ltrasound-guided Platelet-rich Plasma Injection forhronic Patellar Tendinopathy: A Case Report
ames Brown, MSc, FFSEM, Manoj Sivan, MRCS
JcKD
McRpAcIAMD
DC
NTRODUCTION
raumatic and overuse tendinopathies are common problems encountered in musculoskel-tal practice. There are various treatment methods used to treat these conditions, most ofhich lack sufficient evidence to recommend their use [1]. Platelet-rich plasma (PRP)
njection is a relatively new treatment method, which has shown promising results so far2,3]. It is an autologous concentration of platelets in a small volume of plasma and is richn several growth factors that promote tendon healing [4].
Patellar tendinopathy is a chronic condition seen in many sports, particularly in jumpingports [5]. A few case series reported symptom reductions in patients treated with PRP foratellar tendinopathy [5,6]. The injection technique used in these studies is based onurface anatomical landmarks. We report a case of refractory patellar tendinopathy treatedith targeted ultrasound-guided PRP injection with satisfactory results and discuss theotential advantages of this technique.
ASE PRESENTATION
36-year-old active cricketer presented with a 9-month history of right knee pain, whichad started midway through the cricket season. He had a constant dull aching pain evenhile resting. On loading the affected leg during daily activities, the pain became sharp and
tabbing in nature and 10/10 on the visual analog scale. He had to discontinue cricketecause of the severity of his pain. He was treated with analgesics and eccentric quadricepstrengthening exercises (standard and decline squats). The patient’s symptoms did notmprove despite a 9-month trial of conservative treatment.
On examination there was minimal wasting in the quadriceps and no joint effusion oroint line tenderness. The distal patella and the proximal patellar tendon attachment werextremely tender. Active extension was extremely painful. His Victorian Institute of Sportssessment-Patellar (VISA-P) questionnaire score was 11 of 100. He was unable to sit pain
ree for more than 30 minutes.Ultrasound examination of the patellar tendon showed increased thickness of the
endon; 1.37 cm on longitudinal scanning (Figure 1A) and 1.87 cm (Figure 1B) onransverse imaging. There was a central, ovoid-shaped cavity defect within the tendino-athic area. There was significant neovascularity on Doppler flow scan (Figure 1C).
After discussing the various treatment options, the patient opted to try a PRPnjection to the patellar tendon. Informed consent was obtained and 30 mL peripheralhole blood was withdrawn from the patient and centrifuged at 3200 RPM in theravitational platelet separation system GPS III (Biomet; Warsaw, IN) for 15 minutes tobtain 3 mL of PRP. With the patient in the supine position and his knee flexed to 45°,% lidocaine was infiltrated into the skin overlying the patellar tendon at the junctionf upper one-third and distal two-thirds of the tendon. By using a single point of entry,mL of PRP was injected under ultrasound guidance into multiple regions of the
endinopathic proximal patellar tendon. The procedure was uneventful. He was advisedo do some gentle range of motion exercises in the next few days and progress to slowuadriceps eccentric strengthening exercises after 2 weeks. He was back to his routineesk job the day after the injection.
At a 6-week follow-up visit, the patient reported a marked reduction of his resting pain and
he pain that occurred during active knee range of motion. He was able to sit without pain for any
.B. Department of Musculoskeletal Medi-ine, Leeds Primary Care Trust, Leeds, Unitedingdomisclosure: nothing to disclose
.S. Department of Musculoskeletal Medi-ine, Leeds Primary Care Trust, Department ofehabilitation Medicine, Leeds Teaching Hos-itals NHS Trust, Leeds, United Kingdom; andcademic Department of Rehabilitation Medi-ine, Level D, Martin Wing, Leeds Generalnfirmary, Leeds LS1 3EX, United Kingdom.ddress correspondence to: M.S.; e-mail:[email protected]: nothing to disclose
isclosure Key can be found on the Table ofontents and at www.pmrjournal.org
ubmitted for publication February 10, 2010;ccepted May 2.
dicine and RehabilitationVol. 2, 969-972, October 2010
970 Brown and Sivan US GUIDED PRP INJECTION FOR CHRONIC PATELLAR TENDINOPATHY
ength of time. The VISA-P questionnaire score changed to 30 of00. He reported a 50% reduction in his pain. On clinicalxamination, there was minimal tenderness in the proximalendon. Active extension against resistance was more tolerableompared with before the procedure. Ultrasound examinationhowed reduced thickness of the tendon; 1.07 cm in thicknessn the longitudinal scan (Figure 2A) and 1.07 cm on the trans-erse scan (Figure 2B). The hypoechogenic region of the tendonas markedly reduced. There was a significant reduction of newessels on Doppler flow scan (Figure 2C).
