Posts Tagged ‘tendonitis’

Chronic Tendinopathy of the Achilles tendon and Plantar Fascia

December 13, 2015

 

Pain on the back or bottom of the heel caused by a condition known as tendinopathy is a common problem among people who are trying to lead an active lifestyle. The Achilles tendon and the plantar fascia are tendon type tissues that each play a key role in maintaining balance while walking and standing and are commonly afflicted with this condition. The pain in these areas often emerges from overuse following repetitive strain or after a recent increase in activity. Most people who have heel pain from tendinopathy will experience relief with the use of stretching, supportive shoes, anti-inflammatory therapy and shoe inserts. However, if the condition is not addressed, the acute inflammatory process continues as the body attempts to repair the damaged tendon. Eventually, this healing process ceases as the tendon becomes riddled with scar tissue.

Chronic tendinopathy in these areas can severely impair your ability to function in your daily life. Often described as tendinosis or fasciosis, this recalcitrant condition may persist for more than 6 months and is not relieved with the use of anti-inflammatory medicine or corticosteroid injection. This chronic, degenerative process manifests as thickened fibrous tissue within the tendon or fascia. Blood flow decreases to the diseased area and the normal healing process is halted. If conservative options fail to alleviate the symptoms of chronic tendinopathy, novel therapy that involves restarting the healing process should be the next option considered. Since healing is a normal response to injury, restarting the healing process in chronic tendinopathy could involve either introducing a controlled injury to the fibrotic/scarred tissue or directly implanting the necessary growth factors. There are several therapies currently available for treating pain due to chronic tendinopathy.

New Approaches to Treating Chronic Tendinopathy

 TENEX FAST – Focused Aspiration of Scar Tissue

The TENEX FAST system provides a novel way of directly accessing the diseased portion of tendon, using ultrasonic energy to break the fibrous tissue within the Achilles tendon or plantar fascia. This minimally invasive approach uses a handheld device with a micro tip. Using ultrasound imaging as a guide, the handheld micro tip is brought to the area of injury through a small incision in the skin. With the use of a foot pedal, ultrasonic energy is emitted through the micro tip to emulsify the scarred portions of tendon. The micro tip is also equipped with a saline delivery system to flush and aspirate/remove the debrided fibrous tissue. This process has been termed phacoemulsification and essentially cleans the scar tissue in a focused manner, leaving behind healthy tendon. (1) Prior to the procedure, local anesthetic is injected near the affected area to control pain during the procedure.

For procedures involving the plantar fascia, one can bear weight on the affected limb with a CAM boot and cane for assistance for 2 weeks. For Achilles, a CAM boot and crutches for guarded weight bearing is used. After the procedure, the doctor will determine when transition out of the CAM boot to supportive shoe gear and careful return to normal activities is appropriate. Any discomfort experienced following the procedure can be controlled with pain medication as prescribed by the doctor.

Platelet-Rich Plasma Injection

Platelet Rich Plasma, or PRP, is an orthobiologic substance that is used to alleviate pain caused by chronic tendinopathy. As mentioned previously, the diseased portion of the tendon has decreased blood flow and is unable to heal. PRP functions by directly stimulating the healing process in this area through the use of growth factors and inflammatory molecules from the patient’s own body. Prior to the procedure, blood is drawn from the patient. It is then spun in a centrifuge to separate the platelet-rich plasma from the rest of the blood. (Because a centrifuge or spinning machine is used in this procedure, PRP is sometime commonly known as, “Blood Spinning”) The platelet rich plasma is then drawn out of the processed vial and injected into the affected area. This procedure has now directly implanted growth factors into the site of injury. These growth factors help recruit other cells from the body which are involved in healing of the injured soft tissue.

During the procedure, ultrasound imaging is used to visually inspect the tendon or fascia and find the specific region of injury. Once the area of injury is located local anesthetic is used to numb the area of interest and the PRP is injected. In order to stimulate the process of healing, many small injections will be peppered into the diseased tissue to introduce a form of micro trauma and encourage the body to recruit inflammatory cells. Doing this essentially restarts the healing process in the previously scarred tendon. Following the injection, anti-inflammatory medications and icing should be avoided in order to allow the inflammatory healing process to work. A short leg-walking CAM boot is worn following the injection. Avoid walking without the boot on the affected limb for 2 week. After 2 weeks, patient can transition to supportive shoe gear.

