Tendon injuries, especially those of the Achilles tendon, are major concerns in sports medicine. The clinical presentation can be acute or chronic and the pathologic findings can range from peritendonitis to full-thickness tendon rupture. Nonsurgical treatment is not always successful; in particular, significant partial ruptures seem to respond poorly to conservative measures and do not improve with time. Surgery is most often considered the favored treatment option for this kind of lesion to obtain pain relief and full functionality with long-standing effects.
This article describes a case of a partial tear of the Achilles tendon in a 34-year-old competitive athlete where surgical treatment was avoided in favor of a new biological approach. We applied autologous platelet growth factors through multiple platelet-rich plasma injections; approximately 6.5 billion platelets were injected into the lesion 3 times, 7 days apart. The treatment with platelet-rich plasma and a progressive rehabilitation program allowed the patient to play for 20 minutes in a basketball game 64 days after the trauma and in a full game 75 days after the trauma. To date, 18 months later, he has participated regularly in all the seasons games and received no further treatment for his tendon.
The fast tissue repair, confirmed by magnetic resonance and ultrasound imaging, allowed a swift return to full functionality and competitive sports activity, suggesting a possible role of platelet growth factors in promoting rapid tendon healing with high-quality tissue. This biological approach may represent a less-invasive therapeutic option even in cases where severe tendon lesions are candidates for surgical treatment.
Tendon injuries, especially those of the Achilles tendon, are major concerns in sports medicine. Problems related to the Achilles tendon, despite being the strongest in the human body, are among the most common and severe conditions affecting athletes in sports that require running and jumping.1 The clinical presentation can be acute or chronic, and the pathologic findings can range from peritendonitis to full-thickness tendon rupture. The pathophysiologic characteristics of tendon tears likely represent a spectrum of disease, with tendinosis predisposing to partial tearing, which without effective treatment ultimately leads to complete tendon rupture. In fact, histopathologic analysis of chronic Achilles tendinopathy has shown that partial ruptures are always surrounded by a noninflammatory, degenerative lesion, indicating that tendon ruptures are not an independent entity but a complication of tendinosis.2
The management modalities of chronic Achilles tendinopathy can be broadly classified into 2 treatment categories: conservative and surgical. Some authors favor nonoperative treatment, even for partial thickness tears.3,4 This may include rest, anti-inflammatory drugs, steroid injections, orthotic devices, attainment of adequate gastrocnemius/soleus strength and flexibility, proper training methods, and respect for the post-symptomatic phase. In addition to the proven classic stretching and strengthening programs, other modalities such as heat, ultrasound, and electrical stimulation are also commonly used. Recently, a heavy-loaded eccentric calf muscle strength training regimen has been popularized as an alternative treatment before surgical intervention.5
However, nonsurgical treatment is not always successful; thus, it has been reported that surgery is required in approximately 25% of Achilles tendinopathy patients.1,6 In particular, significant partial ruptures seem to respond poorly to conservative measures and do not improve with time. Therefore, surgery is most often considered the favored treatment option for this kind of lesion to obtain pain relief and full functionality with long-standing effects.7
This article describes a case of a partial tear of the Achilles tendon in a competitive athlete. Surgical treatment was avoided in favor of a new biological approach.
A 34-year-old competitive basketball player developed a partial Achilles tendon rupture from jumping in a basketball game. His medical history showed an insertional Achilles tendinopathy at the left ankle that had been investigated with magnetic resonance imaging (MRI) 1 year before his injury and treated with a classic physiotherapy approach (rest, stretching, and strengthening exercises). His current symptoms included acute pain, tenderness, limited active plantar flexion, and difficulty walking. On physical examination, beginning approximately 2 to 3 cm proximal to the insertion of the Achilles tendon, a slight palpable gap and edema were present. Sonography and MRI confirmed the tissue lesion and documented a partial rupture of Achilles tendon (Figures 1, 2).
Considering the limited blood supply and consequently the difficult and slow repair processes of this anatomic region that often requires surgical treatment and several months for full recovery of functional capacities, we used platelet growth factors through multiple platelet-rich plasma injections as treatment to improve the tendon healing potential and favor tissue repair.
The clinical experimentation was approved by the Ethics Committee, and written informed consent was obtained. A 150-mL venous blood sample was collected in a bag containing 21 mL sodium citrate, and then 2 centrifugations (the first at 1800 rpm for 15 minutes to separate erythrocytes, and a second at 3500 rpm for 10 minutes to concentrate platelets) produced a 20-mL unit of platelet-rich plasma. All procedures were performed in the same office setting, and the open procedures were performed in an A-class sterile hood.
