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Theodorou A, Komnos G, Hantes M. Patellar tendinopathy: an overview of prevalence, risk factors, screening, diagnosis, treatment and prevention. Arch Orthop Trauma Surg 2023; 143:6695-6705. [PMID: 37542006 PMCID: PMC10541843 DOI: 10.1007/s00402-023-04998-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 07/18/2023] [Indexed: 08/06/2023]
Abstract
Patellar tendinopathy (PT), or jumper's knee, is an overuse injury that occurs in professional, as well as recreational, athletes. This condition is a noncontact injury, typically characterized by gradually increasing pain in the patellar tendon. It is prevalent in participants of several sports, but it occurs mostly in jumping sports. The diagnosis of PT is primarily clinical; however, imaging techniques can be useful as well. Risk factors differ between sexes, playing conditions, the kind of sport, playing level and personal characteristics. Screening is an essential tool to assess PT. This condition affects athletic performance and often persists for years. The use of preventative methods is imperative because of the persistence of this condition, especially in elite athletes who sometimes end their career after long and failed treatments. There are a wide variety of treatment and rehabilitation options available, the majority of which are non-operative, such as eccentric exercises, cryotherapy, platelet-rich plasma (PRP) injections, and anti-inflammatory strategies. If conservative treatment fails, surgery is the next most preferable step. Even though there are many surgical treatment methods, there is no clear evidence on what is the most effective approach to address PT. Taking this into consideration, as well as the extent of this clinical entity, novel therapeutic techniques, as well as screening and prevention methods, are expected to emerge in the near future.
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Affiliation(s)
- Andreas Theodorou
- Faculty of Medicine, University of Thessaly, 41500, Larissa, Greece.
| | - Georgios Komnos
- Faculty of Medicine, University of Thessaly, 41500, Larissa, Greece
| | - Michael Hantes
- Faculty of Medicine, University of Thessaly, 41500, Larissa, Greece
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Abstract
Platelets play a crucial role in hemostasis, tissue regeneration and host defense. Based on these settings, platelet-rich plasma (PRP) and its derivatives are therapeutically used to promote wound healing in several scenarios. This review summarizes the biological mechanisms underlying the most traditional as well as innovative applications of PRP in wound healing. These mechanisms involve the combined action of platelet-derived growth factors and cytokines, together with the role of plasma-derived fibrillar, antioxidant and homeostatic factors. In addition, regenerative treatments with PRP consist of personalized and non-standardized methods. Thus, the quality of PRP varies depending on endogenous factors (e.g., age; gender; concomitant medication; disease-associated systemic factors; nutrition) and exogenous factors (anticoagulants and cellular composition). This review also analyses whether these factors affect the biological mechanisms of PRP in wound healing applications.
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Affiliation(s)
- Paula Oneto
- Laboratory of Experimental Thrombosis, Institute of Experimental Medicine-CONICET, National Academy of Medicine, Buenos Aires, Argentina
| | - Julia Etulain
- Laboratory of Experimental Thrombosis, Institute of Experimental Medicine-CONICET, National Academy of Medicine, Buenos Aires, Argentina
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Sari A, Eroglu A. Comparison of ultrasound-guided platelet-rich plasma, prolotherapy, and corticosteroid injections in rotator cuff lesions. J Back Musculoskelet Rehabil 2020; 33:387-396. [PMID: 31743987 DOI: 10.3233/bmr-191519] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Injections are a good alternative to conventional treatment-resistant cases with rotator cuff (RC) lesions before operation. Currently, different injection methods are used in RC lesions. OBJECTIVE To evaluate the efficacy of different injection methods (platelet-rich plasma [PRP], corticosteroid [COR] and prolotherapy [PRO]) in RC tendon lesions. METHODS One hundred and twenty-nine patients were divided into 4 groups as PRP, COR, PRO and the lidocaine group. Subacromial injection was applied to all groups. They were evaluated using the Visual Analogue Scale (VAS), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Western Ontario Rotator Cuff Index (WORC) at 3, 12 and 24 weeks post-injection. RESULTS In the COR group in the 3rd week, VAS and WORC scores were significantly lower than the other groups (p< 0.01 and p< 0.05 respectively). In the PRP group in the 24th week, VAS and WORC scores were found to be significantly lower than the COR group (p< 0.01 and p< 0.05 respectively). In the COR group in the 3rd week the ASES score was found to be significantly higher than the PRP and PRO group (p< 0.01). CONCLUSION In patients with RC lesions, corticosteroid injection provides short-term relief for pain, function, and quality of life, while PRP injection works for long-term wellbeing. For all types of applied injections, improvement in pain, function and quality of life were observed.
