Sonographically occult intrasubstance tendon tears revealed by platelet rich plasma injection: evidence of a frequently overlooked pathology? Poster No.: C-1603 Congress: ECR 2013 Type: Scientific Exhibit Authors: N. Upadhyay, D. Amiras, R. Johnson, G. Stenhouse, M. Khanna, S. Babar; London/UK Keywords: Education and training, Education, Ultrasound, Musculoskeletal system DOI: 10.1594/ecr2013/C-1603 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 11
Purpose Studies investigating the efficacy of plasma rich protein (PRP) injections for tendinopathy have demonstrated variable results. The potential reasons for this warrant further evaluation, as these disconcordant results have left clinicians unclear about the best course of treatment for their patients. One possibility is that there is a subgroup of patients which is diagnosed either clinically or sonographically with tendinopathy, but has an additional occult pathology that responds differently to PRP. Only a few studies have been published, and many of these contain modest sample sizes. This increases the risk of disproportionate numbers of such a subgroup in the control or intervention arms, which may skew results. It is our experience that many patients diagnosed with tendinopathy have sonographically occult partial thickness intrasubstance tears which are only revealed during PRP injection into the tendon. It is also our impression that patients with tears respond better to PRP, which is in keeping with studies on the Achilles (Gaweda 2010) and supraspinatus (Rha 2013) that have demonstrated sonographic resolution of partial thickness tears following PRP injection. If this is proven, identification of this subgroup may help to explain the variation in the results of previous studies. To our knowledge, no studies have performed a subgroup analysis on this group of patients. We describe an ongoing prospective study which aims to evaluate the prevalence of partial thickness intrasubstance tendon tears, and determine if this group responds better to PRP. Methods and Materials At our institution, PRP is offered as a routine clinical therapy. The course consists of an initial PRP injection, followed by a second injection after an interval period of 4 weeks. We are recording the number of cases where a sonographically occult intrasubstance partial thickness tear is demonstrated following PRP inection. We are also recording patient outcome using the validated Patient-rated Tennis Elbow Evaluation (PRTEE) and the Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A) scoring systems before and after the course of treatment. Following written consent and an information leaflet, 10 mls of blood is withdrawn from the patient. This is immediately centrifuged for 5 minutes to produce a platelet-rich Page 2 of 11
supernatant that is seperated from the red blood cells. Using an aseptic technique, and under ultrasound guidance, approximately 4 ml of platelet-rich plasma is injected into the damaged tendon following instillation of local anaesthetic to the skin, subcutaneous tissues and paratenon as appropriate. Results This is an ongoing prospective study. From the data available, we estimate that approximately 20 to 40% of patients with sonographic evidence of tendinopathy will have occult intrasubstance tendon tears. The feedback from patients with such tears during interim clinic appointments has been positive, but we await the results from the statistical analysis at the end of our study. Figure 1 demonstrates fusiform thickening and heterogeneity of the mid portion of the right achilles tendon. There is a moderately large intrasubstance tear within the tendon, that is only made visible during the injection, as seen on figure 2. The PRP is delivered directly into the cleft, and then dissipates into the abnormal tendon. Figure 3 is an example of a small partial thickness tear on the deep surface of the right common extensor tendon. On initial sonographic assessment, the tendon is abnormal in echotexture with multiple intrasubstance linear hypoechoic regions on its deep surface. The needle is guided close to linear hypoechoic focus, and during the injection a 3mm x 4mm cleft is demonstated indicating a pre-existing subtle intrasubstance tear. Figures 4 and 5 demonstrate a small intrasubstance tear within the left achilles tendon, which measures 8mm x 3mm. On initial assessment, this was attributed to the heterogeneity seen in chronic tendinopathy. Figure 6 is a further example of a right common extensor origin tear which extends to the tendon-bone interface. Images for this section: Page 3 of 11
Fig. 1: There is fusiform thickening and heterogeneity of the right achilles tendon. No definite intrasubstance tears are identified on initial assessment. The patient had a subsequent PRP injection, as seen in Figure 2. Page 4 of 11
Fig. 2: Right achilles tendon PRP injection, perfomed on the the tendon in figure 1. This demonstrates an intrasubstance tendon tear that becomes apparent during the injection. Page 5 of 11
Fig. 3: Right common extensor tendon PRP injection, which reveals an intrasubstance tear. Page 6 of 11
Fig. 4: Left achilles tendon, immediately prior to injection. The red arrow demonstrates the needle tip, and the blue arrow highlights the subtle intrasubstance tear. Figure 5 is a video of the subsequent injection. Page 7 of 11
Fig. 5: Left achilles tendon PRP injection. Figure 4 was obtained immediately prior to the injection. Page 8 of 11
Fig. 6: Right common extensor origin. The red arrow demonstrates the needle, and the blue arrow shows an tear that partially extends to the articular surface. A further linear intrasubstance tear was also demonstrated in this patient. Page 9 of 11
Conclusion Patients with occult partial thickness intrasubstance tendon tears are likely to represent a relatively large and important subgroup, that are diagnosed with tendinopathy alone. Indirect evidence relating to improvement in the sonographic morphology of tears from other studies, and the experience from our institution, suggests that this group may respond more favourably to PRP. The results from our study will help to clarify this. References de Jonge, S., R. J. de Vos, et al. (2011). "One-Year Follow-up of Platelet-Rich Plasma Treatment in Chronic Achilles Tendinopathy: A Double-Blind Randomized PlaceboControlled Trial." The American Journal of Sports Medicine 39(8): 1623-1629. de Vos Rj, W. A. v. S. H. M. and et al. (2010). "Platelet-rich plasma injection for chronic achilles tendinopathy: A randomized controlled trial." JAMA 303(2): 144-149. Gaweda, K., M. Tarczynska, et al. (2010). "Treatment of Achilles Tendinopathy with Platelet-Rich Plasma." Int J Sports Med 31(08): 577-583. Mishra, A. and T. Pavelko (2006). "Treatment of Chronic Elbow Tendinosis With Buffered Platelet-Rich Plasma." The American Journal of Sports Medicine 34(11): 1774-1778. Monto, R. R. (2012). "Platelet rich plasma treatment for chronic Achilles tendinosis." Foot Ankle Int 33(5): 379-385. Peerbooms, J. C., J. Sluimer, et al. (2010). "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." The American Journal of Sports Medicine 38(2): 255-262. Rha, D.-w., G.-Y. Park, et al. (2013). "Comparison of the therapeutic effects of ultrasound-guided platelet-rich plasma injection and dry needling in rotator cuff disease: a randomized controlled trial." Clinical Rehabilitation 27(2): 113-122. Page 10 of 11
van Schie, H. T. M., R. J. de Vos, et al. (2010). "Ultrasonographic tissue characterisation of human Achilles tendons: quantification of tendon structure through a novel noninvasive approach." British Journal of Sports Medicine 44(16): 1153-1159. Personal Information Page 11 of 11