April 2010

Can PRP Injections Relieve Pain From Chronic Achilles Tendinopathy?

By Brian McCurdy, Senior Editor

   Platelet rich plasma (PRP) injections are among the treatment options for the commonly presenting problem of chronic Achilles tendinopathy. Although a recent study in the Journal of the American Medical Association (JAMA) concludes that PRP does not show a significant benefit for the condition, several DPMs have experienced promising results.

   Researchers focused on 54 patients with chronic Achilles tendinopathy. Patients were randomized to receive either PRP injection with eccentric exercises or a placebo with eccentric exercises. Patients evaluated their pain level and activity by completing the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire.

   After 24 weeks, the mean VISA-A score improved by 21.7 points in the PRP group in comparison to 20.5 points in the placebo group, according to the study. The difference in scores was not statistically significant according to the study authors, who concluded that PRP did not lead to improvement in pain and activity in patients with chronic Achilles tendinopathy.

Raising Questions About The Study

   While the study researchers noted no statistically significant differences between groups, Stephen Barrett, DPM, questions the injection method used in the study. In his eight years of experience of using PRP for plantar fasciosis, he has found that the more one “needles” or debrides the degenerative tissue, the better the outcome. Dr. Barrett says PRP is particularly effective in treating plantar fasciosis because one can intervene without disrupting the biomechanics of the plantar fascia.

   Furthermore, Dr. Barrett says if the study authors had employed pre- and post-op ultrasound in their study, this may have revealed discernible differences between the two groups of treated tendons. In his work with PRP in the plantar fascia, Dr. Barrett has seen complete regeneration with normal ultrasonographic findings, noting that ultrasound comparison provides an objective measurement rather than the subjective pain scale used in the study.

   Dr. Barrett concedes that ultrasound findings do “not always correlate to the clinical situation.” He has discovered that many patients who experience complete pain relief have abnormal ultrasound findings but notes there are “sparsely few” patients who are not pain free with regenerated fascia.

DPMs Cite ‘Promising Results’ With PRP

   David Soomekh, DPM, has seen promising results in using PRP to treat chronic Achilles tendinopathy with the most improvement in patients who have had pain and loss of function for more than six months and who also have failed conservative therapy.

    “Most patients have returned to normal and increased activities with a significant reduction or total resolution of their pain,” says Dr. Soomekh, a Fellow of the American College of Foot and Ankle Surgeons.

   Dr. Soomekh has been surprised to find a reduction in the number of tendon nodules after the use of PRP. He has also found good results in using PRP for posterior tibial tendons.

   In regard to platelet activation, Dr. Barrett adds that he has used low-energy radial shockwave immediately after the administration of the PRP injection.

    “I believe PRP holds great promise for the future treatment of musculoskeletal conditions and is proving to be the case in our management of plantar fasciosis,” says Dr. Barrett, a Fellow of the American College of Foot and Ankle Surgeons.

   In the few patients with Achilles tendinopathy whom he has treated with PRP, Dr. Barrett has experienced no complications and cities only a limited risk of infection as a downside to PRP.

Is ESWT Effective In The Long Run?

By Lauren Grant, Editorial Assistant

   While a variety of studies have examined the effects of extracorporeal shockwave therapy (ESWT), a recent study presented at the American College of Foot and Ankle Surgeons Annual Scientific Meeting found favorable outcomes in patients with plantar fasciitis nine years after treatment.

   Out of 197 patients (treated with ESWT between 2001 and 2002) identified for inclusion in the study, 75 patients completed a survey with questions about patient satisfaction with the ESWT procedure, return to activity, pain improvement and function. Of the 75 patients, 65 indicated a moderate to high satisfaction and of those, 58 were highly satisfied with the ESWT treatment, according to the study abstract. For those highly satisfied patients, there was a 96.4 percent improvement in heel pain.

   Of those who returned the survey, the study says 87.5 percent were able to return to regular activities in an average of 3.44 weeks after treatment.

   Lowell Weil Jr., DPM, MBA, one of the authors of the study abstract, says he has seen even more favorable results with ESWT in his clinical experience.

    “I actually believe that people return to normal daily activities within a week but more heavy sports at six weeks,” notes Dr. Weil, the President of the International Society of Medical Shock Wave Therapy (ISMST).

   Dr. Weil says he was somewhat surprised to see little difference in the high patient satisfaction numbers nine years after the procedure in comparison to five-year and one-year outcomes.

    “I would have expected people to have other problems and blame it on something like ESWT not working,” says Dr. Weil, the Fellowship Director of the Weil Foot and Ankle Institute in Des Plaines, Ill.

   Dr. Weil notes the importance of no lateral column pain or plantar fascial ruptures in this long-term follow-up of patients treated with ESWT.

    “Lateral column pain after surgical release of plantar fascia can be worse than plantar fasciitis itself and more difficult to manage,” maintains Dr. Weil, a Fellow of the American College of Foot and Ankle Surgeons.

   Dr. Weil is also hoping his study will help change the perception of ESWT treatment from “investigational” to a treatment covered by insurance. He adds that Medicare now covers shockwave therapy.

    “There are 10 times more studies showing success with ESWT than those showing failure,” emphasizes Dr. Weil. He and his team are planning on conducting a cost-benefit study of ESWT within the next year.

Editor’s note: Dr. Weil will be presenting these abstract results in oral presentation at the 13th Annual International Society for Medical Shockwave Treatment (ISMST) Congress, which will be held from June 24 to June 26 at the Chicago Hyatt Regency in Chicago. For more information on the meeting, visit www.shockwavetherapy.org.

Can Peripheral Nerve Surgery Help Address CRPS?

By Brian McCurdy, Senior Editor

   A recent study in the Journal of Foot and Ankle Surgery shows positive results in using peripheral nerve surgery to treat complex regional pain syndrome (CRPS).

   In the retrospective study, the authors attempted to determine whether CRPS I, formerly known as reflex sympathetic dystrophy, is due to undiagnosed injured joint afferents or is a misdiagnosed form of CRPS II, a condition that the study notes is the “new” causalgia.

   Researchers followed 13 patients for at least 24 months to determine the long-term outcomes of surgical treatment of peripheral pain generators. Surgery consisted of a combination of joint denervation and neuroma resection as well as muscle implantation and neurolysis, according to the study. The authors measured outcomes in terms of the decreased use of pain medications and recovery of function.

   The results were excellent in 55 percent of patients, good in 30 percent and poor in 15 percent, according to the study. The authors concluded that most patients who have been diagnosed with CRPS I have continued pain input from an injured joint or cutaneous afferents. Such a condition is indistinguishable from CRPS II and can be treated by peripheral nerve surgery, according to the study authors.

   When patients have CRPS-related pain, it may be due to pain in the joint, cutaneous skin or nerve compression, according to the study’s lead author, A. Lee Dellon, MD, a Professor of Plastic Surgery and Neurosurgery at Johns Hopkins University in Baltimore.

   Citing the paucity of research on CRPS, Dr. Dellon says these patients are difficult to treat and physicians often send them to pain management specialists. When it comes to the surgical treatment of patients with CRPS, Dr. Dellon, the author of Pain Solutions (Dellon Institutes for Peripheral Nerve Surgery), maintains that surgeons must have adequate training in peripheral nerve surgery.

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