Non-surgical treatment of Achilles tendon injuries
Ross Hauser, MD discusses the use of Prolotherapy, PRP, and Stem Cells as non-surgical treatmentment for Achilles tendon degeneration and for partial ruptures and as adjunct treatment following complete achilles tendon rupture and surgery.
These treatments stimulate an accelerated healing response in the immune system through a localized, temporary inflammation. Inflammation signals to the body that an area is injured and therefore growth factors and healing cells should be sent to speed healing. This is the swelling that occurs with injury.
In the case of the Achilles tendon, these injections given to the heel early on in the injury allows for full healing of the area. The injections provide the overused Achilles tendon the immune jumpstart it needs to fully heal and not degenerate further.
Chronic achilles tendon injuries
Injury to the achilles tendon increases with age and overuse. That has been clearly and well documented in the medical literature. While age and overuse make athletes and active people predisposed to injury, many patients will come into our office and describe an onset of pain that can be traced to a new and sudden burst in activity (a new exercise program). In many cases this acute injury has occurred from chronic wear and tear – the tendon has finally tore sufficiently enough to be considered an acute injury.
This can be especially true in runners who will report that they pulled their achilles or have a strained achilles. Achilles tendon injuries are especially susceptible in treadmill runners, 1 and people who run on sand. 2
In chronic achilles tendon injuries patients will report that their heel and achilles tendon area feels sore and tender to the touch, with the soreness coming and going to varying degrees. Some patients report a clicking and popping sound. Some will show swelling and an enlargement of the achilles tendon. There may be bumps or nodules in the mid achilles region. A “stiff” achilles tendon or a sensation of tightness is also reported in patients who have difficulties pointing their toes upward.
Patients may have inflammation which may point to paratenonitis – an inflammation of the surrounding sheath, tendinitis with is inflammation of the tendon caused by wear and tear, and tendinosis, degeneration without inflammation.
Noninsertional Achilles Tendinitis is where the tendon has begun to fray and breakdown in the middle of the achilles tendon.
This is an injury more typical of active patients.
Insertional Achilles Tendinitis occurs closer to the heel area where the achilles attaches or inserts itself to the heel bone.
In both conditions, the tendon seeks a way to stabilize itself and the heel-ankle complex area. It does so by calcifying (hardening) and by forming bone spurs on the heel.
Chronic Recalcitrant Achilles Tendinopathies and Prevention of Achilles tendon rupture
In this section we will discuss treatment options. The first treatment option is Platelet Rich Plasma Therapy. Platelet-rich plasma (PRP), is an autologous derivative of whole blood that contains a supraphysiological (a greater than normal amount) concentration of platelets. You can learn more about this treatment here What is Platelet Rich Plasma Therapy?
In new research doctors evaluated the long-term clinical outcome in patients affected by mid-portion Chronic Recalcitrant Achilles Tendinopathies (CRAT) treated with administration of single platelet-rich plasma (PRP).
A total of 73 patients age 43 years old predominantly males had 83 tendons treated with a single PRP injection. They were then evaluated using standard scoring systems.
Here are their results
- 91.6% were rated as satisfactory and patients would repeat the treatment.
- 8.4% were classified as unsatisfactory at the 6 months follow-up and underwent a second PRP injection.
- In addition to this, patients reported no Achilles tendon rupture.
Therefore the conclusion: The use of a single PRP injection can therefore be a safe and attractive alternative in the treatment of non-insertional CRATs.3
Ruptured Achilles Tendon
Achilles tendon ruptures can take on many types. There can be a partial rupture or a complete rupture. The Achilles with a rupture can still be intact – it could also be “totally gone.”
Doctors writing in the medical journal Lancet examined the use of Platelet Rich Plasma Therapy for patients with a ruptured Achilles tendon.
Twenty patients with a ruptured Achilles tendon had tendon tissue samples taken. Ten of the patients had PRP, ten patients had placebo.
The findings reveal that locally applied PRP enhanced the maturity of the healing. Cellularity (the number of cells) and glycosaminoglycans (an amino sugar in hyaluronic acid or chondroitin sulfate useful in healing) content were significantly higher in PRP-treated tendons than in controls.4
Stem Cells and Platelet-rich plasma and a ruptured achilles tendon
Stem cell therapy is the injection of stem cells into the damaged achilles tendon. You can learn more about the treatment here What is Stem Cell Therapy?
