PRP is Not for Routine Office Use

Those two recommended set of injections at $6,000 per series for your Achilles tendinitis hasn’t sounded very good for the past few years. Ever since a controlled, prospective comparison study demonstrated there was absolutely no difference in the efficacy of PRP over saline injected in the same manner, there has been doubt about the use of PRP in the office. But instead of falling by the wayside, like a bad political candidate, it has spread by meme and scheme far and wide and even infiltrated some of the best offices in the country and world.

The British Medical Journal has recently posted an article strongly recommending against the in office use of PRP (platelet rich plasma) outside of PRP Production (from BMJ)established studies.

The article was titled: “How effective are platelet rich plasma injections in treating musculoskeletal soft tissue injuries?” The answer, at this time, seems to lie somewhere between “we have no clue” and “not very”. This study mentions a previous review by the Cochrane review (2014) which examined 19 studies and found insufficient evidence of the usefulness of PRP. This study reviews 10 additional studies and reaches the same conclusion.

The article is readily available and worth a read:

PRP review at BMJ

References:

How effective are platelet rich plasma injections in treating musculoskeletal soft tissue injuries?  Keene,DJ, Alsousou,J, Willett,K BMJ 2016;352:i517
BMJ 2016; 352 doi: http://dx.doi.org/10.1136/bmj.i517 (Published 17 February 2016)

Autologous platelets have no effect on the healing of human achilles tendon ruptures: a randomized single-blind study. Schepull T1, Kvist J, Norrman H, Trinks M, Berlin G, Aspenberg P. Am J Sports Med. 2011 Jan;39(1):38-47. doi: 10.1177/0363546510383515. Epub 2010 Nov 3.

 

 

 

Low Heel Drop And Achilles Tendonitis

Two articles currently up on the Runner’s World news and blog areas take opposite approaches to Achilles tendon problems. One cites a study of normal individuals who were asymptomatic and measured “load” in the Achilles tendon and concluded that there would probably be no help given by a heel lift. This was not a clinical study of treatment however and it has no validity regarding statements made about treatment. In fact the least helpful part of many studies is in the “discussion” part of the study where the authors speculate about what their study means, but which their study did not show. Please beware of author speculation. There are only a few who are accurate in their speculations. And some of them win Nobel prizes.

The other article is a blog by a coach who noted that her runners seemed to be having an inordinate amount of calf and Achilles problems. These are clinical and coaching observations and not a published study. But, there truly may be wisdom in systematic observations. Over the past 6 months she noted that this injury seemed to have surged and become a trend. The calf and Achilles problems were often seen among runners who had thought they were purchasing the same shoe they had run in for years only to find that the “heel drop” (heel to forefoot height differential)  had dramatically decreased. Initially I was going to post on Coach Jenny’s blog article  but I’ll just link to it and make my remarks here.  I believe she is right on top of things in her blog.

Over the past 3 years many manufacturers have attempted  to “minimize” nearly their entire product line. A shoe which had a 12 mm heel drop, now has 8 mm. And of course zero to 2 mm are often touted as the ideal. But the reality is that not everyone responds well or even the same to changes.

As George Sheehan said “we are all an experiment of one”. And the modern reality is that studies, trends, and memes are aggregate while injuries happen to individuals. And individuals need tailored solutions that are not always the trendy advice making the rounds.

So in spite of  some “nay-sayers”, who adamantly disagree, I side with Coach Jenny. Often returning those 4 mm or so back as a heel lift, can make the difference between comfort and pain. Instead of a soft gel or foam heel lift, I prefer a solid heel lift made of firm layered plastic film, hard rubber, or leather. You may find that after months of icing, foam rolling, massage and even lower heel drop shoes, this may be your answer. But if you’ve had the pain that long, you may need to check in with your sports doc. (And hope the advice is different from what has failed during your experiments!)

This is still not the entire answer for many individuals and there are other things to analyze. Shoe changes, training changes, terrain, and recent racing history along with individual biomechanics all come into play for a more complete analysis of the causes and the likely solutions. YMMV

 

 

 

The Science of Bone and Tendon Injuries (slideshare)

Perhaps one day I’ll break this up into 5 slideshares and 5 articles. But for now, here are the slides from a lecture presented at the Sports Medicine Section of the  American Podiatric Medical Associations Annual Scientific Conference.