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Affiliation(s)
- Aylin Sari
- Erenkoy Physical Therapy and Rehabilitation Hospital, Physical Medicine and Rehabilitation Clinic, Istanbul, Turkey
| | - Ali Eroglu
- Erenkoy Physical Therapy and Rehabilitation Hospital, Sports Medicine Clinic, Istanbul, Turkey
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Aicale R, Oliviero A, Maffulli N. Management of Achilles and patellar tendinopathy: what we know, what we can do. J Foot Ankle Res 2020; 13:59. [PMID: 32993702 PMCID: PMC7523300 DOI: 10.1186/s13047-020-00418-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/28/2020] [Indexed: 02/07/2023] Open
Abstract
Tendinopathies are challenging conditions frequent in athletes and in middle-aged overweight patients with no history of increased physical activity. The term “tendinopathy” refers to a clinical condition characterised by pain, swelling, and functional limitations of tendons and nearby structures, the effect of chronic failure of healing response. Tendinopathies give rise to significant morbidity, and, at present, only limited scientifically proven management modalities exist. Achilles and patellar tendons are among the most vulnerable tendons, and among the most frequent lower extremity overuse injuries. Achilles and patellar tendinopathies can be managed primarily conservatively, obtaining good results and clinical outcomes, but, when this approach fails, surgery should be considered. Several surgical procedures have been described for both conditions, and, if performed well, they lead to a relatively high rate of success with few complications. The purpose of this narrative review is to critically examine the recent available scientific literature to provide evidence-based opinions on these two common and troublesome conditions.
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Affiliation(s)
- Rocco Aicale
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084, Baronissi, Italy.,Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131, Salerno, Italy
| | - Antonio Oliviero
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084, Baronissi, Italy.,Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131, Salerno, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084, Baronissi, Italy. .,Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131, Salerno, Italy. .,Centre for Sports and Exercise Medicine, Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, England. .,Institute of Science and Technology in Medicine, Keele University, School of Medicine, Guy Hilton Research Centre, Thornburrow Drive, Hartshill, Stoke-on-Trent, ST4 7QB, England.
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Abstract
Patellar tendinopathy, or jumper's knee is a common musculoskeletal condition characterized by progressive activity-related pain on the anterior aspect of the knee and tenderness on the patellar tendon. A conservative method is often the first choice of treatment, which can include anti-inflammatory medication, injection therapies, physiotherapy, eccentric exercises, extra corporeal shock wave therapy, orthosis, etc. Although there are several treatment options available, the management of patellar tendinopathy is still controversial. The literature reveals many different injection methods are being used by clinicians for the treatment of patellar tendinopathy. Platelet rich plasma, corticosteroids, autologous blood, and aprotinin are the most commonly used injection treatments. Injection therapies give promising results in the management of Patellar tendinopathy. However, due to low quality research and variation in the protocol and population it is difficult to provide a firm conclusion on its effectiveness. More high-quality clinical studies are recommended to determine the effectiveness of injections and at which stage of Patellar tendinopathy they are the most effective. This review can provide insight to clinicians involved in the management of this condition.
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Affiliation(s)
- Shibili Nuhmani
- Department of Physical Therapy, College of Applied Medical Sciences, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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Oneto P, Zubiry PR, Schattner M, Etulain J. Anticoagulants Interfere With the Angiogenic and Regenerative Responses Mediated by Platelets. Front Bioeng Biotechnol 2020; 8:223. [PMID: 32266247 PMCID: PMC7098916 DOI: 10.3389/fbioe.2020.00223] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 03/05/2020] [Indexed: 12/29/2022] Open
Abstract
Background and aims Platelet rich plasma (PRP) obtained from blood anticoagulated with acid-citrate-dextrose (ACD) or sodium-citrate (SC) is used for regenerative medicine as source of platelet-derived growth factors. Allergic reactions against citrate were reported in patients after local injection of PRP allowing us to hypothesize that anticoagulants exert a harmful and local effect that interferes with the regenerative proprieties of platelets. Herein we test this hypothesis by analyzing the effect of ACD and SC on angiogenic and regenerative responses mediated by platelets. Methods PRP was obtained from SC- or ACD-anticoagulated blood; platelets were lysed to release growth factors; and PRP releasates (PRPr) were used to induce in vitro endothelial proliferation and 2D-migration, and regeneration of mouse skin wounds. Results We first compared proliferation and migration of endothelial cells mediated by anticoagulated-PRPr supplemented or not with CaCl2. Alteration of endothelial adhesion and impediment of proliferation and migration was observed without CaCl2. Although endothelial morphology was normalized in SC- and ACD-PRPr after calcium restitution, angiogenic responses were only markedly induced by SC-PRPr. In vivo studies revealed a delay in mouse skin regeneration after treatment with anticoagulated-PRPr without CaCl2. Healing was only induced after calcium restitution in SC- but ACD-PRPr. Moreover, the development of inflammatory intradermal papules was evidenced after injection of ACD-PRPr. Supplementation of SC-PRPr with the equivalent concentration of dextrose (D-Glucose, 18 mM) present in ACD-PRPr resulted in reduction of endothelial proliferation and migration, delay of mouse skin regeneration and development of intradermal papules. Finally, collecting blood with half amount of SC significantly improved all the angiogenic and regenerative responses mediated by PRPr. In contrast, the delay of skin regeneration and the development of inflammatory papules remained stable after dilution of ACD. Conclusion Our findings indicate that (1) calcium restitution is required to impair the cellular and tissue alterations induced by citrated-anticoagulants contained in PRP; (2) ACD-derived dextrose confers anti-angiogenic, anti-regenerative and pro-inflammatory proprieties to PRP; and (3) half concentration of SC improves the angiogenesis and regeneration mediated by PRP.