In new research (May 2016) from doctors in Turkey, bone marrow derived stem cells (MSCs these are stem cells taken in a simple aspiration procedure from the iliac crest of the pelvis or from abdominal fat) promoted the recovery of the ruptured achilles tendon and increase its structural strength.
The doctors concluded: “The use of PRP and MSCs provides hope for the treatment of Achilles tendon ruptures that limit human beings’ functionalities and quality of life, particularly for athletes. It is thought that the use of MSC can be more effective for tendon healing.”5
Treatment following Achilles Tendon Surgery
There have been numerous studies testing the validity of use of Platelet Rich Plasma during open surgery. These studies have lead some to question whether or not PRP can help with post-surgical rehabilitation if applied at the time of surgery.
Doctors in Italy wrote in a July 2016 paper: “The addition of PRP to the surgical treatment of Achilles tendon rupture does not appear to offer superior clinical and functional results.”6
One of the big problems with studies on PRP or stem cell enhancements at the time of surgery is the problem of dilution. In my article on meniscus repair we came upon a study that found that during surgery, surgical dyes, irrigation fluids, and other liquids forced into the repair area significantly diluted healing agents during surgery and more importantly post-surgery.7
So theoretically, we are asking a weakened PRP treatment to heal surgical damage
However, doctors writing in the medical journal Foot and Ankle Specialists said:
Treatment protocols with PRP have been performed in 2 ways- administered adjunctively during tendon surgery and as a stand-alone injection.
The senior researcher has utilized PRP by both methods to treat Achilles tendinopathy over the past 7 years; 26 patients so treated were able to be recalled, half having undergone Achilles tendon surgery in combination with PRP administration and the other half PRP alone.
Both the stand-alone injection group and surgical/injection groups had statistically significant degrees of improvement in pre-MRI and post-MRI imaging studies. There was no statistically significant difference between the 2 treatment groups.8
PRP did help in surgery and helped equally without surgery. This is why seeking a consultation with a doctor experienced in the varied PRP, stem cells, and a comprehensive Prolotherapy approaches can offer the patient more options pre and post surgery for enhanced and accelerated achilles repair.
One note on immobilization
In stark contradiction to the Rice, Ice, Compress, Elevate theory in managing post surgical treatment, doctors in August of 2016 published their research that functional weight-bearing mobilization enhanced the early healing response of achilles tendon recovery. In addition, early ankle range of motion was improved without the risk of Achilles tendon elongation (laxity and instability) and without altering long-term functional outcome.9
Prolotherapy for Achilles Tendinopathy
New research has just been released on effectiveness and safety of prolotherapy injections for management of lower limb tendinopathy and fasciopathy from researchers in Australia writing in the Journal of Foot and Ankle Research (Oct 20 2015)
The doctors were looking to identify and evaluate existing research to determine the clinical effectiveness and safety of prolotherapy injections for treatment of lower limb tendinopathy and fasciopathy.
Results of the analysis provide support for the hypothesis that prolotherapy is effective in both reducing pain and improving function for lower limb tendinopathy and fasciopathy.
The analysis also suggests prolotherapy injections provide equal or superior short-, intermediate- and long-term results to alternative treatment modalities, including eccentric loading exercises for Achilles tendinopathy, platelet-rich plasma for plantar fasciopathy and usual care or lignocaine injections for Osgood-Schlatter disease. No adverse events following prolotherapy injections were reported in any study in this review.10
In 2005-2007, Lyftogt reported treating 169 Achilles tendons over a four year period with chronic Achilles tendinopathy (average length of symptoms two years) with subcutaneous dextrose Prolotherapy.11
Initial VAS Visual Analog Score for Chronic Pain of the group went from 6.5 to 0.5 after six treatments, with a follow-up period of two years. Ninety percent of patients were satisfied with the treatments. 12
Also in 2007 researchers published a study on the use of hyperosmolar dextrose (25%) to treat 32 patients representing 33 tendons with chronic tendinosis of the Achilles with the use of ultrasound. At an average of 12 months after treatment, 20 patients remained symptom free, nine experienced only mild symptoms, and one patient reported moderate symptoms.13
This was supported by research published in 2010 which showed the results of Prolotherapy in 99 patients with pain for greater than six months at either the Achilles tendon insertion or midportion.