Amniovo – Amniotic Membrane Injection

Amniovo is a form of dehydrated human amniotic membrane and is another way to introduce growth factors to the site of injury in chronic tendinopathy. Although amniotic membrane tissue is known to possess healing potential, there would be risks involved with direct implantation of untreated, fresh amniotic membrane. In order to avert these risks, the amniotic membrane used in this process is taken from screened and tested donors, it is then purified using the PURION process. This purification process allows for the dehydrated amniotic membrane to be safely implanted to the affected site without the risk of disease transmission and allows for the graft to be stored for up to 5 years. Once purified, the product is in powder form and is suspended in saline solution to use as an injection. Through the direct implantation of growth factors, injection with Amniovo helps the tendon’s diseased tissue heal. In fact, in a study using dehydrated amniotic membrane injection compared to a control injection of local anesthetic and saline the amniotic membrane injection was shown to be more effective at relieving pain from chronic plantar fasciosis. (2)

Once again, ultrasound-imaging guidance is used to identify the diseased portion of tendon or fascia. An anesthetic injection is first used to numb the affected area and Amniovo is then injected.

Following the injection, a walking boot is used for 2 weeks in order to protect the involved site. Two weeks after the injection the patient can transition to supportive shoe gear.

In Conclusion

Chronic tendinopathy is an issue that plagues many people who are attempting to engage in an active lifestyle. Because the condition may not respond to anti-inflammatory therapies, many patients are frustrated, especially if they would like to avoid surgery. Novel therapies that combat this chronic, degenerative process have emerged that help restart the healing process in the diseased tissue. If you have had heel pain from chronic tendinopathy that has stopped you from leading the daily lifestyle you would like to, speak with your doctor to see which therapeutic option would best suit your needs and help you get back on your feet.

References

1) Barnes, D. Ultransonic Energy in Tendon Treatment. Operative Techniques in Orthopaedics. 2013

2) Zelen, C; Poka, A; Andrews, J. Prospective, Randomized, Blinded, Comparative Study of Injectable Micronized Dehydrated Amniotic/Chorionic Membrane Allograft for Plantar Fasciitis—A Feasibility Study. Foot and Ankle International. 2013

 

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Achilles Tendon Injury

April 12, 2013

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Definition

The Achilles tendon plays an essential role in the day-to-day movement of an individual no matter their level of physical activity.  This tendon connects the muscles of the calf to the heel bone, and helps to raise the heel when standing or flexing the foot away from the body.  It is a very thick band of tissue and can be easily seen and felt along the back of the lower leg, behind the ankle.  Without the Achilles tendon, it would be hard to do simple activities such as walking, running and jumping.

Damage to the Achilles tendon can lead to pain in the back of the lower leg, just above the heel.  Injury usually occurs when there is a sudden increase in stressful force on the tendon.  The three most common types of Achilles injuries are Tendinopathy, Partial Tendon Tear and Complete Tendon Rupture.

 

Achilles Tendonopathy

The term Achilles tendonitis is very commonly used to describe injury to the tendon that has not progressed to partial or complete tear.  The suffix “-itis” is used to describe a state of inflammation, which indicates a very specific sequence of reactions that occur when the body is injured.  Thus, the word “tendonitis” refers to the inflammation of a tendon.  Although tendonitis is often a cause of tendon pain, damage to the Achilles tendon does not always involve inflammation; the disease of the tendon is sometime caused by chronic degeneration.  Therefore, the term “Tendinopathy” which includes all categories of tendon disease, with or without inflammation, will be used in this article to refer to Achilles tendon injuries other than partial or complete tendon tear.

Patients suffering from Achilles tendinopathy will often complain of pain or stiffness just above their heel.

Partial or Complete Rupture

When an intense stress is suddenly placed on the Achilles tendon it can rupture or tear.  The amount of stress needed to tear the tendon can depend on the individual.  Even seemingly small increases in stress, if brought on suddenly, can cause a tendon rupture.  Athletic activities that may result in a tear include sudden pivoting or activities that involve quickly accelerating and decelerating.

Patients who suffer from partial or complete tendon rupture may describe hearing a “pop” followed by sudden pain.  Experiencing sudden pain and a loss or decreased ability to raise the heel increases the probability of a tendon rupture.  It is possible to have a tendon rupture without experiencing pain, so patients complaining of pain in the back of the heel or decreased ability to raise the heel should be evaluated for possible tendon rupture.

