Non-surgical treatment of Achilles tendon injuries
Ross Hauser, MD
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.
- If you have questions about the Non-surgical treatment of Achilles tendon injuries, get help and information from Caring Medical
New research PRP injections repair achilles tendon damage
Doctors in China writing in the Journal of tissue engineering and regenerative medicine have made the case that platelet rich plasma injections awaken and stimulate native stem cells to repair achilles tendon damage. Here are the bullet points:
- The study’s purpose was to investigate whether platelet-rich plasma would activate tendon-derived stem cells to promote regeneration of Achilles tendon post-rupture in rats.
- In the in vitro study, platelet rich growth factors significantly enhanced cell DNA synthesis (cell replication) improved viability and promoted proliferation, while facilitating cell migration and the recruitment of tendon-derived stem cells.
- In other words, PRP promoted the creation and multiplication of stem cells.1
What does this mean to the patient?
- More evidence that PRP can non-surgically repair an achilles tendon in various degrees of rupture and tear.
New research fat stem cells repair achilles tendon damage
Researchers in South Korea also examined adipose stem cell therapy in a new study from March 2017. Writing in the American journal of sports medicine, the Korean doctors found:
- In tendon injury, Human Adipose-Derived Mesenchymal Stem Cells can enhance tendon healing by secreting their own protein and have potential as a therapeutic option in human tendinopathy.2
- Also from March 2017, Italian researchers found PRP and adipose-derived mesenchymal stem cells to be effective treatments for difficult to treat Achilles tendinopathy. These treatments should be taken into consideration for those patients who require an earlier return to daily activities or sport.3
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,4 and people who run on sand. 5
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 Therapy, 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 addition to the research cited above, another Italian research team 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.6
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 treatments.
The findings reveal that locally applied PRP accelerated healing based on 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.7
PRP after Achilles Tendon Surgery
Spanish researchers writing in the medical journal Knee surgery, sports traumatology, arthroscopy used animal models to examine the biomechanical effects of intra-tendinous injections of Platelet Rich Growth Factors on the healing Achilles tendon after surgical repair. The researchers found that Platelet Rich Growth Factors increased Achilles tendon repair strength at eight weeks compared with the use of placebo.16
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 recent research, and as mentioned in the above citations, 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.”8
Prolotherapy for achilles tear and tendinopathy
Researchers have shown the effectiveness and safety of Prolotherapy injections for management of lower limb tendinopathy and fasciopathy. In the Journal of Foot and Ankle Research
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 Prolotherapy as an effective treatment in both reducing pain and improving function in tendinopathy and fasciopathy.
- The analysis also suggests Prolotherapy injections provided 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.9
In an April 2017 study, doctors writing in the Scandinavian journal of medicine and science in sports reported positive results in 12 of 13 research studies for achieving pain relief and patient satisfaction for patient’s receiving Prolotherapy on chronic painful achilles tendinopathy.15
Prolotherapy shows significant clinical results in study
Researchers from London Independent Hospital and Queen Mary University of London examined intra-tendinous achilles tear (A tear within the tendon). They also examined Prolotherapy as a treatment for this tear, which they write “involves injecting an irritant, such as hyperosmolar dextrose, to stimulate a tissue healing response and ultimately reduce pain.”
In their study, 43 patients with an intra-tendinous tear were given Prolotherapy injections A 4-6 week period of walking boot immobilization was followed by progressive rehabilitation (6-8 weeks).
- 30 patients (70%) responded with VISA-A scores (A scoring system to measure achilles tendon pain) showing significant healing after 3 months and even more so at 12 months. Showing long-lasting results.
- After 5 months, 27% of tears were no longer detectable in imagining.
- Treatment resulted in clinically significant improvements.17
Prolotherapy researcher John Lyftogt MD reported positive results for chronic Achilles tendinopathy (average length of symptoms two years) with subcutaneous dextrose Prolotherapy.10,11
In 2007, Canadian researchers published a study on the use of hyperosmolar dextrose prolotherapy (25%) to treat 32 patients representing 33 tendons with chronic tendinosis of the Achilles. At an average of 12 months after treatment, 20 patients remained symptom free, nine experienced only mild symptoms, and one patient reported moderate symptoms.12
This was supported by research published in 2010 which showed the results of Prolotherapy in 99 patients with long-term pain related to the Achilles tendon. Patients received an 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. 13
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.14
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.
Are you a candidate for our non-surgical treatments? Ask our specialists:
- Ross Hauser, MD | Danielle Steilen-Matias, PA-C | Katie Worsnick, PA-C | David Woznica, MD
1 Xu K, Al-Ani MK, Sun Y, et al. Platelet-rich plasma activates tendon-derived stem cells to promote regeneration of Achilles tendon rupture in rats. J Tissue Eng Regen Med. 2017 Apr;11(4):1173-1184. doi: 10.1002/term.2020. [Pubmed]
2 Lee SY, Kwon B, Lee K, Son YH, Chung SG. Therapeutic Mechanisms of Human Adipose-Derived Mesenchymal Stem Cells in a Rat Tendon Injury Model. Am J Sports Med. 2017 Mar 1:363546517689874. [Pubmed]
3 Usuelli FG, Grassi M, Maccario C. Intratendinous adipose-derived stromal vascular fraction (SVF) injection provides a safe, efficacious treatment for Achilles tendinopathy: results of a randomized controlled clinical trial at a 6-month follow-up. Knee Surg Sports Traumatol Arthrosc. 2017 Mar 1. [Pubmed]
4. 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. [Pubmed]
5. Lorimer AV, Hume PA. Stiffness as a Risk Factor for Achilles Tendon Injury in Running Athletes. Sports Med. 2016 May 18 [Pubmed]
6. 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. [Pubmed]
7. 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. [Pubmed]
8 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. [Pubmed]
9. Sanderson LM, Bryant A. Effectiveness and safety of prolotherapy injections for management of lower limb tendinopathy and fasciopathy: a systematic review. J Foot Ankle Res. 2015 Oct 20;8:57. [Journal Citation]
10. Lyftogt J. Prolotherapy and Achilles tendinopathy: a prospective pilot study of an old treatment. Australian Musculoskeletal Medicine Journal. 2005;10:16-19.
11. Lyftogt J. Subcutaneous Prolotherapy for Achilles tendinopathy: the best solution? Australian Musculoskeletal Medicine Journal. 2007;November:107-109
12. 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. [Pubmed]
13. 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. [Pubmed]
14. 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 Br J Sports Med (England), Jun 22 2009, pages pending. [Pubmed]
15. Morath O, Kubosch EJ, Taeymans J, et al. The effect of sclerotherapy and prolotherapy on chronic painful Achilles tendinopathy – a systematic review including meta-analysis. Scand J Med Sci Sports. 2017 Apr 27. [Pubmed]
16. López-Nájera D, Rubio-Zaragoza M, Sopena-Juncosa JJ, et al. Effects of plasma rich in growth factors (PRGF) on biomechanical properties of Achilles tendon repair. Knee Surg Sports Traumatol Arthrosc. 2016 Dec;24(12):3997-4004. [Pubmed]
17. Chan O, Havard B, Morton S, Pritchard M, Maffulli N, Crisp T, Padhiar N, Perry JD, King J, Morrissey D. Outcomes of prolotherapy for intra-tendinous Achilles tears: a case series. Muscles, Ligaments and Tendons Journal. 2017 Jan;7(1):78. [Pubmed] [Google Scholar]