TIME S UP ON HEEL PAIN OPTIONS FOR CHRONIC FASCIAL AND TENDON INJURIES

Transcription

1 TIME S UP ON HEEL PAIN OPTIONS FOR CHRONIC FASCIAL AND TENDON INJURIES ERIKA M. SCHWARTZ, DPM FOOT AND ANKLE SPECIALISTS OF THE MID -ATLANTIC WASHINGTON DC AND CHEVY CHASE, MD

2 TENDON INJURY Tendon injuries are common- affect over 30 million people a year. Can occur with trauma, overuse, aging Typically show pain, inflammation and dysfunction Tendon healing is slow. Acute tendon healing process can take up to 10 weeks in healthy tendons.

3 TENDINOSIS AND FASCIOSIS When inflammatory changes are present, but inflammatory mediators are absent May fail to regain full function with conservative management Conservative or Surgically, fibrosis and scar tissue = poor tensile strength, prone to re-injury resultant tendon can be thickened, fibrotic, and less resistant to tensile stress than when preinjury. Tendons injured with overuse show tendinopathy Tenocyte depletion Collagen fiber disorganization Failure to heal Results in pain, lower function, and tearing at a lesser threshold. healthy number of tenocytes decrease. Inflammatory changes present but inflammatory mediators are absent

4 THE HEEL Achilles Tendon and Plantar Fascia The relatively avascular area 2-6 cm proximal to the Achilles tendon insertion on the calcaneus is the most common site of non insertional tendinopathy Insertional tendinopathy occurs at the junction of bone and tendon Medial band of plantar fascia at/distal to the medial calcaneal tuborosity

5 OPTIONS TO REJOIN HEALING- REGENERATION Amniotic Membrane Allograft Platelet-rich plasma injection High and low frequency extracorporeal shockwave therapy

6 AMNIOTIC MEMBRANE Innermost layer of amniotic sac, surrounds fetus Readily available No ethical concerns- usually discarded after birth and no harm or danger to fetus and/or mother when extract. Harvested from consenting donor during scheduled c-section or during an amniocentesis.

7 AMNIOTIC MEMBRANE ALLOGRAFT Amniotic Stem Cells Can develop into many different types of tissue- skin, cartilage, cardiac, nerves, muscle, bone Synthesizes cytokines and growth factors Can generate tissue from all three germ layers (mesoderm, endoderm, ectoderm) but do not form teratomas Amniotic fluid has a heterogeneous mixture of multipotential stem cells Immunologically privileged

8 ADVANTAGES FOR TENDON REPAIR Amniotic membrane is composed of extracellular matrix to act as scaffold for structural support for cells. Attachment for collagen types I, III, IV, V, VI, growth factors and hyaluronic acid. Has antimicrobial properties

9 PROCESSING Cryopreserved- freezing at extreme temperature- viable cells Lyophilized- freeze drying- viable cells Dehydrated- non viable cells 5 year shelf life, no special storage requirements

10 TENDON WRAPPING

11 INJECTABLE FORM Flowable Amniotic Stem Cell Allograft

12 DEHYDRATED HUMAN AMNION/CHORION PRODUCTS 20mg, 40mg and 100mg Mix with 0.5% Marcaine Needle size doesn t matter Cam Walker type boot, 1 month Painful injection, pain for 2-3 days following Avoid NSAIDs

13 RESULTS Positive results for tendon use in animal studies Clinical trials for use in tendons are limited and show encouraging results British Journal of Sports Medicine, In all literature of randomized and non randomized controlled trials, cohort studies, and case series, only four trials (total of 79 patients) were found to be eligible for consideration and all of them were ultimately seen as having high risk of bias. Foot & Ankle International, Significant improvement AOFAS hindfoot scores with injection of dehydrated allograft for plantar fasciitis.