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Affiliation(s)
- Paula Oneto
- Laboratory of Experimental Thrombosis, Institute of Experimental Medicine, CONICET-National Academy of Medicine, Buenos Aires, Argentina
| | - Paula Romina Zubiry
- Laboratory of Experimental Thrombosis, Institute of Experimental Medicine, CONICET-National Academy of Medicine, Buenos Aires, Argentina
| | - Mirta Schattner
- Laboratory of Experimental Thrombosis, Institute of Experimental Medicine, CONICET-National Academy of Medicine, Buenos Aires, Argentina
| | - Julia Etulain
- Laboratory of Experimental Thrombosis, Institute of Experimental Medicine, CONICET-National Academy of Medicine, Buenos Aires, Argentina
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Mariani E, Pulsatelli L. Platelet Concentrates in Musculoskeletal Medicine. Int J Mol Sci 2020; 21:ijms21041328. [PMID: 32079117 PMCID: PMC7072911 DOI: 10.3390/ijms21041328] [Citation(s) in RCA: 106] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 01/29/2020] [Accepted: 02/06/2020] [Indexed: 12/02/2022] Open
Abstract
Platelet concentrates (PCs), mostly represented by platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) are autologous biological blood-derived products that may combine plasma/platelet-derived bioactive components, together with fibrin-forming protein able to create a natural three-dimensional scaffold. These types of products are safely used in clinical applications due to the autologous-derived source and the minimally invasive application procedure. In this narrative review, we focus on three main topics concerning the use of platelet concentrate for treating musculoskeletal conditions: (a) the different procedures to prepare PCs, (b) the composition of PCs that is related to the type of methodological procedure adopted and (c) the clinical application in musculoskeletal medicine, efficacy and main limits of the different studies.
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Affiliation(s)
- Erminia Mariani
- Laboratorio di Immunoreumatologia e rigenerazione tissutale, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy;
- Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum-University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
- Correspondence: ; Tel.: +39-051-6366803
| | - Lia Pulsatelli
- Laboratorio di Immunoreumatologia e rigenerazione tissutale, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy;
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Abstract
INTRODUCTION Rupture of the patellar tendon is becoming more and more frequent, even in sports activities overloading the extensor mechanism of the knee. Platelet-rich plasma (PRP) treatment has been recently introduced in treatment for several knee- and sport-related injuries including muscle strain cartilage defect and tendinopathies. The aim of this case report is to present a case of rupture of the patellar tendon occurred after injections of PRP. CASE REPORT A case of a 40-year-old male soccer player sustaining a patellar tendon rupture after a series of 4 PRP injections. At surgery, a complete rupture in the middle of the patellar tendon was found, with severe degenerative changes of the tendon tissue. This case questions the actual efficacy and safety of PRP in severe degenerative tendinopathies.
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Orhurhu V, Schwartz R, Potts J, Peck J, Urits I, Orhurhu MS, Odonkor C, Viswanath O, Kaye A, Gill J. Role of Alpha-2-Microglobulin in the Treatment of Osteoarthritic Knee Pain: a Brief Review of the Literature. Curr Pain Headache Rep 2019; 23:82. [PMID: 31502073 DOI: 10.1007/s11916-019-0822-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
PURPOSE OF REVIEW Chronic knee pain remains a debilitating condition that remains difficult to manage. The purpose of this review, therefore, is to summarize current understanding of alpha-2-microglobulin in the treatment of osteoarthritic knee pain. Furthermore, we investigate its role in the anti-inflammatory properties of platelet-rich plasma (PRP). RECENT FINDINGS Alpha-2-microglobulin, a 720-kD protein complex, is an active protease inhibitor with tremendous anti-inflammatory properties in animal models. A growing body of evidence suggests that this complex is the most instrumental factor for cartilage preservation in PRP injections. As an active component of platelet-rich plasma's anti-inflammatory properties, alpha-2-microglobulin has been shown to be an active inhibitor of joint degeneration, cartilage preservation, and improvement in quality of life for patients with knee osteoarthritis compared with a multitude of other modalities.
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Affiliation(s)
- Vwaire Orhurhu
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA.
