Southeast ACSM ConferenceFebruary 5, 2011Mandy 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 511 Weight 192 lbsRLE tender at proximal Achilles/musculotendinous junction? Mild defect hereEdema notedWeakly positive Thompsons4/5 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 recoveryBut 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 junctionPost-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 Thompsons

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

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 ultrasoundPersistent 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 PRPKickboxing, 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 2007Earlier ROM, earlier RTSSmall numberSchepull 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 surgicallyHigh level of activityStrength returnedMinimal period of immobilization*

Still risk of rerupture?

Questions?