Sports Medicine | PRP for Patellar Tendon Injury
The patellar tendon is the tendon connecting your patella (kneecap) to the shinbone (one of the two bones in the leg below the knee). It plays an important role in the way you use your legs. It helps the muscles extend the lower leg so that you can carry out activities like kicking a ball, pushing the pedals of a bicycle, and jumping up in the air.
Patellar tendinosis is a condition that occurs when there is functional stress on the tendon due to activities like jumping, therefore, it is also called as “Jumper’s knee”.
It is a common condition seen more in boys as compared to girls, and especially in athletes whose job involves frequent jumping, e.g., basketball, soccer, and volleyball players and is seen in as many as 20% of athletes. However, anyone can suffer from it, whether a frequent jumper or not.
Causes of Patellar Tendinosis
Patellar tendinosis is a common injury due to repeated stress on the patellar tendon resulting in tiny tears in the tendon. Later, lesions develop in these areas in the tendon as a result of degenerative change or failed healing. Some researchers have also proposed that a stress shielding mechanism by the anterior fibers of the tendon contribute to patellar tendinosis as well as repetitive stress. Being overweight also increases the stress on the patellar tendon, which creates less range of motion and reduced flexibility in thigh muscles.
Symptoms of Patellar Tendinosis
As mentioned above, it is often seen in athletes who are involved in jumping sports. Pain is the usually the first symptom of patellar tendinosis in the area of tendon stretching from kneecap to the area where the tendon attaches to shinbone. Pain may worsen during physical activity and may persist as a dull ache after a workout or practice session. The affected area may feel very stiff first thing in the morning.
Patellar Tendinosis Diagnosis
Based on the signs and symptoms, and asking relevant questions about your condition, your physician will be able to diagnose the condition. Upon clinical examination, there is often tenderness in the area, but the knee range of motion can be normal. Often, x-ray can confirm the diagnosis, but one rarely needs to go for larger investigations like MRI. Laboratory studies can be indicated if your doctor rules out any associated systemic, inflammatory, or metabolic disease.
Treatment options for Patellar Tendinosis
Patellar tendinosis treatment generally is of a longer duration, recovery may take a few weeks or months if the injury isn’t too severe.
Most patients respond to a conservative approach such as decreasing activity related to tendon pressure (e.g., jumping, squatting etc), applying ice on the area for about thirty minutes, four to six times in a day after physical activity, or strengthening the muscles of the tendon by certain exercises your physiotherapist may recommend.
Pain is generally the common symptom which can be reduced by icing the affected area and temporarily reducing stress on the tendon.
A physiotherapist can help you learn to better distribute the force you exert during physical activity. For instance, an athlete who jumps frequently might learn proper takeoff and landing techniques. He may also recommend specific exercises to strengthen the muscles of patella, thigh, and calf. A strap that applies pressure to your patellar tendon can help to distribute force away from the tendon itself and direct it through the strap instead. This may help relieve pain. Massaging the patellar tendon may help encourage tendon healing.
Analgesics can be taken to reduce pain.
Surgery may be considered if more conservative approaches are not helping even after 12 months of treatment, but surgery may also be indicated without going in for conservative approaches if the athlete is a high profile athlete.
Three principal surgical procedures may be carried out which include:
- Drilling of the involved pole of the tendon
- Tendon excision or its complete removal
- Resection of the involved pole.
However, drilling of the involved pole has yielded disappointing results so far and results have been mixed with tendon excision surgery with some patients showing improvement of their condition whereas some others being unable to return to their previous level of performance inspite of taking a prolonged rest. The third surgical procedure has provided benefit in terms of pain reduction and functional improvement and return to sports in a year’s time.
PRP Treatment for Patellar Tendinosis
If conservative treatment does not improve a patients pain associated with patellar tendinosis, then platelet rich plasma(prp)may be a successful form of treatment to heal the nagging pain. High profile athletes have recently chosen this form of treatment to save time, and to return to sports as quickly as possible. Many have chosen this treatment instead of surgery. Prp injection treatment is a new medical innovation, and is quickly emerging as a breakthrough in the medical community. This is a non-surgical treatment which consists of a prp injection, and it has gained popularity not only among elite professional athletes, but among the general population as well.
In patellar tendinosis or Jumper’s knee, there is a tear in the tendon along with degenerative changes. It’s also a very challenging condition because of poor blood supply to the tendon, and therefore poor oxygen, which leads to a lack of nutrition for the patella tendon. In addition, it is believed that because of low blood supply, these areas are extremely hard to heal. Therefore, many athletes and/or weekend warriors are forced to play with increased pain, or quit doing what they love to do. Some may continue to have pain for the rest of their lives. This new innovation in the form of PRP accelerates the healing process, and offers a speedy recovery to the athlete at a much lower cost as compared to surgery without undergoing hospitalization.