I believe that basic science and research is an important component for advances clinical medicine. This lecture highlights some of that research from barebones systems biology to mechanotransduction. Cell mechanics, structure and biology are where the action is.

 

Slideshare: Overuse bone and tendon injuries – science and theories of tomorrow

Heel Lifts and Achilles Tendonitis (Tendinopathy) (repost 2008)

Point / Counter Point: The Truth is Out There Somewhere (or maybe here)

Every now and then the “Fear Factor” comes to the Internet. And if you travel the running blogosphere, you’ll discover that sometimes it takes the form of a red alert for heel lifts for Achilles tendonitis. It seems that some would rather have you run in pain or give up because of the pain for fear that a 1/8″, 1/4″ or 3/8″ lift which alleviates the pain could cause a tendon to “pop”. There is evidence that the sound of a tendon popping may come after an indiscriminate intratendinous injection of steroid though. 

The truth is one should pay attention to what your body is telling you. Running in pain which causes an alteration in form is not good. It will most likely lead to both your original injury not improving, and a few additional injuries because of your altered gait.   

With the knowledge that medicine is an art and a science, it is probably best to avoid dogmatic opinions such as  “no, no ,no” to a heel lift. While some will be helped with shoe and surface corrections, orthotics, stretching and strengthening alone, the addition of a 1/8 – 3/8″ heel lift can often make the difference in both comfort and eventual healing of this condition. The lift is used on both sides to avoid creating a longer leg and altering the gait in such a manner that could create low back pain, hip pain or other problems in the absence of the affected leg being a short limb. The lift is best made of a non-compressible material. It is extremely important to avoid compressible materials which will lead to continued slow stretch movement which could add to either activating the stretch reflex of the achilles tendon or allow for eccentric contraction of the muscle-tendinous complex. This may work to inhibit the healing of the tendon, and stop the individual from being able to run without pain. We certainly, and the ladies among us, especially, will vary our heels by much more than this over the course of a week. A slight change in the heel contact and foot angle should not put your Achilles tendon at greater risk of injury. 

While there are flaws in evidence based medicine and in the ability of us to accurately predict those most likely to become injured, there is  no evidence that 1/8 to 3/8 ” lifts cause ruptured Achilles tendons. Not even the slightest hint that muscles and tendons would be ruined by such a lift or adapted so much that you’ll never be the same. I do not know of any study that shows a 1/4″ lift used for a limited amount of time each day could shorten the muscle/tendon complex. There is adequate time spent in other shoes, barefoot, and even doing stretching exercises. 

Running in pain without a heel lift, or more dramatically running on a soft surfacer with a mushy, over cushioned shoe or a racing flat is far more likely to lead to chronic pain and disability. Proper orthotics are a must, along with avoiding over cushioned running shoes to prevent the tendon while functioning from being over stretched and causing eccentric working of the muscle-tendon complex . There seems to be no reason to avoid a heel lift, but it is not the be all and end all of a program to treat Achilles tendonitis. 

For more details:

Website article: Dr. Pribut on Achilles Tendon Injuries

 Previous Blog entry on Achilles Tendon and stretching

Quick Search of Textbook Comments On Heel Lifts:

I wasn’t sure what I’d find in the texts, but thought it would be interesting to see what other minds have come up with on this issue. I did not think that Noakes would agree with the heel lift, but he did. I do not know what is the scientific basis or aggregate clinical experience to imply that heel lifts are the worst possible therapy for this problem. 

Alfredson, H. and Cook, J. in Clinical Sports Medicine, 3rd Edition eds. Bruckner et. al. McGraw Hill 2006, reprinted 2007. Chapter 32 “Pain in the Achilles Region” p.  606 “A heel lift worn inside both shoes (0.5 – 1.0 cm, .25-0.5 “) is a good practical way of unloading the region. 

Alfredson is famous for his self termed “painful” eccentric stretching for non-insertional Achilles tendinopathy. He has published numerous articles on Achilles tendon problems and on the treatment of them. I am not convinced that eccentric stretching is appropriate in as many cases it is recommended. If you find something isn’t working, including the eccentric work is not helping, you need to change the approach. Measurements have shown that the calf is often weak in eccentric strength when one has Achilles tendonitis. One approach is to work on strengthening that (which can be painful). The other is to diminish the pain by lessening stresses which add to the eccentric contraction strength required. Both approaches and sometimes a combination may be appropriate for different patients and at different times for a specific patient.  I continue  to read Alfredson’s  articles with interest. (And in actuality will recommend his exercises in a manner and when it can be done without causing pain. 2012)

Bradshaw, C. and Hislop, M. in Clinical Sports Medicine, 3rd Edition eds. Bruckner et. al. McGraw Hill 2006, reprinted 2007. Chapter 31 “Calf Pain” Since the calf includes the muscles which create the Achilles tendon, we’ll look at comments in this chapter also. “A heel raise should be used on the injured and uninjured side”. 