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15 PLATELET-RICH PLASMA Platelet-rich plasma (PRP)- fractionated plasma from patient with high level platelets Platelets contain growth factors Stimulate healing by recruiting stem cells Promotes collagen formation and angiogenesis

16 PRP- ADVANTAGES AND DISADVANTAGES Platelet-rich plasma (PRP)- autogenous source growth factors Considered safe and natural Less expensive than amniotic stem cell use Clinical studies have not demonstrated efficacy of PRP alone in enhancing tendon repair Combination of PRP with stem cells may have enhancing effects

17 SHOCKWAVE Extracorporeal Shock Wave Therapy

18 MECHANISM OF ACTION- HOW DOES ESWT WORK? Mechanism uncertain, but several theories- Increasing pressure in calcium deposition- causing fragmentation. Induction of an inflammatory response- inflammatory mediated healing process Neovascularization- enhancing angiogenesis to increase blood flow to the treated site Analgesic effect- inhibits activation of serotonergic system Peripheral denervation

19 ESWT AND EPAT Extracorporeal Shock Wave Therapy is high energy Extracorporeal Pulse Activated Therapy is low energy. Low energy shock wave therapy- no need for local/regional anesthesia, but need three-four applications

20 RESULTS OF ESWT AND EPAT 2015 J. Orthopaed Traumatol study showed significant AOFAS score increase when used for chronic Achilles and best results were seen at weeks 8 and 12 weeks after use. Multiple other studies (including Rasmussen in 2008) have found better results at 8 and 12 weeks follow up Foot Ankle Int study demonstrated a 1.3mm decrease in thickness of the plantar fascia after EPAT treatment, seen on ultrasonographic measurement. July/August 2018 J of Foot & Ankle Surgery demonstrated 63% and 79% reduction in pain in active and non-active duty military, respectively.

21 EPAT Avoid NSAIDs Energy Level Pulse Number Pulse Frequency Applicators Standard Deep impact Oscillating

22 TREATMENT CHOICE- WHICH ONE IS RIGHT FOR THE PATIENT?

23 CHOOSING TREATMENT Efficacy Immobilization/Restrictions Cost Availability

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26 REFERENCES 1. Larson, A and Gallicchio, VS; Amniotic Derived Stem Cells: Role and Function in Regenerative Medicine, Journal of Cell Science & Therapy, May 14, Rasmussen S, Christensen M, Mathiesen I, Simonson O, Shockwave therapy for chronic Achilles tendinopathy: a double-blind, randomized clinical trial of efficacy, Acta Orthop. 2008;79(2): Young, M; Stem Cell Applications in Tendon Disorders: A Clinical Perspective, Stem Cells Int Po, P and Lui, Y; Stem cell technology for tendon regeneration: current status, challenges, and future research directions, Stem Cells Cloning, Dec 2015, Carulli, C, Tonelli, F, Innocenti, M, Gambardells, B, Muncibi, F, Effectiveness of extracorporeal shockwave therapy in three major tendon diseases, J Orthopaed Traumatol, 2016; Wilson, M, Stacy, J; Shock wave therapy for Achilles Tendinopathy, Curr Rey Musculoskelet Med, 2011 Mar; 4(1) Liu, L, Hindieh, J, Leong, D, Sun, H; Advances of stem cell based-therapeutic approaches for tendon repair, Journal of Orothopaedic Translation (2017) 9, Haiko, IMF, Pas, L, Maarten, HM, Hidde, JH, Winters, M, No Evidence of the Use of Stem Cell Therapy for Tendon Disorders, Br J Sports Med, 2017;51 (13): Andres, BM and Murrell, GAC, Treatment of Tendinopathy: What Works, What Does Not, and What is on the Horizon, Clin Orthop Relat Res July; 466(7): Zelen, CM, Poka, A, Andrews, J, Prospective, Randomized, Blinded, Comparative Study of Injectable Micronized Dehydrated Amniotic/Chorionic Membrane Allograft for Plantar Fasciits- A Feasibility Study, Foot Ankle Int : Mamidi, MK, Singh, G, Husin JM, Nathan, KG, Sasidharan, G, Zakaria, Z, Majumdar, AS, Das, AK, Impact of passing mesenchymal stem cells through smaller bore size needles for subsequent use in patients for clinical or cosmetic indications, J Transl Med. 2012; 10: Rodriguez-Ares, MT, Lopez-Valadares MJ, Tourino R, Vieites, B, Gude, F, Silva, MT, Couceiro, J, Effects of Lyophilization on human amniotic membrance, Acta Ophthalmol Jun;87(4): Purcell RL, Schroeder, IG, Keeling, LE, Formby PM, Eckel, TT, Shawen SB, Clincial Outcomes After Extracorporeal Shock Wave Therapy for Chronic Plantar Fasciitis in a Predominantly Active Duty Population, J of Foot & Ankle Surgery, Jul/August 2018;57(4):