PRP treatment for Patella tendinosis requires only a small amount of blood from the patient. Blood (usually around 10-60ml’s depending upon what prp company is used) is withdrawn and placed in a plastic test tube/disposable container. Blood contains plasma, red blood cells, white blood cells and platelets. This test tube/disposable container is then placed in a machine called a centrifuge that is located in the doctor’s clinic or outpatient surgery center and is spun for approximately fifteen minutes. After spinning, the red blood cells and concentrated platelets are seperated. The concentrated platelets that are responsible for accelerating the healing process are then extracted from the disposable in the centrifuge. The syringe of platelet rich plasma is now ready to be injected into the patient. Before injecting, the area of injury may be locally anesthesized by your doctor so that the actual injection is slightly uncomfortable.
Your doctor may use imaging such as fluoroscopy or dynamic musculoskeletal ultrasound to place the needle that delivers the PRP directly into the area of injury (patellar tendon). To ensure the accuracy of the placement of the platelet rich plasma, a diagnostic ultrasound is used. Then a needle attached to a syringe containing the prp is guided by ultrasound into the areas of injury. After the procedure, a simple Band-Aid is applied. Because there is no surgical incision involved there is little or literally no pain immediately after the procedure.
The increased presence of these platelets in areas where blood would otherwise rarely go, has been shown to regenerate ligament and tendon fibers.
This treatment may be considered better than surgery for many reasons. It is an outpatient procedure with little to no risk of infection at the injection site and requires no general anesthesia. Most recent studies have shown a success rate of 80 – 85%. Some patients experience only partial improvement, but most have had complete recovery because it stimulates healing and replaces degenerative tissue with new tissue. Its use has largely increased in recent years. The major plus point about this therapy is the use of patient’s own blood, therefor is no risk of any communicable infections & rarely any danger of allergic reactions.
PRP versus Cortisone Injections
Cortisone injections are generally given for inflammatory conditions, but patellar tendinosis is not an inflammatory condition. Cortisone injections result in immediate pain relief while PRP injections take a little more time to act and reduce pain. This is because the growth factors take time to grow the new tissue. Cortisone reduces the inflammation immediately, but actually causes tissue weakening and damage, while PRP takes longer to relieve pain, but repairs and renews the tissue.
Patients may be under observation for a few minutes to about half an hour. There might be some discomfort in the area of the injection that can even last upto a few days and the discomfort can get worse too, but it is temporary and is because of an inflammatory response which has just been stimulated.
When home, patients can use ice over the injected area, elevate the leg, limit physical activities, and stay comfortable as much as you can. Your doctor may prescribe some analgesics to relieve pain, but not an anti-inflammatory medication because the treatment is designed to set up an inflammatory response, so you don’t want to stop that process with medications.
Many patients usually respond just after their first treatment, but a follow up is generally scheduled six to eight weeks after the injection to evaluate the patient’s progress. Some patients may need up to three injections.
Cost of PRP Treatment for Patellar Tendinosis
The cost of PRP treatment is approximately $400 and you will have to bear the cost. Currently, there is no insurance cover, but it has many advantages over the surgical approach of treatment which consists of safety, convenience, faster healing, cost-effectiveness, and ease of use. Since PRP harvesting is done with a small amount of blood in the doctor’s office or outpatient surgery center, the patient need not incur the expense of the harvesting procedure in hospital or at the blood bank.
This new innovative and cutting-edge technique is just the beginning of the new branch of science and is one of the modalities that are currently available to help the body accelerate the healing process and create new, repaired, healthy tissue.
Questions about PRP treatment you may like to ask your doctor
- How soon after the first treatment can I start activity/sports?
- How many days will it take for complete recovery after injection?
- What kind of medications should I avoid after the procedure and for how many days?
- Are there any side effects to this procedure?
- What is the cost associated with PRP procedure?
- Is it covered by insurance?
Complications of Patellar Tendinosis
If ignored and left untreated, there could be further damage to the tendon. As the leg compensates for the pain in your knee, the thigh muscles and calf muscles can weaken. Knee pain can persist if the factors contributing to patellar tendinosis are not addressed.
Knee immobilization should not be done as it results in stiffness of the muscle or the joint, further prolonging the athlete’s return to play.
Jumper’s knee causes mild but long-lasting symptoms after an athletic career. While symptoms may persist even after exhaustive conservative or even surgical treatment, the athlete must weigh the benefits and risks/ consequences of playing in pain.
Prevention of Patellar Tendinosis
Avoid sports as soon as you notice pain. Counseling for appropriate flexibility and plyometric exercises in patients whose tendinosis is still in early stages can prevent more serious damage.
Questions a physician may ask you about your condition on your first doctor visit include:
- How long have you had this complaint? When did you first notice this? Is it getting worse day by day?
- How severe is your pain?
- Are you still able to perform your sports at a satisfactory level?
- Have you tried any treatments at home so far? If yes, has it helped?
- Do you have any other illness or are you taking any medicine?
- If you practice sports, for how long do you practice and what kind of sports?
- Were you recently injured? How were you injured?