Southeast ACSM ConferenceFebruary 5, 2011

Mandy Huggins, MDEmory Sports Medicine Center

HPI35 year old male corporate banker Very active in kickboxing, weight lifting, running, etc.Presents on 7/15 with history of injury on 6/19Felt a pop and pain in the posterior ankle of planted

right foot while sparring (“like someone kicked me”)He currently has only mild to no discomfort; reports

steady improvement in painMain reason for presentation is weakness, unable to

jump or sprintContinued weight lifting and CrossFit; no kickboxing

Physical ExamHeight 5’11” Weight 192 lbsRLE tender at proximal

Achilles/musculotendinous junction? Mild defect hereEdema notedWeakly positive Thompson’s4/5 weakness with plantarflexionDistal neurovascular exam intact

Diagnosis?Achilles injury

Performed 7/17Full-thickness defect involving the lateral 2/3

of the tendon with a 3.5 cm gapCONCLUSION = high grade partial tear

MRI

MRI

Clinical decision makingReferral to orthopedic foot and ankle

specialist on 7/20Recommendation for surgical repairNon-operative course would likely leave him

with residual plantar flexion weakness If he needed surgery in the future, it would

be difficult and he would have a prolonged recovery

But… “It will take an act of Congress for me to agree to have surgery”

Now what?PRP of course!

Initial ultrasound findings

PRPPerformed on 7/21 with ultrasound guidance10 cc PRP with 1% lidocaine injected into the

Achilles proximal tendon near the musculotendinous junction

Post-procedural instructionsComplete rest and walking boot for 4 days Avoidance of lower extremity activities for at

least 2 weeksGradually increase activity as toleratedReturn to clinic in 6 weeks

PRP

Follow upPatient returned to clinic on 9/13Denied pain or discomfortAdmitted to wearing the boot for only 2 days

and rest for only 1 weekReturned to most activities at 1 weekHas not returned to kickboxing or runningPhysical exam:

no tenderness but mild thickening on palpation, normal strength, negative Thompson’s

Repeat US 9/13Improved tendon architecture by comparisonPersistent thickeningHeterogenous signal c/w partial tear in the

proximal tendon and musculotendinous junction

Neovessels

Repeat US 9/13

Repeat US 9/13

Second follow up visit4 month follow up 11/17No pain reportedRunning, weight lifting, cross fit without

difficultyRepeat ultrasound

Persistent thickening of the Achilles tendon from the muscles and junction all the way down to approximately 1 cm proximal to the insertion.

Tendon appears to have filled inNo gaps seen at all within the tendon itselfNo neovessels seen

Repeat US 11/17

Repeat US 11/17

Third follow up visit6 month follow up 2/2/10Now 6 months post procedurePatient unable to keep appointment (no US

pics)Per his report, he was 100% at end of

November4 months after PRP

Kickboxing, sprinting, bleachers, jumping, etc.

Alternative managementWould he have been back this soon after

surgery?NWB 2 weeks, boot 3 months, RTS at least 6

months

What about non-operative management without PRP?Immobilization for about 8 weeks

CONCLUSIONCurrent evidenceNone to compare PRP vs surgical repairTwo compare surgery + PRP to surgery onlySanchez et al 2007

Earlier ROM, earlier RTSSmall number

Schepull et al 2011No difference at 1 year – functionally or

mechanicallyLower rerupture score for PRP (1 rerupture in 16)Concentration higher, PRP storage, longer casting

CONCLUSIONThis case shows a successful outcome of PRP

treatment to a near complete Achilles tendon tear that would normally have been treated surgically

High level of activityStrength returnedMinimal period of immobilization*

Still risk of rerupture?

Questions?