Mehmet Can UNLUA, Aybars KİVRAKA, Mahmut Enes KAYAALPA, Isık AKGUNC, Received July JULY, Accepted October OCTOBER

Peritendinous injection of platelet-rich plasma to treat tendinopathy: A retrospective review

Contents lists available at ScienceDirect

Objective: The aim of this study was to determine factors associated with the likelihood of a betterclinical outcome after the peritendinous injection of PRP for the treatment of chronic tendinopathy andidentify whether PRP represents an effective treatment option for chronic tendinopathies.Methods: The study included 214 patients (86 males and 128 females; mean age: 39.3 (18e75) years)who received PRP injections for tendinopathy refractory to conventional treatments. The mean durationof symptoms at the moment of the PRP treatment was 8.3 months. Primary outcome measurement wasperceived improvement in symptoms for each anatomic compartment for upper and lower limbs at 6months after treatment. Also, a visual analog scale (VAS) score (pain intensity on a 0e10 scale) was usedfor pain scoring questionnaire before treatment, 6 weeks and 6 months following the PRP injection(s). Toidentify factors associated with the likelihood of a better clinical outcome, patients were categorized onthe basis of their perceived improvement in symptoms 6 months after the PRP injection(s)dthat is, aslower (less than 50% global improvement) or higher (more than 50% global improvement).Results: A visual analogue scale score and perceived improvement in symptoms were signiŞcantly lowerafter peritendinous injection in 6-week and 6-month follow-ups compared with the baseline (P< 0.001)except for peroneal and Achilles tendons. Overall, 83% of patients indicated moderate to completeimprovement in symptoms. The most common injection sites were the lateral epicondyle, Achilles, andpatellar tendons. Furthermore, 30% of patients received only 1 injection, 30% received 2 injections, and40% received 3 or more injections. A total of 85% of patients were satisŞed (more than 50% globalimprovement) with the procedure. In addition, upper limb tendons, increase in the age, and femalegender were associated with a higher likelihood of perceived improvement in symptoms.Conclusions: In the present retrospective study assessing PRP injections in the treatment of chronictendinopathy, a moderate improvement (>50%) in pain symptoms was observed in most of the patients.Our research found that results were most promising with patellar and lateral epicondylar tendinopathyin the short to medium term. Female patients, patients with upper extremity tendinopathy and olderpatients appeared to beneŞt more from PRP injection.Level of evidence: Level IV, Therapeutic study.

___

1. Jarvinen TA, Kannus P, Maffulli N, Khan KM. Achilles tendon disorders: etiology EUR and epidemiology. Foot Ankle Clin. 2005;10(2):255e256.

2. Maffulli N, Wong J, Almekinders LC. Types and epidemiology of tendinopathy. Clin Sports Med. 2003;22(4):675e692.

3. Tsai WC, Hsu CC, Chang HN, Lin YC, Lin MS, Pang JH. Ibuprofen upregulates expressions of matrix metalloproteinase-1, -8, -9, and -13 without affecting expressions of types I and III collagen in tendon cells. J Orthop Res. 2010;28(4): 487e491.

4. Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomized controlled trials. Lancet. 2010;376(9754):1751e1767.

5. Sanchez M, Anitua E, Orive G, Mujika I, Andia I. Platelet rich therapies in the treatment of orthopaedic sport injuries. Sports Med. 2009;39(5):345e354.

6. Filardo G, Kon E, Della Villa S, Vincentelli F, Fornasari PM, Marcacci M. Use of platelet-rich plasma for the treatment of refractory jumper's knee. Int Orthop. 2010;34(6):909e915.

7. Hammond JW, Hinton RY, Curl LA, Muriel JM, Lovering RM. Use of autologous platelet-rich plasma to treat muscle strain injuries. Am J Sports Med. 2009;37(6):1135e1142.

8. Peerbooms JC, Sluimer J, Bruijn DJ, Gosens T. Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: platelet-rich plasma versus corticosteroid injection with a 1- year follow-up. Am J Sports Med. 2010;38(2):255e262.

9. Hall MP, Band PA, Meislin RJ, Jazrawi LM, Cardone DA. Platelet-rich plasma: current concepts and application in sports medicine. J Am Acad Orthop Surg. 2009;17(10):602e608.

10. Sharma P, Maffulli N. Tendon injury and tendinopathy: healing and repair. J Bone Jt Surg Am. 2005;87(1):187e202.

11. de Vos RJ, Weir A, van Schie HTM, et al. Platelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial. JAMA. 2010;303(2):144e149.

12. Gosens T, Peerbooms JC, van Laar W, den Oudsten BL. Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: a double-blind randomized controlled trial with 2-year follow-up. Am J Sports Med. 2011;39(6):1200e1208.

13. Sanchez M, Anitua E, Azofra J, Andia I, Padilla S, Mujika I. Comparison of surgically repaired Achilles tendon tears using platelet-rich fibrin matrices. Am J Sports Med. 2007;35(2):245e251.

14. Ollivierre C, Nirschl R, Pettrone F. Resection and repair for medial tennis elbow. A prospective analysis. Am J Sports Med. 1995;23(2):214e221.

15. Dallaudiere B, Pesquer L, Meyer P, et al. Intratendinous injection of platelet-rich plasma under US guidance to treat tendinopathy: a long-term pilot study. J Vasc Interv Radiol. 2014;25(5):717e723.

16. Mautner K, Colberg RE, Malanga G, et al. Outcomes after ultrasound-guided platelet-rich plasma injections for chronic tendinopathy: a multicenter, retrospective review. PMR. 2013;5(3):169e175.

