The Power to Heal Comes from Within

Powerful chemical weapons, also known as drugs, and sophisticated surgical procedures have dominated the practice of medicine for many decades.  For at least the last 15 years, maverick researchers and physicians have been exploring biologic alternatives to drugs and surgery.  Instead of searching the world for a novel chemical compound or engineering a sleek surgical device, they have looked in an unusual place--inside the body itself.  Could it be possible that the power to heal comes from within our own bodies?  The answer today is a qualified yes.  

Think about it for just a moment.  Next time your get a small paper cut, simply observe what happens.  You bleed a little.  It stops on it own.  You put a bandaid on it and magically it heals over the course of less than a week.  Similarly, if you sustain a simple fracture, it typically heals on its own with immobilization and a few weeks of time.  Your liver is your most amazing regenerative organ.  You can literally cut out a lobe of your liver and transplant it into someone else.  That missing lobe will then regrow on its own.  Skin, bone and liver are tissues that have excellent capacity to self heal. Other tissues need a helping hand.  Fortunately, within our own bodies are many tissues that can help heal other tissues.  Blood, bone marrow and adipose tissue (also known as Fat) are three examples.

To begin, let's explore platelet rich plasma, also known as "PRP".  PRP is a component of blood that can be prepared using a simple desktop sized centrifuge in about 10 minutes.  I have using PRP to treat chronic tennis elbow now for more than a decade with excellent success rates.  Multiple studies now confirm the value of PRP in the treatment of this common disorder.  A recent meta-analysis of randomized controlled trials noted PRP to be "of great clinical significance."  PRP has also been used to treat diabetic foot ulcers, knee arthritis and degenerative disc disease.  Overall, there are now more than 8600 published studies evaluating the basic science and clinically efficacy of PRP.   Importantly, in all of the areas studied, PRP has an excellent safety record.  That of course makes sense.  PRP is simply a component of your own blood.

Cancer immunotherapy is another example of using your body to help heal itself.  Cancer immunotherapy essentially reprograms your immune system to help fight nasty cancers.  Recently published data has found an "unprecedented" 94% of patients with a specific type of blood cancer achieving complete resolution of their symptoms.  The technique involves removing your own white blood cells, reprogramming them to attack tumors in the lab and then injecting them back into your body.  To quote one researcher, "This is really a revolution."

Finally, a therapy that sounds like it came out of a science fiction or horror movie is just beginning.  The idea of parabiosis involves merging the circulation of two animals.  The original research was done in young and old rats in 1956.  For the details please review a tantalizing paper entitled "Experimental Prolongation of the Life Span (Ref 1)  When their circulations were connected, the young mice started becoming "old" and the old mice started to appear "young".  Something in the blood of young mice was helping reverse the affects of aging in older mice.  The coats of the old gray mice were turning brown again.  Other research conducted at Stanford suggested young blood could boost brain cell growth in older mice.  (Ref 2, Ref 3 Ref 4)  This research was so intriguing, it led to the development of a clinical trial focused on the transfusion of young blood to older patients with Alzheimer's disease.   Silicon Valley tycoons are also helping finance similar "treatments" for middle aged rich people who want to stay young or reverse the affects of aging.  A company has even been started and is presently conducting clinical trials.  Interestingly, the company is named Ambrosia after the mythologic Greek drink that was supposed to confer longevity or even immortality.  Peter Thiel, an iconoclastic venture capitalist , appears to be quite interested in this approach to combating the aging process.  This approach is clearly not yet proven but is intriguing.

If we are seeking transformative solutions to difficult problems, I suggest we look inside.  We might just find the power to heal.

Allan Mishra

Platelet Rich Plasma beats Surgery for Tennis Elbow

Treatment of tennis elbow using platelet rich plasma (PRP) resulted in an average of 83% improvement in pain scores at one year compared to baseline in a recently published study of 110 patients by Karaduman et al.  The surgery group had 46% improvement in pain scores.   Mayo elbow scores were also higher in the PRP group.  (See graphs below)  

The study used the Biomet GPS PRP device and the Nirschl surgical technique

This is an interesting study comparing the value of PRP versus a commonly recommended surgical procedure.  The data suggest PRP is a safe and effective alternative to the much more invasive and expensive surgical procedure.

AM

@bloodcure

Total Tendon

See abstract and reference below:

Karaduman et el 2016

Abstract

Purpose

To compare short and mid-term results in the treatment of chronic elbow tendinosis with platelet-rich plasma (PRP) or Nirschl surgical technique.

Method

A retrospective study was conducted on patients with chronic lateral epicondylitis, treated by Nirschl surgical technique (50 elbows) or PRP (60 elbows). Outcome was evaluated with Visual Analog Score (VAS), Mayo Elbow Scores and grip strength measurements.

