
17.
de VosRJ, WeirA, van SchieHTMPlatelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial. JAMA.2010; 303(2): 144–149.
18.
EppleyBL, WoodellJE, HigginsJ. Platelet quantification and growth factor analysis from platelet-rich plasma: implications for wound healing. Plast Reconstr Surg.2004; 114(6): 1502–1508.
19.
FilardoG, KonE, Della VillaS, VincentelliF, FornasariPM, MarcacciM. Use of platelet-rich plasma for the treatment of refractory jumper's knee. Int Orthop.2010; 34(6): 909–915.
20.
FufaD, ShealyB, JacobsonM, KevyS, MurrayMM. Activation of platelet-rich plasma using soluble type I collagen. J Oral Maxillofac Surg.2008; 66(4): 684–690.
21.
GawedaK, TarczynskaM, KrzyzanowskiW. Treatment of Achilles tendinopathy with platelet-rich plasma. Int J Sports Med.2010; 31(8): 577–583.
22.
KhanKM, CookJL, BonarF, HarcourtP, AstromM. Histopathology of common tendinopathies: update and implications for clinical management. Sports Med.1999; 27(6): 393–408.
23.
KnoblochK. The use of a neovascularization score to predict clinical severity in Achilles tendinopathy. Am J Sports Med.2008; 36(2):395; author reply 395-397.
24.
KonE, FilardoG, DelcoglianoMPlatelet-rich plasma: new clinical application: a pilot study for treatment of jumper's knee. Injury.2009; 40(6): 598–603.
25.
LongoUG, RongaM, MaffulliN. Achilles tendinopathy. Sports Med Arthrosc.2009; 17(2): 112–126.
26.
MaffulliN, KhanKM, PudduG. Overuse tendon conditions: time to change a confusing terminology. Arthroscopy.1998; 14(8): 840–843.
27.
MishraA, PavelkoT. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Am J Sports Med.2006; 34(11): 1774–1778.
28.
MovinT, GadA, ReinholtFP, RolfC. Tendon pathology in longstanding achillodynia: biopsy findings in 40 patients. Acta Orthop Scand.1997; 68(2): 170–175.
29.
NinJR, GasqueGM, AzcarateAV, BeolaJD, GonzalezMH. Has platelet-rich plasma any role in anterior cruciate ligament allograft healing?Arthroscopy.2009; 25(11):1206–1213.
30.
OhbergL, AlfredsonH. Effects on neovascularisation behind the good results with eccentric training in chronic mid-portion Achilles tendinosis?Knee Surg Sports Traumatol Arthrosc.2004; 12(5): 465–470.
31.
PeerboomsJC, de WolfGS, ColarisJW, BruijnDJ, VerhaarJA. No positive effect of autologous platelet gel after total knee arthroplasty. Acta Orthop.2009; 80(5): 557–562.
32.
PeerboomsJC, SluimerJ, BruijnDJ, GosensT. Positive effect of an autologous platelet concentrate in lateral epicondylitis in a doubleblind randomized controlled trial: platelet-rich plasma versus cortico-steroid injection with a 1-year follow-up. Am J Sports Med.2010; 38(2): 255–262.
33.
RabagoD, WilsonJ, ZgierskaA. Platelet-rich plasma for treatment of Achilles tendinopathy. JAMA.2010; 303(17): 1696–1697; author reply 1697-1698.
34.
RineerCA, RuchDS. Elbow tendinopathy and tendon ruptures: epi-condylitis, biceps and triceps ruptures. J Hand Surg Am.2009; 34(3): 566–576.
35.
RompeJD, NafeB, FuriaJP, MaffulliN. Eccentric loading, shockwave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial. Am J Sports Med.2007; 35(3): 374–383.
36.
SchepullT, KvistJ, NorrmanH, TrinksM, BerlinG, AspenbergP. Autologous platelets have no effect on the healing of human Achilles tendon ruptures: a randomized single-blind study. Am J Sports Med.2011; 39(1): 38–47.
37.
ScottA, AsheMC. Common tendinopathies in the upper and lower extremities. Curr Sports Med Rep.2006; 5(5): 233–241.
38.
SengkerijPM, de VosRJ, WeirA, van WeeldeBJ, TolJL. Interobserver reliability of neovascularization score using power Doppler ultrasonog-raphy in midportion Achilles tendinopathy. Am J Sports Med.2009; 37(8): 1627–1631.
39.
SilvaA, SampaioR. Anatomic ACL reconstruction: does the platelet-rich plasma accelerate tendon healing?Knee Surg Sports Traumatol Arthrosc.2009; 17(6):676–682.
40.
SmidtN, van der WindtDA. Tennis elbow in primary care. BMJ.2006; 333(7575): 927–928.
41.
van SchieHT. Ultrasonographic Tissue Characterization of Equine Superficial Digital Flexor Tendons: Development and Applications of Computer-Aided Image Analysis [thesis]. Utrecht, the Netherlands; 2004.
42.
van SchieHT, BakkerEM, CherdchuthamW, JonkerAM, van de LestCH, van WeerenPR. Monitoring of the repair process of surgically created lesions in equine superficial digital flexor tendons by use of computerized ultrasonography. Am J Vet Res.2009; 70(1): 37–48.
43.
van SchieHT, de VosRJ, de JongeSUltrasonographic tissue characterisation of human Achilles tendons: quantification of tendon structure through a novel non-invasive approach. Br J Sports Med.2010; 4416: 1153–1159
44.
VenturaV, TerzaghiC, BorgoE, VerdoiaC, GallazziM, FailoniS. Use of growth factors in ACL surgery: preliminary study. J Orthop Trau-matol.2005; 6(2): 76–79.
45.
VirchenkoO, AspenbergP. How can one platelet injection after tendon injury lead to a stronger tendon after 4 weeks? Interplay between early regeneration and mechanical stimulation. Acta Orthop.2006; 77(5): 806–812.
46.
WiegerinckJI, ReilinghML, de JongeMC, van DijkCN, KerkhoffsCM. Injection techniques of platelet-rich plasma into and around the Achilles tendon: a cadaveric study [published online ahead of print April 19, 2011]Am J Sports Med. doi:10.1177/0363546511401577.
47.
WillbergL, SundingK, OhbergL, ForssbladM, FahlstromM, AlfredsonH. Sclerosing injections to treat midportion Achilles tendinosis: a randomised controlled study evaluating two different concentrations of poli-docanol. Knee Surg Sports Traumatol Arthrosc.2008; 16(9): 859–864.
48.
YinZ, ChenX, ChenJL, OuyangHW. Stem cells for tendon tissue engineering and regeneration. Expert Opin Biol Ther.2010; 10(5): 689–700.