The unit of platelet-rich plasma was divided into 4 small units of 5 mL each. One unit was sent to the laboratory for an analysis of platelet concentration and quality tests (platelet count and bacteriological test), 1 unit was used for the first injection within 2 hours, and the other 2 units were stored at -30°C. The total number of platelets per milliliter in the platelet-rich plasma presented a concentration that was 6.1 times higher than whole blood values, and approximately 6.5 billion platelets were injected into the lesion each time.
The first application was performed 6 days after the trauma, and the other injections were done every 7 days thereafter. For the second and third treatment, the samples were unfrozen in a dry thermostat (at 37°C for 30 minutes) just before the application. Before the injection, 10% of Ca-chloride (Ca++= 0.22 mEq×dose) was added to the platelet-rich plasma unit to activate platelets. The skin was sterilely dressed, and the targeted area was identified through clinical evaluation and ultrasound. The injection technique involved a single skin portal and multiple (4 to 6) penetrations of the tendon using a 22-gauge needle to distribute the platelet-rich plasma in the intratendinous site in the lesion and at the peritendinous level.
After the procedure, the patient was kept in a prone position for 15 minutes to allow the platelet-rich plasma to remain in the local area. Cold therapy was used on the affected area for pain during the first day, and nonsteroidal anti-inflammatory drugs were avoided. The patient was sent home and told to use ice, rest, and slight weight bearing for the 2 weeks of the injection treatment. Afterwards, a standard stretching protocol and a formal strengthening program were gradually introduced.
The patient returned to competitive sports 64 days after the trauma. The treatment with platelet-rich plasma and a progressive rehabilitation program allowed the patient to play for 20 minutes in an official basketball game 64 days after the trauma and in a full game 75 days after the trauma. To date, 18 months later, the patient has participated regularly in all the seasons games and has received no further treatment for his tendon.
Achilles tendinopathy is a condition with unknown etiology and pathogenesis. Most often, excessive load with repeated microtrauma is considered the major causal factor; however, those with a sedentary lifestyle and elderly persons can also have Achilles tendon problems.8
Other common features considered to predispose an individual to tendon pathology are if the sites are highly stressed; are often exposed to repeated strain, including shear and compressive forces; and are relatively less vascularized. In fact, the site of pathologic findings is typically a zone of relative avascularity 2 to 6 cm from the calcaneal insertion. Histopathology shows little evidence of vascularization in ruptured tendons that are combined with changes in cellularity and decreased matrix organization.9,10
Tendon healing is a complex process that involves several stages, including angiogenesis, cell proliferation, and deposit of the extracellular matrix. These stages are followed by remodeling and maturation, during which the healing tendon should ultimately regain its mechanical strength. In the past few years, several studies have documented a complex regulation of growth factors for the reaction to tissue damage in the reparative process and show the important role of the effectiveness of the growth factor application in the healing of damaged tissue. Studies have shown the role of transforming growth factor beta (TGF-β) in the increased expression of procollagen type I and III and improved mechanical properties.11 Platelet-derived growth factor-BB, insulin-like growth factor 1, and basic fibroblast growth factor promote tendon cell proliferation and tendon healing, whereas vascular endothelial growth factor is a powerful stimulator of angiogenesis.12 In addition, a synergistic effect was observed with a combination of growth factors, resulting in greater proliferation in cell cultures as compared to maximal doses of individual growth factors.13
The fact that platelets secrete growth factors and active metabolites means that their applied use can have a positive influence in clinical situations requiring rapid healing and tissue regeneration. Platelets contain storage pools of growth factors, including platelet-derived growth factor, transforming growth factor, platelet-derived epidermal growth factor, vascular endothelial growth factor, insulin-like growth factor 1, fibroblastic growth factor, and epidermal growth factor, as well as cytokines, chemokines, and newly synthesized metabolites.14
Platelet-rich plasma is a natural concentrate of autologous growth factors and is widely experimented in medical fields such as orthopedics, sports medicine, dentistry, dermatology, ophthalmology, plastic and maxillofacial surgery, and cosmetic surgery. The method is simple, low cost, and minimally invasive, and it allows a high platelet concentration and therefore many growth factors. Their administration in the form of platelet gel provides an adhesive support that can confine secretion to a chosen site.
