Emerging Insights On Platelet-Rich Plasma

Author(s): 
David J. Soomekh, DPM, FACFAS

Pertinent Insights On Using PRP For Achilles Tendinopathy And Rupture Repair

Recent studies have shown that PRP can positively affect gene expression and matrix synthesis in tendon and tendon cells.11 It is important, however, to distinguish acute tendon injury from chronic cases when discussing and studying the use of PRP for tendon pathology.    Achilles tendon injury leads to a cascade of degenerating events, including hypovascularity, repetitive microtrauma and the addition of fibrous tissue, which can then lead to degeneration and weakness of the tendon. This eventually leads to rupture. In theory, PRP reverses the effects of tendinopathy by stimulating the revascularization and improving healing at the microscopic level.14    Alfredson and Lorentzon categorize Achilles tendon pathology into paratendinitis, paratendinitis with tendinosis and pure tendinosis.14 In paratendinitis, adhesions form between the paratenon and the tendon. Paratendinitis with tendinosis involves degenerative changes within the substance of the tendon as well as inflammation in the paratenon. In patients with pure tendinosis, there is often a palpable nodule. The hypothesis is that the introduction of PRP into the pathologic tendon will aid in the repair and remodeling of the tendon by tenocytes.    In a randomized, double-blind, placebo-controlled study, de Vos and colleagues assessed and treated patients with tendinopathy between the ages of 18 and 70.10 The clinical diagnosis included findings of a painful and thickened tendon in relation to activity and on palpation with symptoms lasting greater than two months. The patient base included 27 in the PRP group and 27 in the control group.    Researchers used 54 mL of whole blood to derive the PRP that was mixed with sodium bicarbonate to match the pH of tendon tissue. They injected a non-disclosed amount of PRP into five sites along the injured tendon under ultrasound guidance.    Patients were only allowed to walk short distances indoors in the first 48 hours. In days three to seven, patients were allowed walks up to 30 minutes. After one week, patients started an exercise routine with one week of stretching and a 12-week daily eccentric exercise program. Patients were not allowed to participate in weightbearing sports activities for four weeks after the injection and subsequently had a gradual return to these activities. They were only to use acetaminophen during the follow-up period.    Patient results were based on patient questionnaires that quantify pain and activity level. The results showed an improvement in 24 weeks by 21.7 points in the PRP group and 20.5 points in the placebo group. The study concluded that there was no significant difference between the groups.10    This study is limited by a number of factors. Researchers did not identify any characteristics of the tendon anatomy pre- and post-injection, neither clinically nor with imaging techniques. The sample size was small. They could not quantify the concentrations of PRP they used for each patient.    Sánchez and colleagues investigated the augmentation of Achilles tendon rupture repair with PRP in athletes (six in both the PRP group and control group).15 They used two PRP preparations on the primary repair of the Achilles in comparison with controls. Researchers mixed 4 mL of PRP with CaCl2. After 30 minutes, this mixture produced a fibrin scaffold, which researchers incorporated into the repair site between the tendon ends. Researchers mixed the remaining PRP with CaCl2 and immediately sprayed it onto the wound site before closure.    At the one-year follow-up, the study authors assessed the patients via physical examination and ultrasound imaging. They found that the PRP group was able to return to mild running with earlier range of motion and without wound complications in comparison to the control group.15    I have used PRP for the treatment of chronic Achilles tendinopathy in many patients. The treatment protocol is very similar to that of plantar fasciitis.

Comments

How do you bill for this?

I would also like to know what coding is being used for this and do most insurance companies recognize PRP treatment for plantar fasciitis?

There is a new code for this. 0232T Came out in January 2010 but only became valid July, 2010.

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