17. Krogh TP, Fredberg U, Stengaard-Pedersen K, Christensen R, Jensen P, Ellingsen T. Treatment of lateral epicondylitis with platelet-rich plasma, glucocorticoid, or saline: a randomized, double-blind, placebo-controlled trial. Am J Sports Med. 2013;41(3):625e635.

18. Omar Aziza S, Maha EI, Amal SA, Mahmoud S. Local injection of autologous platelet rich plasma and corticosteroid in treatment of lateral epicondylitis and plantar fasciitis: randomized clinical trial. Egypt Rheumatol. 2012;34(2):43e49.

19. Rha DW, Park GY, Kim YK, Kim MT, Lee SC. Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease: a randomized controlled trial. Clin Rehabil. 2013;27(2): 113e122.

20. Kesikburun S, Tan AK, Yilmaz B, Yas¸ ar E, Yazicioglu K. Platelet-rich plasma injections in the treatment of chronic rotator cuff tendinopathy: a randomized controlled trial with 1-year follow-up. Am J Sports Med. 2013;41(11): 2609e2616.

21. Song N, Armstrong AD, Li F, Ouyang H, Niyibizi C. Multipotent mesenchymal stem cells from human subacromial bursa: potential for cell based tendon tissue engineering. Tissue Eng Part A. 2014;20(1e2):239e249.

22. Kida Y, Morihara T, Matsuda K, et al. Bone marrow- derived cells from the footprint infiltrate into the repaired rotator cuff. J Shoulder Elb Surg. 2013;22(2):197e205.

23. Utsunomiya H, Uchida S, Sekiya I, Sakai A, Moridera K, Nakamura T. Isolation and characterization of human mesenchymal stem cells derived from shoulder tissues involved in rotator cuff tears. Am J Sports Med. 2013;41(3):657e668.

24. Milano G, Saccomanno MF, Careri S, Taccardo G, De Vitis R, Fabbriciani C. Efficacy of marrow-stimulating technique in arthroscopic rotator cuff repair: a prospective randomized study. Arthroscopy. 2013;29(5):802e810.

25. Milano G, Deriu L, Sanna Passino E, Masala G, Manunta A, Postacchini R, Saccomanno MF, Fabbriciani C. Repeated platelet concentrate injections enhance reparative response of microfractures in the treatment of chondral defects of the knee: an experimental study in an animal model. Arthroscopy. 2012;28(5):688e701.

26. Dragoo JL, Wasterlain AS, Braun HJ, Nead KT. Platelet-rich plasma as a treatment for patellar tendinopathy: a double-blind, randomized controlled trial. Am J Sports Med. 2014;42(3):610e618.

27. Vetrano M, Castorina A, Vulpiani MC, Baldini R, Pavan A, Ferretti A. Platelet-rich plasma versus focused shock waves in the treatment of jumper's knee in athletes. Am J Sports Med. 2013;41(4):795e803.

28. Kon E, Filardo G, Delcogliano M, et al. Platelet-rich plasma: new clinical application: a pilot study for treatment of jumper's knee. Injury. 2009;40(6): 598e603.

29. Wetzel RJ, Patel RM, Terry MA. Platelet-rich plasma as an effective treatment for proximal hamstring injuries. Orthopedics. 2013;36(1):e64ee70.

30. Kearney RS, Parsons N, Costa ML. Achilles tendinopathy management: a pilot randomised controlled trial comparing platelet-rich plasma injection with an eccentric loading programme. Bone Jt Res. 2013;2(10):227e232.

31. Volpi P, Marinoni L, Bait C, De Girolamo L, Schoenhuber H. Treatment of chronic patellar tendinosis with buffered platelet rich plasma: a preliminary study. Med Sport. 2007;60(4):595e603.

32. Deans VM, Miller A, Ramos J. A prospective series of patients with chronic Achilles tendinopathy treated with autologous-conditioned plasma injections combined with exercise and therapeutic ultrasonography. J Foot Ankle Surg. 2012;51(6):706e710.

33. Gross CE, Hsu AR, Chahal J, Holmes Jr GB. Injectable treatments for noninsertional Achilles tendinosis: a systematic review. Foot Ankle Int. 2013;34(5): 619e628.

34. McCarrel TM, Minas T, Fortier LA. Optimization of leukocyte concentration in platelet-rich plasma for the treatment of tendinopathy. J Bone Jt Surg Am. 2012;94(19). e143(1e8).

35. Boswell SG, Schnabel LV, Mohammed HO, Sundman EA, Minas T, Fortier LA. Increasing platelet concentrations in leukocyte-reduced platelet-rich plasma decrease collagen gene synthesis in tendons. Am J Sports Med. 2014;42(1): 42e49.

36. Protzman NM, Stopyra GA, Hoffman JK. Biologically enhanced healing of the human rotator cuff: 8-month postoperative histological evaluation. Orthopedics. 2013;36(1):38e41.

37. Kaux JF, Croisier JL, Leonard P, Le Goff C, Crielaard JM. Exuberant in flammatory reaction as a side effect of platelet-rich plasma injection in treating one case of tendinopathy. Clin J Sport Med. 2014;24(2):150e152.

38. Bowman Jr KF, Muller B, Middleton K, Fink C, Harner CD, Fu FH. Progression of patellar tendinitis following treatment with platelet-rich plasma: case reports. Knee Surg Sports Traumatol Arthrosc. 2013;21(9):2035e2039.