Platelet-rich Plasma (PRP) Injections Coupled with Non-rigorous Exercise to

Rehabilitate Patellar Tendinopathy (Jumper’s Knee)

Mitchell Langley & JC McDearman

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What is Patellar Tendinopathy?❖ Commonly referred to as

“Jumper’s Knee”❖ Due to repetitive

compressive stresses on the patellar tendon

❖ Leads to structural degeneration of the tendon➢ Painful➢ Loss of mechanical

strength

Lochead, K., & Physio Direct. (2019, February 18). Patellar Tendinopathy. Retrieved from https://physiodirectnz.com/patellar-tendinopathy/.

Prevalence of Injury❖ Very common in sports that

require frequent jumping (volleyball, basketball)

❖ Study by the Oslo Sports Trauma Research Center showed evidence of patellar tendinopathy in 44.6% ± 6.6% of men’s volleyball players and 31.9% ± 6.8% of men’s basketball players.

Lian OB Engebretsen L Bahr R. Prevalence of jumper's knee among elite athletes from different sports: a cross-sectional study. Am J Sports Med. 2005;33(4):561-567.

Physics of Injury❖ Ground reaction forces (GRF) are greater in

the landing phase❖ Counteracted by eccentric contractions of

the quadriceps❖ Repetitive jumping and poor landing

techniques place compressive stresses on the patellar tendon leading to microtears in the tendon

❖ Eccentric quadricep strength and ankle dorsiflexion velocity in landing play major roles in susceptibility to patellar tendinopathy.

Biology of InjuryNormal Tendon Affected Tendon

Levey, D. S. (2014, November 26). MRI Web Clinic: Jumper's Knee. Retrieved November 16, 2019, from http://radsource.us/jumpers-knee/

Goals/Aims

❖ Use Platelet-Rich Plasma injections to increase the speed and efficacy of the healing process➢ Optimize growth factor concentrations

❖ Identify specific Physical Therapy program to promote healing and prevent future injury through strengthening.

❖ Shorten time spent in recovery and reduce the risk of re-injury to the tendon post-treatment.

Current Treatment & Motivation❖ Corticosteroids & other steroid hormones:

➢ May reduce inflammation, shows no evidence of tendon strength/growth

➢ Known to affect the cardiovascular, gastrointestinal, and renal systems

❖ Physical Therapy:➢ Inefficient for recovery time, pain was often only

temporarily gone even after 3 month rehabilitation period

Previous Investigations: PRP

❖ Plasma centrifuged from 150-mL blood sample. ➢ Produced 20-mL of plasma

❖ 6.5 ± 1.5 million platelets were administered per injection❖ Plasma was enhanced with CaCl to activate platelets❖ Subjects showed significant improvement within 6 months,

especially those with long-term patellar tendinopathy. ❖ Concluded that the process has potential as a treatment for patellar

tendinopathy, but more studies must be done to optimize the components of the plasma.

Filardo G, Kon E, Della Villa S, Vincentelli F, Fornasari PM, Marcacci M. Use of platelet-rich plasma for the treatment of refractory jumper’s knee. Int Orthop. 2010;34(6):909–915.

Previous Investigations: PRP (cont.)❖ The roles of growth factors in tendon and ligament healing [13]

➢ TGF-𝛽 and PDGF-AA are primary constituents in the healing process❖ Addition of Hyaluronic Acid to PRP increases TGF-𝛽 and PDGF-AA growth

factors [15]➢ 31.9 ± 4.8 μg/mL (TGF-𝛽 Day 5, PRP+HA) vs 24.1 ± 5.2 μg/mL (TGF-𝛽 Day 5,

PRP)➢ 2.69 ± 0.70 μg/mL (PDGF-AA Day 5, PRP+HA) vs 1.48 ± 0.46 μg/mL

(PDGF-AA Day 5, PRP)❖ Study comparing single injection of PRP versus two consecutive injections

➢ Two consecutive injections showed much higher VISA-P and Tegner scores. [14]

Shortcomings

❖ Previous PRP research offers reasoning to believe that PRP will improve strength and repair rate; however, there is little tested evidence to prove this

❖ Variations of PRP provide confusion of which ones are most effective

❖ Release of growth factors from platelets was often mistimed or simply unaccounted for.