| | - Ruben Schwartz
- Department of Anesthesiology, Mount Sinai Medical Center of Florida, Miami, FL, USA
| | - Jacob Potts
- Department of Bioengineering, Northeastern University, Boston, MA, USA
| | - Jacqueline Peck
- Department of Anesthesiology, Mount Sinai Medical Center of Florida, Miami, FL, USA
| | - Ivan Urits
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Mariam Salisu Orhurhu
- Departments of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Charles Odonkor
- Department of Anesthesia, Critical Care and Pain Medicine, Division of Pain, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Omar Viswanath
- Valley Anesthesiology and Pain Consultants, Phoenix, AZ, USA.,Department of Anesthesiology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA.,Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
| | - Alan Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Jatinder Gill
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
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Andriolo L, Altamura SA, Reale D, Candrian C, Zaffagnini S, Filardo G. Nonsurgical Treatments of Patellar Tendinopathy: Multiple Injections of Platelet-Rich Plasma Are a Suitable Option: A Systematic Review and Meta-analysis. Am J Sports Med 2019; 47:1001-1018. [PMID: 29601207 DOI: 10.1177/0363546518759674] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patellar tendinopathy is a condition characterized by anterior knee activity-related pain. It has a high incidence among athletes engaged in jumping sports and may become a chronic condition. Nonoperative management is the first choice in these patients, and several nonsurgical treatment options have been proposed. Nonetheless, clear indications on the most effective approach to address patellar tendinopathy are still lacking. PURPOSE To analyze the evidence on nonoperative options to treat chronic patellar tendinopathy through a systematic review of the literature and to perform a meta-analysis to identify the most effective nonsurgical option. STUDY DESIGN Systematic review and meta-analysis. METHODS The search was conducted with the PubMed and Cochrane databases on January 4, 2017. All clinical English-language reports of any level of evidence on nonsurgical treatment of patellar tendinopathy were included. The quality of each article was assessed by use of the Coleman score. A meta-analysis was performed on all articles reporting the Victorian Institute of Sport Assessment scale for patellar tendinopathy to evaluate the results of the most described treatments. RESULTS A total of 70 studies involving 2530 patients were included in the qualitative data synthesis. The Coleman score showed an overall poor study quality. The most described treatment groups that could be included in the meta-analysis were reported in 22 studies on eccentric exercise, extracorporeal shockwave therapy (ESWT), and platelet-rich plasma (PRP). Single and multiple PRP injections were evaluated separately. Eccentric exercise therapies obtained the best results ( P < .05) at short-term (<6 months, mean 2.7 ± 0.7 months). However, multiple injections of PRP obtained the best results ( P < .05), followed by ESWT and eccentric exercise, at long-term follow-up (≥6 months, mean 15.1 ± 11.3 months). CONCLUSION The literature documents several nonsurgical approaches for the treatment of chronic patellar tendinopathy with important limitations in terms of study quality. The available evidence showed an overall positive outcome, but some differences have been highlighted. Eccentric exercises may seem the strategy of choice in the short-term, but multiple PRP injections may offer more satisfactory results at long-term follow-up and can be therefore considered a suitable option for the treatment of patellar tendinopathy.
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Affiliation(s)
- Luca Andriolo
- II Orthopaedic and Traumatologic Clinic, Rizzoli Orthopaedic Institute, Via Di Barbiano, Bologna, Italy
| | - Sante Alessandro Altamura
- II Orthopaedic and Traumatologic Clinic, Rizzoli Orthopaedic Institute, Via Di Barbiano, Bologna, Italy
| | - Davide Reale
- II Orthopaedic and Traumatologic Clinic, Rizzoli Orthopaedic Institute, Via Di Barbiano, Bologna, Italy
| | | | - Stefano Zaffagnini
- II Orthopaedic and Traumatologic Clinic, Rizzoli Orthopaedic Institute, Via Di Barbiano, Bologna, Italy
| | - Giuseppe Filardo
- Nano-Biotechnology Laboratory, Rizzoli Orthopaedic Institute, Via Di Barbiano, Bologna, Italy
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Unlu MC, Kivrak A, Kayaalp ME, Birsel O, Akgun I. Peritendinous injection of platelet-rich plasma to treat tendinopathy: A retrospective review. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2017; 51:482-487. [PMID: 29108884 PMCID: PMC6197157 DOI: 10.1016/j.aott.2017.10.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 09/18/2017] [Accepted: 10/12/2017] [Indexed: 12/29/2022]
Abstract
Objective The aim of this study was to determine factors associated with the likelihood of a better clinical outcome after the peritendinous injection of PRP for the treatment of chronic tendinopathy and identify whether PRP represents an effective treatment option for chronic tendinopathies. Methods The study included 214 patients (86 males and 128 females; mean age: 39.3 (18–75) years) who received PRP injections for tendinopathy refractory to conventional treatments. The mean duration of symptoms at the moment of the PRP treatment was 8.3 months. Primary outcome measurement was perceived improvement in symptoms for each anatomic compartment for upper and lower limbs at 6 months after treatment. Also, a visual analog scale (VAS) score (pain intensity on a 0–10 scale) was used for pain scoring questionnaire before treatment, 6 weeks and 6 months following the PRP injection(s). To identify factors associated with the likelihood of a better clinical outcome, patients were categorized on the basis of their perceived improvement in symptoms 6 months after the PRP injection(s)—that is, as lower (less than 50% global improvement) or higher (more than 50% global improvement). Results A visual analogue scale score and perceived improvement in symptoms were significantly lower after peritendinous injection in 6-week and 6-month follow-ups compared with the baseline (P < 0.001) except for peroneal and Achilles tendons. Overall, 83% of patients indicated moderate to complete improvement in symptoms. The most common injection sites were the lateral epicondyle, Achilles, and patellar tendons. Furthermore, 30% of patients received only 1 injection, 30% received 2 injections, and 40% received 3 or more injections. A total of 85% of patients were satisfied (more than 50% global improvement) with the procedure. In addition, upper limb tendons, increase in the age, and female gender were associated with a higher likelihood of perceived improvement in symptoms. Conclusions In the present retrospective study assessing PRP injections in the treatment of chronic tendinopathy, a moderate improvement (>50%) in pain symptoms was observed in most of the patients. Our research found that results were most promising with patellar and lateral epicondylar tendinopathy in the short to medium term. Female patients, patients with upper extremity tendinopathy and older patients appeared to benefit more from PRP injection. Level of evidence Level IV, Therapeutic study.