Physical Exam

A proper physical exam must assess the patient’s complaints and rule out all other potential diagnoses.  The Achilles tendon should be palpated for any signs of tenderness, thickening/thinning, swelling or other abnormalities.  If pain is present, it is typically felt 2-6 cm above the attachment of the tendon to the heel bone.

In every instance of Achilles injury, it is important to evaluate the tendon for possible rupture.  The tendon should be tested with the patient standing and off weight bearing in order to assess any loss of function.  Specific tests like the Thompson Test (squeezing the patient’s calf while they are relaxed on the exam table with their feet off the table) can be used to check for tendon rupture.

Imaging

X-ray and Ultrasound imaging can be used to evaluate the degree of tendon injury, and may help rule out other possible causes of the patient’s complaints.  If there is a high suspicion of tendon rupture, MRI imaging is frequently used to assess the severity of the tear and to help plan for proper treatment.

Treatment

Achilles tendinopathy can often be treated non-surgically.  Patients should avoid any activities that might cause pain or worsening of symptoms.  Ice can be used whenever symptoms occur, and nonsteroidal anti-inflammatory drugs (Ibuprofen for example) may be recommended.  Shoe wear modifications, inserts or medical orthotics may be used to help prevent continual injury.  Patients may expect to gradually return to normal activity over the course of 6 to 8 weeks.  Stretching, physical therapy, and laser treatment may also be recommended.  If the pain is severe, a CAM boot may be required for several weeks.  If the Tendinopathy does not resolve within 3 months, the patient should be re-evaluated.

Partial or complete tendon rupture may require surgical care.  Ice, pain medication, rest and immobilization of the ankle are used initially until surgical care is deemed necessary.  Once a patient suffers an Achilles tendon rupture there is an increased risk of repeat injury.

Platelet-Rich Plasma Injections

Platelet-Rich Plasma (“PRP”) injection is a relatively new therapy that has been developed to treat various forms of injury.  Concentrating platelets and other growth factors that contribute to the healing process which are naturally found in the blood forms the PRP.  The blood is taken from the patient.  Spinning the blood at high speeds separates the different components of the blood.  Once separated, the portion of the blood rich in platelets and growth factors is extracted and injected into the site of injury.  Studies have shown that PRP injections into acute injuries may increase the speed of recovery, and injections into long-standing (chronic) injuries may cause the body to renew the healing process.

The application of PRP injections are still being investigated, but the treatment has already been used for various forms of injury with positive results.  PRP treatment has been used to help treat Achilles tendon injury, and is typically reserved for patients who fail traditional therapy.  PRP injection therapy may not be for everyone, and treatment must be considered on an individual basis.

Source Material

Achilles Injury

Alfredson, H; Lorentzon, R.  Chronic Achilles tendinosis: recommendations for treatment and prevention.Sports Med. 2000;29(2):135.

Jozsa, L; Kvist, M; Balint, BJ; Reffy, A; Jarvinen, M; Lehto, M; Barzo, M. The role of recreational sport activity in Achilles tendon rupture: A clinical, pathoanatomical and sociological study of 292 cases. Am J Sports Med. 1989; 17(3): 338.

Gravlee, JR; Hatch, RL; Galea, AM.  Achilles tendon rupture: a challenging diagnosis. J Am Board Fam Pract. 2000; 13(5):371.

Maffulli, N.  The clinical diagnosis of subcutaneous tear of the Achilles tendon: A prospective study in 174 patients.  Am J Sports Med. 1998; 26(2):266.

Mayer, F; Hirschmuller, A; Muller, S; Schuberth, M; Baur, H.  Effects of short-term treatment strategies over 4 weeks in Achilles tendinopathy.  Br J Sports Med. 2007; 41(7):e6.

Khan, RJ, Carey Smith, RL. Surgical interventions for treating acute Achilles tendon ruptures. Cochrane Database Syst Rev. 2010.

PRP Injections

de Jonge, S; de Vos, RJ; Weir, A; van Schie, HT; Bierma-Zeinstra, SM; Verhaar, JA; Weinans, H; Tol, JL. One-year follow-up of platelet-rich plasma treatment in chronic Achilles tendinopathy: a double-blind randomized placebo-controlled trial. Am J Sports Med. 2011 Aug;39(8):1623-9.

Griffin, LY.  Treating tendinopathy with PRP.  AAOS. 2010 Sept; 7(3). http://www.aaos.org/news/aaosnow/sep10/clinical2.asp .