Experimental Proposal

❖ 3 separate groups containing 10 people each:➢ Control: Basic steroid injection + Phys Th.➢ Experimental 1: PRP + Phys Th.➢ Experimental 2: PRP + Hyaluronic Acid + Phys Th.

❖ There will be check-ups to track the patient’s pain tolerance over a 2-month period.

❖ Success of the treatment will be based on the results of a Tegner score and a VISA score.

Methodology 1: PRP

Steps for PRP injection:1. Blood is drawn from patient (~34mL)2. Blood is centrifuged once and

the RBCs are separated3. The resulting WBC and plasma layer are centrifuged4. The top ⅔ of the tube are removed

(PPP), leaving ~5mL of ready PRP after homogenization

5. PRP is injected into the site. Hyaluronic acid will be injected 10 minutes after the PRP.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4338460/

Methodology 2: Physical therapy❖ Eccentric Exercises to strengthen the quadriceps and

surrounding muscle groups❖ Exercises utilized will start easy, weight will be augmented

as the pain reduces in a patient❖ The exercises will promote the following:

➢ Flexibility in tendon from stretching➢ Tendon tolerance with body weight exercises➢ Eccentric strength in hamstring, quadriceps, and

calves

Examples of Exercises

https://www.precisionmovement.coach/rectus-femoris-stretch/

https://www.skimble.com/exercises/26826-step-down---forward-how-to-do-exercise

https://www.skimble.com/exercises/26826-step-down---forward-how-to-do-exercise

Data & Expected Results

❖ We will measure improvement based on how tolerable the patient’s tendon becomes over time (VISA/Tegner Score)

❖ We expect the recovery period to decrease the most with PRP doped with hyaluronic acid as well as demonstrate the largest increase in tendon durability

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Section, Dec. 2016, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5095939/.[3] Lian OB Engebretsen L Bahr R. Prevalence of jumper's knee among elite athletes from different sports: a cross-sectional study. Am J Sports Med. 2005;33(4):561-567.[4] Hussain, N., Johal, H., & Bhandari, M. (2017). An evidence-based evaluation on the use of platelet rich plasma in orthopedics – a review of the literature. Sicot-J, 3, 57. doi:

10.1051/sicotj/2017036[5] Patellar Tendonitis (Jumper’s Knee). Retrieved from https://www.hackensackumc.org/wellness/health-information/article/diseases-and-conditions/patellar-tendonitis-jumpers-knee/.[6] Chen, X., Jones, I. A., Park, C., & Vangsness, C. T. (2018, July). The Efficacy of Platelet-Rich Plasma on Tendon and Ligament Healing: A Systematic Review and Meta-analysis

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4338460/.[9] PRP Therapy Provides Advances in Tissue Healing. (2019, March 29). Retrieved from https://www.harringtonhospital.org/prp-therapy-provides-advances-in-tissue-healing/.[10] Platelet-Rich Plasma for Tendinopathy? Researchers See Promise. (2017, June 7). Retrieved from https://www.apta.org/PTinMotion/News/2017/6/7/PRPForTendinopathy/.[11] Rutland, M., O'Connell, D., Brismée, J.-M., Sizer, P., Apte, G., & O'Connell, J. (2010, September). Evidence-supported rehabilitation of patellar tendinopathy. Retrieved from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2971642/.[12] Walden, M. (2019, August 21). Patellar Tendonitis Exercises (Jumper's Knee) - Stretching & Strengthening. Retrieved from

https://www.sportsinjuryclinic.net/sport-injuries/knee-pain/anterior-knee-pain/jumpers-knee-exercises [13] Molloy, T., Wang, Y., & Murrell, G. A. C. (2003). The Roles of Growth Factors in Tendon and Ligament Healing. Sports Medicine, 33(5), 381–394. doi:

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Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology, 4, 27–32. doi: 10.1016/j.asmart.2016.01.001