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Affiliation(s)
- Mehmet Can Unlu
- Istanbul University, Cerrahpasa Medical Faculty, Department of Orthopedics and Traumatology, Istanbul, Turkey.
| | - Aybars Kivrak
- Istanbul University, Cerrahpasa Medical Faculty, Department of Orthopedics and Traumatology, Istanbul, Turkey.
| | - Mahmut Enes Kayaalp
- Istanbul University, Cerrahpasa Medical Faculty, Department of Orthopedics and Traumatology, Istanbul, Turkey.
| | - Olgar Birsel
- Koc University Hospital, Department of Orthopedics and Traumatology, Istanbul, Turkey.
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Everhart JS, Cole D, Sojka JH, Higgins JD, Magnussen RA, Schmitt LC, Flanigan DC. Treatment Options for Patellar Tendinopathy: A Systematic Review. Arthroscopy 2017; 33:861-872. [PMID: 28110807 DOI: 10.1016/j.arthro.2016.11.007] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 10/24/2016] [Accepted: 11/03/2016] [Indexed: 02/07/2023]
Abstract
PURPOSE To compare the efficacy of common invasive and noninvasive patellar tendinopathy (PT) treatment strategies. METHODS A systematic search was performed in PubMed, Google Scholar, CINAHL, UptoDate, Cochrane Reviews, and SPORTDiscus. Fifteen studies met the following inclusion criteria: (1) therapeutic outcome trial for PT, and (2) Victorian Institute of Sports Assessment was used to assess symptom severity at follow-up. Methodological quality and reporting bias were evaluated with a modified Coleman score and Begg's and Egger's tests of bias, respectively. RESULTS A total of 15 studies were included. Reporting quality was high (mean Coleman score 86.0, standard deviation 9.7), and there was no systematic evidence of reporting bias. Increased duration of symptoms resulted in poorer outcomes regardless of treatment (0.9% decrease in improvement per additional month of symptoms; P = .004). Eccentric training with or without core stabilization or stretching improved symptoms (61% improvement in the Victorian Institute of Sports Assessment score, 95% confidence interval [CI] 53% to 69%). Surgery in patients refractory to nonoperative treatment also improved symptoms (57%, 95% CI 52% to 62%) with similar outcomes among arthroscopic and open approaches. Results from shockwave (54%, 95% CI 22% to 87%) and platelet-rich plasma (PRP) studies (55%, 95% CI 5% to 105%) varied widely though PRP may accelerate early recovery. Finally, steroid injection provided no benefit (20%, 95% CI -20% to 60%). CONCLUSIONS Initial treatment of PT can consist of eccentric squat-based therapy, shockwave, or PRP as monotherapy or an adjunct to accelerate recovery. Surgery or shockwave can be considered for patients who fail to improve after 6 months of conservative treatment. Corticosteroid therapy should not be used in the treatment of PT. LEVEL OF EVIDENCE Level IV, systematic review of Level II-IV studies.
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Affiliation(s)
- Joshua S Everhart
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio, U.S.A.; College of Medicine, The Ohio State University, Columbus, Ohio, U.S.A
| | - Devon Cole
- College of Medicine, The Ohio State University, Columbus, Ohio, U.S.A
| | - John H Sojka
- College of Medicine, The Ohio State University, Columbus, Ohio, U.S.A
| | - John D Higgins
- College of Medicine, The Ohio State University, Columbus, Ohio, U.S.A
| | - Robert A Magnussen
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio, U.S.A.; College of Medicine, The Ohio State University, Columbus, Ohio, U.S.A
| | - Laura C Schmitt
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio, U.S.A.; College of Medicine, The Ohio State University, Columbus, Ohio, U.S.A.; Division of Physical Therapy, School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio, U.S.A
| | - David C Flanigan
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio, U.S.A.; College of Medicine, The Ohio State University, Columbus, Ohio, U.S.A.; Division of Physical Therapy, School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio, U.S.A.; Cartilage Restoration Center, The Ohio State University, Columbus, Ohio, U.S.A..