Results

VAS and Mayo Elbow Scores of the PRP group had improved as a mean of 83% (p = 0.0001), 74% (p = 0.0001) over baseline and 34.2 pounds gain of grip strength.

Conclusion

The PRP seems to be better for pain relief and functionality in the short and mid-term periods.

Keywords

• Nirschl surgical technique; 
• Platelet rich plasma (PRP); 
• Chronic elbow tendinosis

Will Biologics Revolutionize Musculoskeletal Care?

The economic costs of musculoskeletal care in the United States is approaching $800 billion or about 5.7% of annual GDP.  (Ref)  These costs are expected to increase significantly as our population ages.  This is clearly not a sustainable path.  A recent article published by the American Academy of Orthopedic Surgeons (AAOS) suggests the "early evidence is promising" for biologics to revolutionize musculoskeletal care.  (AAOS Article in full)

Biologic therapies represent a rapidly evolving frontier similar to arthroscopy in the 1970s and 1980s.  There will always be a need for continued research and development but the data supporting treatments such as platelet rich plasma (PRP) and stem cell treatments for tendinopathy and arthritis is increasing significantly.  PRP is now a recognized treatment for chronic tennis elbow that has been shown to be better than surgery.  (See Ref)  The number of PRP articles on PubMed now is over 8000 and the Google Trends for PRP is rising rapidly. (See Graph)

Biologic orthopedic procedures are in the process of revolutionizing the options available for patients for difficult problems such as arthritis.  It is an exciting time to execute on these point-of-care biologic treatments.   Continued progress will demand hard work and innovation by elite motivated teams in order to produce transformative outcomes for patients.


AM
TotalTendon

PRP enhances healing after Achilles Tendon Rupture

PRP being added to an Achilles Tendon Repair

If you rupture your Achilles tendon, new data suggests platelet rich plasma can enhance the healing.  In an abstract published by the journal Lancet, researchers from England discussed how they treated patients who had ruptured their Achilles with either PRP or a placebo.  Six weeks later, they biopsied the healing tendons under ultrasonic guidance.  In the study, they found improved cell content, better tendon fiber structure and more normal collagen (type 1) in the tendons treated with PRP.  The study included 20 patients (10 PRP, 10 Control) and is the first investigation in humans showing the significant value of using PRP to help treat Achilles tendon ruptures.  Of course, more data will be needed to confirm these important findings.  For years, I have been adding PRP to my achilles tendon repairs and if I ever rupture my own, I will certainly request that PRP is included in the treatment protocol.

AM 

Total Tendon

$87 Billion Dollars for Total Knee Replacements by 2030?

We have an epidemic of knee arthritis in the United States with over 10 million affected Americans (Ref).  Many treatments are prescribed with variable efficacy for this common problem.  When all else fails, knee replacement is often recommended.  This procedure is overall highly successful but also expensive.

In 2009, the CDC reported the estimated costs of knee replacement in the US to be $28.5 billion dollars (Ref).  Published reports suggest there will be a need for almost 3.5 million knee replacements in the United States by 2030 (See paper).  At a conservative total cost of $25,000 per surgery, that translates into $87 billion dollars. So, the projections suggest the costs will triple over the next 15 years.

That is $87 Billion Dollars just in the United States to treat end-stage knee arthritis.  That is just the cost of knee replacements.  It does not include other surgical or non-operative costs.  It also doesn't include treatment of other potentially arthritic joints such as the hip or shoulder.

We can and should immediately begin an all-in assault against arthritis.

Patients need to act on the first line of treatment.  They can help themselves with a program of diet and exercise.  Simple exercises such as the QuadCrunch and Hamstring Stretching can be quite helpful.  Riding a bike is another way to exercise with arthritic knees.  Losing even a small amount of weight can result in less pain and more function.

The good news is many new treatments are in development to treat this difficult problem.  The bad news is the effort is fractionated.  It is important to note that knee arthritis is not simply a disease of the cartilage.  There is dysfunction in muscle, tendon, ligament, cartilage and bone when a patient has arthritis.  A better understanding of the genetic and epigenetic causes of arthritis is also needed.  We will need a systematic approach to treating all of the components of the disease in order to be successful.

On the horizon are a plethora of biologic treatments including platelet rich plasma, stem cells and even gene therapy.  We need to embrace these novel treatments do the hard work that is needed to prove their safety and value.

A coalition of patients, providers, payers, researchers and industry need to come together and execute on potential treatments and prevention strategies.  We cannot afford to continue with the status quo and spend almost $90 Billion Dollars on knee replacements in 2030.