It has been demonstrated that the healing tendon is responsive to local application of growth factors, and platelet concentrate injections may prove useful for the treatment of tendon ruptures. Releasate from platelet-rich plasma has been shown to stimulate tendon cell proliferation in tendon culture. In vitro studies demonstrated mitogenic activity and that the stimulated tenocytes synthesize vascular endothelial growth factor and hepatocyte growth factor, suggesting a beneficial effect for the treatment of tendon injuries by inducing cell proliferation and promoting the synthesis of angiogenic factors during the healing process.15,16 In a recent study, locally injected platelet-rich plasma has also shown to be useful as an activator of the circulation-derived cells that play a crucial role in the healing process of tissue. The delay of the time-dependent decrease in number of circulation-derived cells may therefore contribute to the enhancement of the initial tendon healing process.17 Animal studies confirm the usefulness of platelet concentrate for the treatment of Achilles tendon ruptures that have increased tendon callus strength and stiffness after percutaneous injections in transacted tendons,18,19 and in a human study, a more rapid recovery in surgically repaired tendons was also seen.20
We applied this biological approach for the treatment of a partial Achilles tendon tear in a 34-year-old patient and obtained a quick recovery with pain relief and a full return to previous sports activity.
- Järvinen TA, Kannus P, Paavola M, Järvinen TL, Józsa L, Järvinen M. Achilles tendon injuries. Curr Opin Rheumatol. 2001; 13(2):150-155.
- Aström M. Partial rupture in chronic achilles tendinopathy. A retrospective analysis of 342 cases. Acta Orthop Scand. 1998; 69(4):404-407.
- Clement DB, Taunton JE, Smart GW. Achilles tendinitis and peritendinitis: etiology and treatment. Am J Sports Med. 1984; 12(3):179-184.
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- Ohberg L, Lorentzon R, Alfredson H. Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up. Br J Sports Med. 2004; 38(1):8-11.
- Paavola M, Kannus P, Paakkala T, Pasanen M, Järvinen M. Long-term prognosis of patients with Achilles tendinopathy. An observational 8-year follow-up study. Am J Sports Med. 2000; 28(5):634-642.
- Smigielski R. Management of partial tears of the gastro-soleus complex. Clin Sports Med. 2008; 27(1):219-229.
- Shalabi A, Svensson L, Kristoffersen-Wiberg M, Aspelin P, Movin T. Tendon injury and repair after core biopsies in chronic Achilles tendinosis evaluated by serial magnetic resonance imaging. Br J Sports Med. 2004; 38(5):606-612.
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- Kashiwagi K, Mochizuki Y, Yasunaga Y, Ishida O, Deie M, Ochi M. Effects of transforming growth factor-beta 1 on the early stages of healing of the Achilles tendon in a rat model. Scand J Plast Reconstr Surg Hand Surg. 2004; 38(4):193-197.
- Molloy T, Wang Y, Murrell G. The roles of growth factors in tendon and ligament healing. Sports Med. 2003; 33(5):381-394.
- Costa MA, Wu C, Pham BV, Chong AK, Pham HM, Chang J. Tissue engineering of flexor tendons: optimization of tenocyte proliferation using growth factor supplementation. Tissue Eng. 2006; 12(7):1937-1943.
- Sánchez AR, Sheridan PJ, Kupp LI. Is platelet-rich plasma the perfect enhancement factor? A current review. Int J Oral Maxillofac Implants. 2003; 18(1):93-103.
- Anitua E, Andía I, Sanchez M, et al. Autologous preparations rich in growth factors promote proliferation and induce VEGF and HGF production by human tendon cells in culture. J Orthop Res. 2005; 23(2):281-286.
- Anitua E, Sanchez M, Nurden AT, et al. Autologous fibrin matrices: a potential source of biological mediators that modulate tendon cell activities. J Biomed Mater Res A. 2006; 77(2):285-293.
- Kajikawa Y, Morihara T, Sakamoto H, et al. Platelet-rich plasma enhances the initial mobilization of circulation-derived cells for tendon healing. J Cell Physiol. 2008; 215(3):837-845.
- Aspenberg P, Virchenko O. Platelet concentrate injection improves Achilles tendon repair in rats. Acta Orthop Scand. 2004; 75(1):93-99.
- Virchenko O, Aspenberg P. How can one platelet injection after tendon injury lead to a stronger tendon after 4 weeks? Interplay between early regeneration and mechanical stimulation. Acta Orthop. 2006; 77(5):806-812.
- Sánchez M, Anitua E, Azofra J, Andía I, Padilla S, Mujika I. Comparison of surgically repaired Achilles tendon tears using platelet-rich fibrin matrices. Am J Sports Med. 2007; 35(2):245-251.
Drs Filardo, Lo Presti, Kon, and Marcacci are from the Department of Orthopedic and Sports Trauma, Biomechanics Laboratory, Rizzoli Orthopaedic Institute, Bologna, Italy.
Drs Filardo, Lo Presti, Kon, and Marcacci have no relevant financial relationships to disclose.
Correspondence should be addressed to: Giuseppe Filardo, MD, Biomechanics Laboratory, Rizzoli Orthopaedic Institute, Via Di Barbiano, 1/10 - 40136 Bologna, Italy (email@example.com).