Mautner, K; Colberg, RE; Malanga, G; Borg-Stein, JP; Harmon, KG; Dharamsi, AS; Chu, S; Homer, P. Outcomes after ultrasound-guided platelet-rich plasma injections for chronic tendinopathy: a multicenter, retrospective review.  PM R. 2013 Mar;5(3):169-75.

Monto, RR. Platelet rich plasma treatment for chronic Achilles tendinosis.  Foot Ankle Int. 2012 May; 33(5):379-85.

Soomekh, D; Yau, SK; Baravarian, B. A Closer Look At Platelet-Rich Plasma For Achilles Tendon Pathology. Podiatry Today. 2011 Nov; 24(11):50.

Storrs, C.  Is Platelet-Rich Plasma an Effective Healing Therapy? Scientific American.  Dec 18, 2009. http://www.scientificamerican.com/article.cfm?id=platelet-rich-plasma-therapy-dennis-cardone-sports-medicine-injury.

Healing yourself with Protein Rich Plasma

February 18, 2009

placing-disposablePlatelet rich plasma (PRP) therapy is a cutting-edge non-surgical technique that is now available for use as an in-office procedure. Years ago, it was thought that platelets functioned solely to form blood clots — or, more specifically, to bind to each other at the sight of bleeding in order to form a “plug” to stop the flow of blood. Recent research has shown, however, that the platelet has a far greater role in the healing process than initially thought. When platelets aggregate at the sight of an injury, they not only form the plug to stem the bleeding but they also release growth factors. These growth factors, also known as cytokines, aid in the healing of injured tissues.

PRP Therapy: The Process

PRP therapy requires only a small amount of normal blood from the patient (approximately 20 cc’s). This blood sample is placed into a centrifuge in the office and is spun for approximately fifteen minutes. The final product is a highly concentrated platelet rich gel, which, when applied to injured tissue, accelerates the normal healing process.

On the day of the treatment, the patient is seated in the exam chair and blood is taken from his or her arm. Once the PRP gel is ready for implantation, the area being treated is injected with local anesthesia after which there is no further discomfort from the procedure.

To insure the accuracy of the placement of the platelet rich gel a diagnostic ultrasound is used. Then a needle attached to a syringe containing the gel is guided by the ultrasound into the areas of injury. After the procedure, a simple Band-Aid is applied. Because there is no surgical incision involved there is little or no post procedural pain.

The Science

When the PRP gel is applied to the area of injury, the platelets are activated to produce proteins capable of stimulating cellular growth, proliferation and cellular differentiation called growth factors. By concentrating the number of platelets found in normal blood by 10 times, the concentration of growth factors in the area is equally enhanced. This is significant in terms of the healing process because growth factors are responsible for attracting stem cells that will eventually become new tendon, bone or fascia.
The procedure is very safe. Since the blood is drawn and processed immediately in the same facility there is no chance of contamination or blood from another patient. Also since the injection consist of blood from the same patient begin treated there is no chance of allergy or drug reactions. Additionally, platelets have a natural antibiotic quality so there is very little chance of infection.

Use

In my practice, by far the most common ailment treated with PRP is the painful heel condition known as plantar fasciitis. However, I have also successfully treated tendonitis, partial tendon ruptures and inflammatory bone conditions.

PRP versus Cortisone Injections

When PRP is compared to cortisone injections for inflammatory conditions there are many striking differences. Cortisone injections result in immediate pain relief. PRP injections do not act as quickly. PRP procedures take longer to deliver results because the growth factors take time to grow the new tissue. However, the platelets release the growth factors that attract the stem cells and then produce repaired “new” tissue. The cortisone reduces the inflammation immediately but actually causes tissue weakening and damage. So the choice between cortisone and PRP comes down to fast relieve with potential tissue damage or actual new and repaired tissue that takes longer to relieve pain.
This new innovative and cutting-edge technique is just the beginning of the new branch of science known as “orthobiologics”. The day is fast approaching when medical science will be able to create new parts to cure the ailments and injuries that plague our bodies. “Protein Rich Plasma” is one of the modalities that are currently available to help the body accelerate the healing process and create new, repaired, healthy tissue.

PRP in the news:

The following articles on PRP are sited for your further reading on this subject:
http://articles.latimes.com/2008/oct/03/sports/sp-dodfyi3

http://www.nytimes.com/2009/02/17/sports/17blood.html?_r=1&emc=eta1

http://www.sportsgeezer.com/sportsgeezer/2009/02/simple-blood-treatment-helps-heal-most-sports-injuries.html