Patients received and average of five injection sessions spaced on average 5.6 weeks apart. A statistically significant improvement in pain scores was observed for both midportion and insertional in mean percent reduction in pain at 28 month follow-up. 14
This research supported that of a paper published in 2009 that Prolotherapy and eccentric loading exercises for painful Achilles Tendon provided great improvements in the patient’s condition.15
For patients who have already received steroid injections or surgery for Achilles tendinopathy, but still have pain, Prolotherapy and Platelet Rich Plasma Injections may be a good regenerative treatment to consider to improve the entire heel, achilles, ankle complex, especially with tight achilles tendon pain that may be causing Equinus a condition that limits the motion of the ankle.
1. Willy RW, Halsey L, Hayek A, Johnson H, Willson JD. Patellofemoral Joint and Achilles Tendon Loads During Overground and Treadmill Running. J Orthop Sports Phys Ther. 2016 Aug;46(8):664-72. doi: 10.2519/jospt.2016.6494. Epub 2016 May 12.
2. Lorimer AV, Hume PA. Stiffness as a Risk Factor for Achilles Tendon Injury in Running Athletes. Sports Med. 2016 May 18
3. Guelfi M, Pantalone A, Vanni D, Abate M, Guelfi MG, Salini V. Long-term beneficial effects of platelet-rich plasma for non-insertional Achilles tendinopathy. Foot Ankle Surg. 2015 Sep;21(3):178-81. doi: 10.1016/j.fas.2014.11.005. Epub 2014 Dec 11.
4. Alsousou J, Thompson M, Harrison P, Willett K, Franklin S. Effect of platelet-rich plasma on healing tissues in acute ruptured Achilles tendon: a human immunohistochemistry study. Lancet. 2015 Feb 26;385 Suppl 1:S19. doi: 10.1016/S0140-6736(15)60334-8.
5 Yuksel S, Guleç MA, Gultekin MZ, Adanır O, Caglar A, Beytemur O, Küçükyıldırım BO, Avcı A, Subaşı C, İnci Ç, Karaoz E. Comparison of the Early-Period Effects of Bone Marrow-Derived Mesenchymal Stem Cells and Platelet-Rich Plasma on Achilles Tendon Ruptures in Rats. Connect Tissue Res. 2016 May 18.
6. De Carli A, Lanzetti RM, Ciompi A, et al. Can platelet-rich plasma have a role in Achilles tendon surgical repair? Knee Surg Sports Traumatol Arthrosc. 2016 Jul;24(7):2231-7. doi: 10.1007/s00167-015-3580-1. Epub 2015 Mar 22.
7. Stopka SS, Wilson GL, Pearsall AW. Dilution Effect of Intra-articular Injection Administered After Knee Arthroscopy. Dilution Effect of Intra-articular Injection Administered After Knee Arthroscopy. J Surg Orthop Adv. 2015 Winter;24(4):209-12.
11. Lyftogt J. Prolotherapy and Achilles tendinopathy: a prospective pilot study of an old treatment. Australasian Musculoskeletal Medicine Journal. 2005;10:16-19.
12. Lyftogt J. Subcutaneous Prolotherapy for Achilles tendinopathy: the best solution? Australasian Musculoskeletal Medicine Journal. 2007;November:107-109
13. Maxwell N, et al. Sonographically guided intratendinous injection of hyperosmolar dextrose to treat chronic tendinosis of the Achilles tendon: a pilot study. American Journal of Radiology. 2007;October:w215-w220.
14. Ryan M, et al. Favorable outcomes after sonographically guided intratendinous injection of hyperosmolar dextrose for chronic insertional midportion Achilles tendinosis. AJR. 2010;194:1047-1053.
15. Yelland MJ, Sweeting KR, Lyftogt JA, Ng SK, Scuffham PA, Evans KA. Prolotherapy injections and eccentric loading exercises for painful Achilles tendinosis: a randomised trial [epub ahead of print] Br J Sports Med (England), Jun 22 2009, pages pending.