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Sensini A, Gualandi C, Cristofolini L, Tozzi G, Dicarlo M, Teti G, Mattioli-Belmonte M, Letizia Focarete M. Biofabrication of bundles of poly(lactic acid)-collagen blends mimicking the fascicles of the human Achille tendon. Biofabrication 2017; 9:015025. [DOI: 10.1088/1758-5090/aa6204] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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14
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Ho KY, Kulig K. Changes in water content in response to an acute bout of eccentric loading in a patellar tendon with a history of tendinopathy: A case report. Physiother Theory Pract 2016; 32:566-70. [PMID: 27472664 DOI: 10.1080/09593985.2016.1206646] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This case-based report assessed resting water content and exercise-driven water exchange within a tendon with a history of tendinopathy and compared the response to that of a healthy uninvolved tendon. DESIGN Case Report. SETTING University imaging center. PARTICIPANT The participant was a 27-year-old female basketball player 39 months following knee trauma. Patellar tendinopathy developed 12 months after the injury episode and was treated with eccentric exercises. Eighteen months from the beginning of the first eccentric training bout, the participant reported full resolution of symptoms and returned to her pre-injury sport participation without symptoms. INTERVENTION Eccentric decline squat exercise. MAIN OUTCOME MEASURES Tendon water content obtained from magnetic resonance imaging (MRI). RESULTS MRI acquired 39 months post-injury demonstrated increased resting water content of the involved tendon (involved: 91.1% vs. uninvolved: 84.6%). Immediately after the eccentric squat maneuver, water content decreased on both involved and uninvolved tendons (involved: 89.5% vs. uninvolved: 83.3%). CONCLUSIONS Elevated resting water content of the involved tendon found in this report may be indicative of reduced tendon stiffness. A similar amount of water content reduction was observed on both sides following mechanical loading, suggesting that the involved tendon may respond to the eccentric exercise similarly to the uninvolved tendon. Future investigations are needed to study the relationships among tendon water exchanges, mechanical properties, patient symptoms, and tissue injuries.
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Affiliation(s)
- Kai-Yu Ho
- a Department of Physical Therapy , University of Nevada , Las Vegas, Las Vegas , NV , USA
| | - Kornelia Kulig
- b Division of Biokinesiology and Physical Therapy , University of Southern California , Los Angeles , CA , USA
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Kaux J, Croisier J, Forthomme B, Le Goff C, Buhler F, Savanier B, Delcour S, Gothot A, Crielaard J. Using platelet-rich plasma to treat jumper's knees: Exploring the effect of a second closely-timed infiltration. J Sci Med Sport 2016; 19:200-204. [DOI: 10.1016/j.jsams.2015.03.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Revised: 03/05/2015] [Accepted: 03/13/2015] [Indexed: 01/15/2023]
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Liddle AD, Rodríguez-Merchán EC. Platelet-Rich Plasma in the Treatment of Patellar Tendinopathy: A Systematic Review. Am J Sports Med 2015; 43:2583-90. [PMID: 25524323 DOI: 10.1177/0363546514560726] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patellar tendinopathy (PT) is a major cause of morbidity in both high-level and recreational athletes. While there is good evidence for the effectiveness of eccentric exercise regimens in its treatment, a large proportion of patients have disease that is refractory to such treatments. This has led to the development of novel techniques, including platelet-rich plasma (PRP) injection, which aims to stimulate a normal healing response within the abnormal patellar tendon. However, little evidence exists at present to support its use. PURPOSE To determine the safety and effectiveness of PRP in the treatment of PT and to quantify its effectiveness relative to other therapies for PT. STUDY DESIGN Systematic review. METHODS A systematic review was conducted in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. A literature review was conducted of the Medline, EMBASE, and Cochrane databases as well as trial registries. Both single-arm and comparative studies were included. The outcomes of interest were pain (as measured by visual analog or other, comparable scoring systems), functional scores, and return to sport. Study quality and risk of bias were assessed using the methodological index for nonrandomized studies (MINORS) score and the Cochrane risk of bias tool. RESULTS Eleven studies fit the inclusion criteria. Of these, 2 were randomized, controlled trials (RCTs), and 1 was a prospective, nonrandomized cohort study. The remainder were single-arm case series. All noncomparative studies demonstrated a significant improvement in pain and function after PRP injection. Complications and adverse outcomes were rare. The results of the comparative studies were inconsistent, and superiority of PRP over control treatments could not be conclusively demonstrated. CONCLUSION Platelet-rich plasma is a safe and promising therapy in the treatment of recalcitrant PT. However, its superiority over other treatments such as physical therapy remains unproven. Further RCTs are required to determine the relative effectiveness of the many available treatments for PT and to determine the subgroups of patients who stand to gain the most from the use of these therapies.
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Affiliation(s)
- Alexander D Liddle
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Kaux JF, Drion P, Croisier JL, Crielaard JM. Tendinopathies and platelet-rich plasma (PRP): from pre-clinical experiments to therapeutic use. J Stem Cells Regen Med 2015. [PMID: 26195890 PMCID: PMC4498322 DOI: 10.46582/jsrm.1101003] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The restorative properties of platelets, through the local release of growth factors, are used in various medical areas. This article reviews fundamental and clinical research relating to platelet-rich plasma applied to tendinous lesions. MATERIALS AND METHOD Articles in French and English, published between 1 January 2012 and 31 December 2014. dealing with PRP and tendons were searched for using the Medline and Scopus data bases. RESULTS Forty-seven articles were identified which addressed pre-clinical and clinical studies: 27 relating to in vitro and in vivo animal studies and 20 relating to human studies. Of these, five addressed lateral epicondylitis, two addressed rotator cuff tendinopathies, ten dealt with patellar tendinopathies and three looked at Achilles tendinopathies. CONCLUSIONS The majority of pre-clinical studies show that PRP stimulates the tendon's healing process. However, clinical series remain more controversial and level 1, controlled, randomised studies are still needed.
