Achilles tendon rupture non operative treatment

Danielle.Steilen.ProlotherapistDanielle R. Steilen-Matias, MMS, PA-C discusses the use of Prolotherapy, PRP, and Stem Cells as non-surgical treatment for Achilles tendon degeneration and for partial ruptures and as adjunct treatment following complete Achilles tendon rupture and surgery.

What are we going to cover in this article?

Prolotherapy and PRP: An introduction to non-surgical options

Prolotherapy is a regenerative injection technique that stimulates repair of injured tissue. We inject in around an Achilles tear or degenerated tendon to create new healthy, regenerated tissue and get athletes and runners back to their activities.

In 2016, Ross Hauser MD and I noted in our published review of Prolotherapy in the journal: Clinical Medicine Insights Arthritis and Musculoskeletal Disorders

“Consensus is growing regarding the efficacy of dextrose prolotherapy as an alternative to surgery for patients with chronic tendinopathy who have persistent pain despite appropriate rehabilitative exercise.”(1)

Most people that we see in the office for Achilles tendon tear or degeneration have not had success with typical treatments such as anti-inflammatories or standard immobilizing. People who do end up in our office for evaluation of Achilles tendon degeneration and tears heel very well Prolotherapy. This is documented in the research below.

Sometimes we may have to differentiate the treatment based on the type of injury. We can inject dextrose into a degenerative tendon and regenerate tissue but if we’re trying to essentially glue back fibers from a more significant tear, we get healing factor cells from the patient.  This would be platelet rich plasma or PRP cells which come from the patient’s own blood. These cells are injected into the tendon using ultrasound guidance. We may also recommend immobilization to the area. Immobilization is usually not ideal because tendons need motion to heal, however, the exception to that is when we are putting PRP or Prolotherapy in the tendon and we are trying to heal that tendon from more significant damage, then immobilization is sometimes necessary.

Understanding 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 torn sufficiently enough to be considered an acute injury.

In chronic Achilles tendon injuries:

Noninsertional Achilles Tendinitis and Insertional Achilles Tendinitis

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 (Difficult to treat) Achilles Tendinopathies and Prevention of Achilles tendon rupture: Introducing Platelet Rich Plasma Therapy

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 (greater than the normal amount) concentration of platelets. You can learn more about this treatment here What is Platelet Rich Plasma Therapy?

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:

What does this mean to the patient?

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

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.(5)

 

Achilles Tendon Ultrasound

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 the treatment of lower limb tendinopathy and fasciopathy.

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.(7)

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).

Prolotherapy researcher John Lyftogt MD reported positive results in two studies published in the Australian Musculoskeletal Medicine Journal, for chronic Achilles tendinopathy (average length of symptoms two years) with subcutaneous dextrose Prolotherapy.(9,10)

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. (11)

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. (12)

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. (13)

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.

Stem Cell Prolotherapy | Stem cells repair Achilles tendon damage

When there is advanced tearing or more damage to the Achilles tendon, in addition to PRP discussed above, stem cell therapy may be introduced.

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:

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.

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.(16)

Realistic expectations of stem cells and platelet-rich plasma treatments 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:

Treatment following 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.(18)

There have been numerous studies testing the validity of the use of Platelet Rich Plasma during open surgery. These studies have led some to question whether or not PRP can help with post-surgical rehabilitation if applied at the time of surgery.

One of the big problems with studies on PRP or stem cell enhancements at the time of surgery is the problem of dilution.(20) In our article on arthroscopic knee surgery for osteoarthritis, I 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.

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 (please see our article What is Platelet Rich Plasma Therapy?)

The senior researcher had utilized PRP by both methods to treat Achilles tendinopathy over a 7 year period. Twenty-six patients were followed, half having undergone Achilles tendon surgery in combination with PRP administration and the other half PRP injections 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.(21)

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.(22)

In this article, we have shown that Prolotherapy, PRP PRolotherapy, and Stem Cell Prolotherapy can be viable options for your Achilles tendon problems. If you have questions, send it to our staff.

Prolotherapy Specialists

Get Help & Information on your Achilles problem

Danielle Steilen-Matias, PA-C | Katherine Worsnick, PA-C | Ross Hauser, MD | David Woznica, MD

1 Hauser RA, Lackner JB, Steilen-Matias D, Harris DK. A Systematic Review of Dextrose Prolotherapy for Chronic Musculoskeletal Pain. Clinical Medicine Insights Arthritis and Musculoskeletal Disorders. 2016;9:139-159. doi:10.4137/CMAMD.S39160. [Google Scholar]

2. 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. [Google Scholar]

3. Lorimer AV, Hume PA. Stiffness as a Risk Factor for Achilles Tendon Injury in Running Athletes. Sports Med. 2016 May 18 [Google Scholar]

4
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. [Google Scholar]

5. 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. [Google Scholar]

6. 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. [Google Scholar]

7. 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. [Google Scholar]

8 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.  [Google Scholar]

9. Lyftogt J. Prolotherapy and Achilles tendinopathy: a prospective pilot study of an old treatment. Australian Musculoskeletal Medicine Journal. 2005;10:16-19.  [Google Scholar]

10. Lyftogt J. Subcutaneous Prolotherapy for Achilles tendinopathy: the best solution? Australian Musculoskeletal Medicine Journal. 2007;November:107-109 [Google Scholar]

11. Maxwell NJ, Ryan MB, Taunton JE, Gillies JH, Wong AD. Sonographically guided intratendinous injection of hyperosmolar dextrose to treat chronic tendinosis of the Achilles tendon: a pilot study. American Journal of Roentgenology. 2007 Oct;189(4):W215-20. [Google Scholar]

12. Ryan M, Wong A, Taunton J. Favorable outcomes after sonographically guided intratendinous injection of hyperosmolar dextrose for chronic insertional and midportion achilles tendinosis. American Journal of Roentgenology. 2010 Apr;194(4):1047-53. [Google Scholar]

13. 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. [Google Scholar]

14 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. [Google Scholar]

15 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. [Google Scholar]

16.  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. [Google Scholar]

17 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.[Google Scholar]

18 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.[Google Scholar]

19 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. [Google Scholar]

20. 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. [Google Scholar]

21. Oloff L, Elmi E, Nelson J, Crain J. Retrospective Analysis of the Effectiveness of Platelet-Rich Plasma in the Treatment of Achilles Tendinopathy: Pretreatment and Posttreatment Correlation of Magnetic Resonance Imaging and Clinical Assessment. Foot Ankle Spec. 2015 Dec;8(6):490-7. [Google Scholar]

22. Valkering KP, Aufwerber S, Ranuccio F, Lunini E, Edman G, Ackermann PW. Functional weight-bearing mobilization after Achilles tendon rupture enhances early healing response: a single-blinded randomized controlled trial. Knee Surg Sports Traumatol Arthrosc. 2016 Aug 18. [Google Scholar]

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