Please post your comments or suggestions below.

AM
TotalTendon

Microfracture Surgery Jadaveon Clowney

The Houston Texans' Jadeveon Clowney recently underwent "microfracture" surgery on his ailing right knee.  (See ESPN report)

The report suggests the talented Mr. Clowney will be out for 9 months or more.  Just what is microfracture surgery and why does it take as long to recovery as it does for a baby to born?

Microfracture Surgery

Let's start with the basics.  There are two types of cartilage in the knee.  The surface cartilage which covers the bone.  This is known as articular cartilage and can be thought of a type of cap or covering of the end of the bone.  This cartilage is present in any joint.  In the knee, there is another type of cartilage, the meniscus cartilage.  There are two menisci in the knee--medial (inside) and lateral (outside).  When the surface "articular" cartilage is damaged, the knee can become quite painful especially with loading and twisting.  Think rushing a passer for example.  Similar symptoms can occur when the meniscus is torn.  It is often difficult to distinguish between the two in terms of which one is the pain generator.

Microfracture surgery is an attempt to create a tire patch over a cartilage defect by poking a hole in the end of the bone and creating an access channel to the bone marrow.  The bone marrow then leaks out via the holes that are created and forms a clot which over time can help cover the defect.  It takes time, many months, for this surgery to work because the "patch" needs to mature.  This technique is useful for small defects in the cartilage but hasn't proven to be great for larger defects.  We do not know the size of Mr. Clowney's knee cartilage injury.

Recent evidence suggests that the addition of platelet-rich plasma can enhance microfracture surgery results.  This has been shown in basic science, preclinical and now clinical studies.

This type of surgery at such a young age is clearly not a good sign.  In the long run, he may require further intervention.  Please read the post below for further information about why we need to accelerate our regenerative medicine efforts.  Mr. Clowney is one of tens of millions of people worldwide with symptomatic cartilage damage.  We need to maximize outcomes of today's surgical techniques and develop new procedures to help keep our athletes and patients in the game.

AM

TotalTendon

Will Kobe Bryant go to Japan to Treat his Knee Arthritis?

Japan Accelerates Regenerative Medicine with Regulatory Reforms

Why the United States Must Follow Their Lead

Sign the online petition supporting Regenerative Medicine

Kobe Bryant, an elite professional athlete from the National Basketball Association’s Los Angeles Lakers, has gone to Germany multiple times to be treated with a portion of his own blood for his creaky, arthritic knees.  The reason why he went to Germany is simple.  He wanted to have the best chance to play at the highest level in the NBA and he had exhausted all his options in the United States.  He went there to be treated with a component of his own blood that targets the inflammation associated with knee osteoarthritis.  The treatment he received is not approved here in the United States. 

Will he go to Japan next time to get the most advanced therapy?  That may happen because in November 2014 Japan enacted legislation creating a new pathway that accelerates the approval process for regenerative medicine products.  We here in the United States need to figure out how to best accelerate our own regenerative medicine efforts or continue to watch our elite athletes and other patients seek treatment beyond our shores.  Let’s explore why Japan acted boldly in favor of regenerative medicine. 

A Nobel Prize was awarded to Japanese researcher and former orthopedic surgeon, Dr. Shinya Yamanaka in 2012 for his pioneering work on how to reprogram mature skin cells into pluripotent stem cells.  His potentially life saving work and the national pride associated with it helped Japan become a worldwide leader in stem cell research.  Importantly, Japan has also prospectively pursued and passed legislation that will dramatically stimulate regenerative medicine.  The country took a leap into a bright future last week with the implementation of regulatory reforms directed at accelerating the development of cell-based treatments. 

The new law established a separate pathway for regenerative medicine products apart from traditional drugs and medical devices. The regulations also created a system that fosters faster commercialization of novel biologic products and can lead to time limited approvals for up to seven years.   Post market data analysis will continue to confirm the safety and efficacy of the regenerative medicine products with the potential to revoke approvals. 

The action by the Japanese government creates the proper equilibrium between the need for accelerated approvals for cell based therapies that have established efficacy while ensuring product safety.  The typical phase one, phase two and phase three trials for new drugs are not a proper pathway for cell-based therapies that have highly complex mechanisms of action that may or may not be identified even with elite preclinical models.  Importantly, many cell-based products come directly from a patient’s own body and therefore have a dramatically higher safety profile. 

Americans are screaming for new treatments for a variety of difficult problems such as arthritis, heart disease and diabetes.  Regenerative medicine and especially cell-based treatments have a chance to help treat and potentially cure these problems.  We need to follow the Japanese lead and create similar pathways in the United States.  Last year during a visit to Japan and its PMDA (the equivalent of the FDA), I was staggered by how engaged they were about regenerative medicine and receptive they were to understanding how to bring safe and effective biologic products to their populace.

