March Madness and PRP

Basketball is the second most popular sport in the United Sates when counting amateur levels after football. According to the National Sporting Goods Association, over 26 million Americans play basketball on a regular basis. This is more than any other team sport.

The worldwide participation in basketball is huge. Basketball has become one of the most popular sports globally with an estimated 450 million people playing basketball in some form.

Basketball was invented in 1891 by Canadian physical education teacher, James Naismith in Springfield Massachusetts to give the children exercise indoor in the winter months. From the elementary schools to the professional leagues, basketball in enjoyed by all genders and age groups.

However, arguably, the most awaited basketball tournament is the NCAA 68 team Division One national champion tournament. This has been named March Madness. People from across the world, pick their favorite team to advance until a champion is crowned.

What does this have to do with platelet rich plasma?

Patellar tendinopathy has been reported in greater than 20% of collage basketball players and in asymptomatic players 12% had ultrasound evidence of early involvement of the tendon. Patellar tendinopathy is the second most frequent knee injury after the medial collateral ligament in athletes. This injury can have significant impact on athletes and their teams. It has been given the name of “jumper’s knee” due to its frequent occurrence in jumping sports that involve repetitive knee extensor loading and unloading as in basketball.

Jumper’s Knee causes pain, swelling, and stiffness. This can occur during and after activity. This effects performance and can adversely effects training and competition. In severe cases, patellar tendinopathy has caused retirement from the sporting activity. Across all sports, 40% of elite athletes have reported patellar tendon pain at some point during their career.

What is Jumper’s Knee?

Patellar tendinopathy is a source of anterior knee pain localized to the inferior pole of the knee cap. Pain is present in activities where energy is stored and then released involving the patellar tendon. The demand of this activity is knee extension in a motion such as jumping.

The quadriceps muscles are connected to the patella by the quadriceps tendon, and the patella is connected to the tibia by the patellar tendon. When the quadriceps contract, the force is generated through the patella to the patellar tendon causing the knee to extend.

Healthy tendons are composed of parallel collagen fibers predominately collagen type 1.

Other components of the tendon matrix are elastin, proteoglycans and other inorganic components. The collagen in tendons are bound together with proteoglycans and attached to the collagen fibrils.

Tenocytes are a tendon fibroblast cell that produce collagen molecules and when bundled together form collagen fibrils. Fibril bundles are organized with the tenocytes between. This organization can detect and respond to mechanical loads.

Pathology and Stages

Reactive tendinopathy- This is a non-inflammatory phase where the body responds to increased loads. This is manifest by the tenocytes increasing protein production and they themselves proliferate. The result is an increased cross-sectional area in the tendon. Reactive tendinopathies occur with acute overload.

Tendon Disrepair- This follows the reactive phase with greater matrix breakdown. There is an increase in the number of cells present in the matrix resulting in an increased protein production of collagen and proteoglycan. The proteoglycan increases causes collagen separation and overall disorganization.

Degenerative Tendinopathy- This is the final phase with tenocyte exhaustion and tissue apoptosis. The matrix is terminally disorganized and has little room for pathological changes to be reversed. This is commonly seen in the elderly.

Diagnosis

Typically, the diagnosis is by physical exam. Pain is elicited with loading and rapid extension of the knee joint. The pain is relieved with rest initially.

X-rays are used to examine any possible bony abnormality.

Ultrasound can examine the tendon and view small tears and areas of inflammation.

MRI is rarely needed but may be used to rule out other pathologies. Commonly done if surgery is contemplated,

Differential Diagnosis

Infrapatellar bursitis
Fat pad impingement
Patellofemoral pain
Plica injuries
Osgood Schlatter Syndrome
Sinding Larsen Johansson Syndrome

Medical Management and Rehabilitation

Exercise is an important component of the management of patellar tendinopathy. A variety of loading programs have been used with the two main types being eccentric loading and eccentric concentric loading.

Eccentric loading has been the primary approach to rehabilitation. This exercise is a modified load to a muscle group slowly then a quicker opposite action. Example would be a slow squat then a more rapid extension to the standing position.
Eccentric Concentric Loading can begin with normal weight (for example squats) but a significant load is then placed on the movement (such as weighted squats)

Other modalities include ultrasound, cryotherapy, lower extremity ranges of motion and strength training.

Non-Steroidal Anti-Inflammatory Agents in the treatment of tendinopathy remains controversial in both the acute and chronic stages. NSAIDS have been reported to impede soft tissue healing. NSAIDS have a negative effect on tendon repair.