Title, C. and Schon, L. “Achilles tendon disorders including tendinosis and tears” in Baxter’s The Foot and Ankle In Sport, Second Edition. Mosby Elsevier. Eds. Porter, D. and Schon, L. 2008. “The initial treatment for Achilles tendinitis is nonoperative. The majority of symptoms respond to rest; activity modification; improved training techniques; stretching and at times, shoe modifications and heel lifts. Initial treatment should include …At times, a heel lift (one fourth to three eights inch)….”

Noakes “The Lore of Running, Fourth Edition”  Human Kinetics Press. 2003. Noakes feels a shoe with a heel height of higher than 12 – 15 mm and says “most authorities agree that a 7 to 15 mm heel-raise should be added to the running shoes”.

Achilles Tendinopathy: 2010 – Disappointing Results with PRP (repost from 01/2010)

Update: The results are still controversial and contradictory on PRP and Achilles tendinopathy. This is a repost of a blog from 2010. (The primary reason for the repost is moving material of archival interest to a site which functions better.)

A study published in the Journal of the American Medical Association, Jan. 13, 2010 gave disappointing results in using plasma rich protein to treat non-insertional Achilles tendinopathy. It showed no difference between using a sham injection of saline and combining it with a painful eccentric stretching protocol  in comparison with an injection of plasma rich protein injection along with the standard painful eccentric stretching protocol.

The authors note that previous studies did not have good control groups. In this small study, 27 patients were in the placebo group and 27 in the treatment group. The VISA-A score was used to assess improvement. Both groups improved somewhat without a significant difference between the two groups.

The study was called a “preliminary communication” which is often done with small studies. Other studies on similar topics with fewer than 30 individuals studies have also been billed as “preliminary studies”, but when they are talked up afterward, the “preliminary study” status is usually forgotten. As far as study design goes, the design, blinding, and performance of the study seems just right. I am not entirely convinced of the efficacy of the painful eccentric stretching protocol and would have not minded another study group omitting that treatment. Apparently it is not a panacea (or there would not be studies looking to add to the results), although the initial preliminary study made it sound as though it would be. Follow up journal articles by the primary author of the first study have been positive and are referenced below. Others have expressed reservations on the methodology. (see Woodley et. al. 2007 and Kingma et. al. 2006) Eccentric stretching and overload for tendinopathy has mixed results at best in other body areas.

Note: VISA-A is the Victorian Institute of Sports Assessment-Achilles

References:

Platelet-Rich Plasma Injection for Chronic Achilles Tendinopathy: A Randomized Controlled Trial
Robert J. de Vos; Adam Weir; Hans T. M. van Schie; et al. JAMA. 2010;303(2):144-149 (doi:10.1001/jama.2009.1986)

Alfredson H. Chronic midportion Achilles tendinopathy: an update on research and treatment. Clin Sports Med. 2003;22(4):727-741.

Alfredson H and Cook J (2007), A treatment algorithm for managing Achilles tendinopathy, new treatment options, British Journal of Sports Medicine, 41, 4, 211.

J J Kingma, R de Knikker, H M Wittink, T Takken. Eccentric overload training in patients with chronic Achilles tendinopathy: a systematic review. Br J Sports Med 2007;41:e3 (http://www.bjsportmed.com/cgi/content/full/41/6/e3). doi: 10.1136/bjsm.2006.030916 (concludes: Studies on the effectiveness of eccentric overload training in patients with Achilles tendinopathy show many methodological shortcomings)

Woodley, B.L., R.J. Newsham- West, and D.B. Baxter, Chronic tendinopathy: effectiveness of eccentric exercise. Br J Sports Med, 2007. 41: p. 188-199.

Additional Information:

Pribut, S.M.,  Top 5 Running Injuries. Podiatry Management, 2008

Blog on: Heel Lifts and Achilles Tendinitis

Dr. Pribut on Achilles Tendinopathy

Dr. Pribut on The Science of Tendinopathy