His symptoms remained well controlled 8 months afternjection, at the time of writing this article. Functionally, heas back to jogging and cycling, and was able to train in
ricket for more than 30 minutes. He continues to do quad-
igure 1. Pretreatment images. (A) Longitudinal scan of the paow study, showing marked neovascularity.
iceps eccentric loading exercises. The patient was satisfied b
ith his outcome from the procedure and was optimisticbout his ability to return to sports.
ISCUSSION
wo earlier studies from a single center reported satisfactoryesults from treating chronic patellar tendinopathy with PRP.he investigators treated patients with chronic tendinopathy20 patients in the first study [6] and 16 patients in theecond study [5]) with 3 PRP injections 2 weeks apart. Theysed ultrasound or magnetic resonance imaging for clinicalvaluation, but their injections were performed by usingnatomical clinical landmarks (without ultrasound guid-nce). The protocol involved withdrawing 150 mL of venous
endon. (B) Transverse scan of the patellar tendon. (C) Doppler
tellar t
lood to produce 20 mL of PRP (5 mL PRP for each injec-
tmal
matndtOttfa
bnHt
oahscsttrb
Ft
971PM&R Vol. 2, Iss. 10, 2010
ion). The success rate, based on participant satisfaction, wasore than 80% in both studies [5,6]. No complications or
dverse effects were observed during the treatment and fol-ow-up period in both studies.
Ultrasound has become a widely accepted investigationethod for patellar tendinopathy and can be as sensitive
s magnetic resonance imaging in evaluation of the condi-ion [7]. Doppler scanning enables the assessment ofeovascularity, which correlates to the symptoms in ten-inopathy. Use of ultrasound for guided injections enablesargeting of the intervention to the exact pathologic area.ne potential advantage of using ultrasound guidance is
hat it enables the physician to target the tendinopathicissue, thus possibly reducing the volume of PRP requiredor this procedure. This could considerably reduce the
mount of peripheral blood needed for the procedure p
ecause the ratio of the volume of the peripheral bloodeeded to the volume of PRP extracted is high (10:1).owever, further research is required to confirm or refute
his supposition.In our case, the patient had participated in 14 sessions
f physical therapy over 6 months before the procedure, atn estimated cost of £960 ($1400). This included theospital outpatient session charges and the professionaltaff charges. The single PRP injection was performed at aost of £230 GBP ($345), which included the hospitalession charge, professional staff charge, and the manufac-urer’s charge for using the centrifuge machine for a singlereatment. The outcome from the PRP injection was supe-ior to the conventional physical therapy program, and theenefit has been maintained, even 8 months after the
scan of the patellar tendon. (B) Transverse scan of the patellar
dinality.
rocedure. Therefore, it can be concluded that, in our
cc
C
Tgm
R1
2
3
4
5
6
7
972 Brown and Sivan US GUIDED PRP INJECTION FOR CHRONIC PATELLAR TENDINOPATHY
ase, PRP injection has been more cost effective than aonventional physical therapy program.
ONCLUSION
his case presentation suggests that ultrasound-guided, tar-eted PRP injection can be a safe and cost-effective treatmentethod for chronic patellar tendinopathy.
EFERENCES. Scott A, Ashe MC. Common tendinopathies in the upper and lower
extremities. Curr Sports Med Rep 2006;5:233-241.
. Mishra A, Pavelko T. Treatment of chronic elbow tendinosiswith buffered platelet-rich plasma. Am J Sports Med 2006;34:1774-1778.
. Sanchez M, Anitua E, Azofra J, Andia I, Padilla S, Mujika I. Comparisonof surgically repaired Achilles tendon tears using platelet-rich fibrinmatrices. Am J Sports Med 2007;35:245-251.
. Malloy T, Wang Y, Murrell G. The roles of growth factors in tendon andligament healing. Sports Med 2003;33:381-394.
. 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 2009 Jul 31 [Epub ahead of print].
. Kon E, Filardo G, Delcogliano M, et al. Platelet-rich plasma: new clinical appli-cation: a pilot study for treatment of jumper’s knee. Injury 2009;40:598-603.
. Peers KH, Brys PP, Lysens RJ. Correlation between power Dopplerultrasonography and clinical severity in Achilles tendinopathy. Int Or-