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Affiliation(s)
- Jean-François Kaux
- Physical Medicine and Sports Traumatology Department, University and University Hospital of Liège, Liège, Belgium
| | - Pierre Drion
- ULg-GIGA-R, Experimental Surgery, University of Liège, Belgium
| | - Jean-Louis Croisier
- Physiotherapy Service, Department of Motility Sciences, University of Liège, Liège, Belgium
| | - Jean-Michel Crielaard
- Physical Medicine and Sports Traumatology Department, University and University Hospital of Liège, Liège, Belgium
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Andia I, Maffulli N. Muscle and tendon injuries: the role of biological interventions to promote and assist healing and recovery. Arthroscopy 2015; 31:999-1015. [PMID: 25618490 DOI: 10.1016/j.arthro.2014.11.024] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 10/30/2014] [Accepted: 11/13/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To summarize clinical studies after platelet-rich plasma (PRP) therapy for tendinopathy, plantar fasciopathy, and muscle injuries; to review PRP formulations used across studies; and to identify knowledge deficits that require further investigation. METHODS After a systematic review in PubMed, we identified clinical studies assessing PRP efficacy in tendon and muscle during the past decade. We standardized data extraction by grouping studies based on anatomic location; summarized patient populations, PRP formulations, and clinical outcomes; and identified knowledge deficits that require further investigation. RESULTS Overall, 1,541 patients had been treated with PRP in 58 clinical studies; of these, 26 addressed upper limb tendinopathies and 32 addressed the lower limb (810 patients and 731 patients treated with PRP, respectively). The quality of research is higher for the upper limb than for the lower limb (23 controlled studies, of which 17 are Level I, v 19 controlled studies, of which 6 are Level I, respectively). Patients have been treated mostly with leukocyte-platelet-rich plasma, except in the arthroscopic management of the rotator cuff. The safety and efficacy of PRP for muscle injuries has been addressed in 7 studies including 182 patients. Differences across results are mainly attributed to dissimilarities between tissues and different stages of degeneration, numbers of PRP applications, and protocols. CONCLUSIONS Given the heterogeneity in tendons and tendinopathies, currently, we are not able to decide whether PRP therapies are useful. Despite advances in PRP science, data are insufficient and there is a clear need to optimize protocols and obtain more high-quality clinical data in both tendinopathies and muscle injuries before making treatment recommendations. LEVEL OF EVIDENCE Level IV, systematic review of Level I through IV studies.
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Affiliation(s)
- Isabel Andia
- Regenerative Medicine Laboratory, BioCruces Health Research Institute, Cruces University Hospital, Barakaldo, Spain
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, University of Salerno School of Medicine and Dentistry, Salerno, Italy; Queen Mary University of London, London, England; Barts and The London School of Medicine and Dentistry, London, England; Centre for Sports and Exercise Medicine, Mile End Hospital, London, England.
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Lomas A, Ryan C, Sorushanova A, Shologu N, Sideri A, Tsioli V, Fthenakis G, Tzora A, Skoufos I, Quinlan L, O'Laighin G, Mullen A, Kelly J, Kearns S, Biggs M, Pandit A, Zeugolis D. The past, present and future in scaffold-based tendon treatments. Adv Drug Deliv Rev 2015; 84:257-77. [PMID: 25499820 DOI: 10.1016/j.addr.2014.11.022] [Citation(s) in RCA: 135] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 11/08/2014] [Accepted: 11/12/2014] [Indexed: 02/07/2023]
Abstract
Tendon injuries represent a significant clinical burden on healthcare systems worldwide. As the human population ages and the life expectancy increases, tendon injuries will become more prevalent, especially among young individuals with long life ahead of them. Advancements in engineering, chemistry and biology have made available an array of three-dimensional scaffold-based intervention strategies, natural or synthetic in origin. Further, functionalisation strategies, based on biophysical, biochemical and biological cues, offer control over cellular functions; localisation and sustained release of therapeutics/biologics; and the ability to positively interact with the host to promote repair and regeneration. Herein, we critically discuss current therapies and emerging technologies that aim to transform tendon treatments in the years to come.
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Abstract
Context: Patellar tendinopathy is a common condition. There are a wide variety of treatment options available, the majority of which are nonoperative. No consensus exists on the optimal method of treatment. Evidence Acquisition: PubMed spanning 1962-2014. Study Design: Clinical review. Level of Evidence: Level 4. Results: The majority of cases resolve with nonoperative therapy: rest, physical therapy with eccentric exercises, cryotherapy, anti-inflammatories, corticosteroid injections, extracorporeal shockwave therapy, glyceryl trinitrate, platelet-rich plasma injections, and ultrasound-guided sclerosis. Refractory cases may require either open or arthroscopic debridement of the patellar tendon. Corticosteroid injections provide short-term pain relief but increase risk of tendon rupture. Anti-inflammatories and injectable agents have shown mixed results. Surgical treatment is effective in many refractory cases unresponsive to nonoperative modalities. Conclusion: Physical therapy with an eccentric exercise program is the mainstay of treatment for patellar tendinopathy. Platelet-rich plasma has demonstrated mixed results; evidence-based recommendations on its efficacy cannot be made. In the event that nonoperative treatment fails, surgical intervention has produced good to excellent outcomes in the majority of patients.