Corticosteroids decrease pain and inflammation but also decrease cell proliferation and protein production. Repeated corticosteroid use has been shown to reduce tendon diameter at 7 and 21 days after injection. Repeated tendon injections with corticosteroids can cause tendon rupture.

Surgery for chronic painful tendons has varied outcomes with only 50-80% of athletes able to return to their sport at their previous level. Surgery in non-active patients produced poorer results than in active people.

Platelet Rich Plasma has been proven in many studies to be an effective treatment option for patellar tendinopathy. PRP injections into the tendon under ultrasound guidance has been considered a second line treatment for patients not responding to physical therapy. PRP stimulates soft tissue healing and greatly improves tendon remodeling. Patients who had no previous treatment and received PRP had significantly better results in the long term, and in comparison, to those who had received previous therapies. Therefore, one could infer, PRP should be the first line therapy for patellar tendinopathy.

In a study comparing operative treatments versus PRP injections, it was found though operative treatments were shown to be safe and somewhat effective, PRP is less invasive and could lead to tendon healing and therefore should be considered before an operative approach.

Ferrero et al assessed the effectiveness of US guided autologous PRP injections in patellar tendinopathy with a 20 day and 6 month follow up. VISA-P scores, tendon thickness and the hypoechoic areas of the tendon was compared. At the 6 month follow up, there was significant improvement for all parameters. Also, intratendinous vascularity was significantly improved at both times of examination. They concluded PRP injections to be safe and effective for the treatment of patellar tendinopathy.

In a study by Andriolo et al, the conclusion indicated that even though eccentric exercises can be used as treatments in the short term, multiple PRP injections may offer more satisfactory results in the long term.

Shockwave Therapy is a noninvasive therapeutic procedure in which an acoustic wave is applied to body regions to produce analgesia and facilitate healing. Shock wave treatment produces a biological effect in its passage through the tissues. This achieves analgesia, neovascular and tissue regenerative effects. This effect facilitates protein synthesis, increases cell proliferation and has protective effects of tissue such as cartilage and bone.

In tendon pathological states, ischemia is an important factor in the degeneration of the tissue. This ischemia causes fibers to be disorganized and the strong type 1 collagen to be replaced with the weaker type 3 collagen resulting in pain and reduced tendon strength. Repeated stress on the tendon, as in patellar tendinopathy, results in a cumulative chronic micro trauma.

Histologically, tendinopathy is characterized by the absence of inflammatory cells, intra tendon collagenous degeneration, thinning and disorganized collagen fibers, and high concentrations of glycosaminoglycan and proteoglycans.

It has been proven that ESWT provokes reactions that modulate the microenvironment and stimulate repair.

Shockwave therapy has an immediate significant effect on pain and increases vertical jump distance when compared to placebo treatment.

Combination treatment with platelet rich plasma and shockwave therapy has been proven to be significantly more efficacious then either one alone. Therefore, the combination should be considered for immediate pain relief and long-term healing in these patients with “Jumper’s Knee”.

Enjoy March Madness!!

Juventix Regenerative Medical is an industry leader in the regenerative medical field. Our Platelet Rich Plasma Kits are FDA cleared and designed for safety, sterility and effectiveness. Our kits are scientifically manufactured to provide a platelet concentrate, devoid of red blood cells with a minimum number of leukocytes, critical to the regenerative process.

Juventix Regenerative Medical offers a LED Activator to activate the platelets and begin the regenerative process. The activation is a critical step in the release of cytokines, growth factors and bioactive proteins from the alpha granules on the platelets and is accomplished with LED light. This negates the use of chemical additives such as Calcium Chloride, Thrombin of Collagen. This mode of activation by LED light provides sustained growth factor release versus older methods of activation while adhering to the minimal manipulation guidelines of the FDA.

Juventix Regenerative Medical supplies a Bio-Incubator to transform the Platelet Rich Plasma into Platelet Rich Fibrin. The Platelet Rich Fibrin commonly called the “second generation of platelet products” has different cytokines and growth factors than the original PRP. These different cytokines provide an anti-inflammatory environment and can be used confidently in inflammatory conditions.

Juventix Regenerative Medical is proud to offer the PhysioPro Shockwave Therapy System. This is a clinical grade shockwave therapy system that induces intracellular and extracellular reactions to assist in the healing of soft tissue and musculoskeletal injuries. The deep penetrating waves activate cellular pathways involved in the proliferation and remodeling of damaged tissues. This low-cost device is lightweight, easy to use and complimentary to other regenerative treatments.

Regenerative Regards,

Dr. Robert McGrath