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Affiliation(s)
- Aaron Schwartz
- Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Jonathan N Watson
- Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Mark R Hutchinson
- Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois
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Talaie T, Pratt SJP, Vanegas C, Xu S, Henn RF, Yarowsky P, Lovering RM. Site-specific targeting of platelet-rich plasma via superparamagnetic nanoparticles. Orthop J Sports Med 2015; 3. [PMID: 25664326 PMCID: PMC4316754 DOI: 10.1177/2325967114566185] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background: Muscle strains are one of the most common injuries treated by physicians. Standard conservative therapy for acute muscle strains usually involves short-term rest, ice, and nonsteroidal anti-inflammatory medications, but there is no clear consensus regarding treatments to accelerate recovery. Recently, clinical use of platelet-rich plasma (PRP) has gained momentum as an option for therapy and is appealing for many reasons, most notably because it provides growth factors in physiological proportions and it is autologous, safe, easily accessible, and potentially beneficial. Local delivery of PRP to injured muscles can hasten recovery of function. However, specific targeting of PRP to sites of tissue damage in vivo is a major challenge that can limit its efficacy. Hypothesis: Location of PRP delivery can be monitored and controlled in vivo with noninvasive tools. Study Design: Controlled laboratory study. Methods: Superparamagnetic iron oxide nanoparticles (SPIONs) can be visualized by both magnetic resonance imaging (MRI) (in vivo) and fluorescence microscopy (after tissue harvesting). PRP was labeled with SPIONs and administered by intramuscular injections of SPION-containing platelets. MRI was used to monitor the ability to manipulate and retain the location of PRP in vivo by placement of an external magnet. Platelets were isolated from whole blood and incubated with SPIONs. Following SPION incubation with PRP, a magnetic field was used to manipulate platelet location in culture dishes. In vivo, the tibialis anterior (TA) muscles of anesthetized Sprague-Dawley rats were injected with SPION-containing platelets, and MRI was used to track platelet position with and without a magnet worn over the TA muscles for 4 days. Results: The method used to isolate PRP yielded a high concentration (almost 4-fold increase) of platelets. In vitro experiments showed that the platelets successfully took up SPIONs and then rapidly responded to an applied magnetic field. Platelets without SPIONs did not respond to the magnetic field. In vivo experiments showed that the SPION-containing platelets can be noninvasively maintained at a specific site with the application of a magnetic field. Conclusion: PRP may be a useful product in the clinical treatment of muscle injuries, but one problem with using it as a therapeutic tool is retaining PRP at the site of injury. This study proposes a potential solution, with findings that support this method at the cell, whole muscle, and in vivo levels. Controlling the location of PRP will allow the clustering of PRP to enrich the target area with growth factors and will prevent loss of platelets over time at the site of injury.
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Affiliation(s)
- Tara Talaie
- Department of Orthopaedics, University of Maryland School of Medicine
| | - Stephen J P Pratt
- Department of Orthopaedics, University of Maryland School of Medicine
| | - Camilo Vanegas
- Department of Orthopaedics, University of Maryland School of Medicine
| | - Su Xu
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine
| | - R Frank Henn
- Department of Orthopaedics, University of Maryland School of Medicine
| | - Paul Yarowsky
- Department of Pharmacology, University of Maryland School of Medicine
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Demange MK, de Almeida AM, Rodeo SA. Updates in biological therapies for knee injuries: tendons. Curr Rev Musculoskelet Med 2014; 7:239-46. [PMID: 24957507 DOI: 10.1007/s12178-014-9230-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Tendons are subjected to tendinopathies caused by inflammation, degeneration, and weakening of the tendon, due to overuse and trauma, which may eventually lead to tendon rupture. Recently, there has been increasing interest in biological approaches to augment tissue healing. Tendon healing occurs through a dynamic process with inflammation, cellular proliferation, and tissue remodeling. In this review article, we discuss the more frequently proposed biological therapies for tendon injuries as platelet-rich plasma, mesenchymal stem cells, extracorporeal shockwave, and scaffolds.
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Affiliation(s)
- Marco Kawamura Demange
- Knee Surgery Division, Hospital das Clínicas, Orthopedic Surgery, Faculty of Medicine, University of São Paulo - Brazil, São Paulo, Brazil,
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Abstract
Nonsurgical care by a specialist in physical medicine and rehabilitation is typically a multifaceted approach, which can include modalities, bracing, medication, injection, proprioceptive techniques, restoration of normal movement patterns, and overall conditioning. There is evidence that physical therapy interventions have significant beneficial effect on pain and function compared with no treatment.
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Affiliation(s)
- Melody Hrubes
- Department of Orthopaedic Surgery, UIC Sports Medicine Center, 839 West Roosevelt Avenue, Suite #102, Chicago, IL 60608, USA
| | - Terry L Nicola
- Department of Orthopaedic Surgery, UIC Sports Medicine Center, 839 West Roosevelt Avenue, Suite #102, Chicago, IL 60608, USA.
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