The United States can learn a great deal from Japan’s enlightened approach to regenerative medicine.  Safety of course should be paramount.  The idea of a conditional, time-limited approval with reimbursement strikes a perfect chord as we seek better treatments for our patients at more affordable prices.  Competition will arise to obtain approvals based on phase two trials that confirm safety and show a solid degree of efficacy.  Importantly, more competition will lead to better options and faster innovation similar to the computer industry over the last several decades. 

We need to also emulate our Silicon Valley technology colleagues and call for a Medical Moore’s Law.  Identify a specific clinical problem, create a novel solution and within five years double the efficacy and decrease the price by fifty percent.  Data analysis via powerful graphical algorithms should assist with new discoveries and also help with better management of many diseases.  

We must seek dramatically higher horizons instead of being satisfied with iterative improvements.  The Japanese government should be congratulated for passing regulatory reform and implementing transformative solutions.  Sooner, not later, we need to find ways to execute our own regulatory reforms here in the United States to help our patients and to remain competitive on the world stage in regenerative medicine.

Perhaps, then Kobe will be treated in California instead of Germany or Japan.

Allan Mishra, MD

TotalTendon


Sign the online petition supporting Regenerative Medicine

Please post any comments or suggestions about how to safely accelerate regenerative medicine.

References

(http://www.nobelprize.org/nobel_prizes/medicine/laureates/2012/yamanaka-facts.html)

Accessed 11/30/14

http://www.pmda.go.jp/english/events/2014taiwan_sympo/14_Keynote1.pdf

Accessed 11/30/14

Google Trends for Platelet Rich Plasma Rose 107% Last Week

The interest in Platelet Rich Plasma  (PRP) rose dramatically last week according to Google Trends.  This autologous biologic product and treatment continues to gain traction as a simple way to address challenging problems such as chronic tennis elbow.  As more clinicians, researchers and patients gain experience with it, better formulations and protocols will be developed to treat injuries and disorders safely and effectively.

We are now in the second decade of using PRP therapeutically and this trend is a signpost of worldwide interest.  This interest will also spark new innovations surrounding the use of blood therapeutically.

Patients and even payers will benefit from blood based breakthroughs because many newer biologic procedures will be as or more effective than surgery and less costly.

AM
Total Tendon

Sign up for a free PRP and Biologic Orthopedic Newsletter.  

Platelet Rich Plasma (PRP) Helps Patients

Platelet Rich Plasma (PRP) has been used now for more than a decade to treat a variety of orthopedic conditions.  Hundreds of thousands of patients have been treated with a stellar safety record.  The efficacy of PRP has evolved over the years but there are now multiple randomized controlled trials supporting the use of PRP.  This data has been presented at major medical conferences all over the world and published in peer reviewed elite journals such as the American Journal of Sports Medicine.

Below are the highlights from a few of the published papers:


Large Randomized Controlled Trial using PRP for Chronic Tennis Elbow Patients
American Journal of Sports Medicine 2014 

82.1% had successful treatment using PRP  compared to 60.3% in the active control group at six months.  (P = 0.008)  (See Figure)

There was also significantly less elbow tenderness in the PRP treated patients compared to the active control group at six months. (P = 0.009)

PRP Beats Cortisone for Chronic Tennis Elbow at 2 year Follow up
American Journal of Sports Medicine 2011 (100 patient trial)
Patients treated with PRP had dramatically better success rates at 2 years compared to cortisone.
(P < 0.001)

These two trials used the same protocol and same PRP device (Biomet GPS PRP).  There were no significant complications in either study.   Successfully treated patients were able to avoid more invasive and expensive surgical interventions.  This is clear evidence supporting the use of PRP for chronic tennis elbow.

PRP More Effective than Placebo in the Treatment of Knee Osteoarthritis
American Journal of Sports Medicine 2013 (156 knees)
50% improvement in pain scores was noted using PRP compared to worsening of pain in the placebo group at 6 months.  (P < 0.001)

There are now over 7400 references to PRP on PubMed with more than 500 publications last year alone.  This is an indication of the worldwide interest in this topic.   There are literally hundreds of published papers supporting the use of PRP and other blood components to treat disease.  More research and development will always be needed but using a patient's own blood to treat their injuries and disorders simply makes intuitive and scientific sense.  

Patients and providers with experience with platelet rich plasma or other biologic treatments are encouraged to post comments below.

AM
TotalTendon

Kobe returns to Germany for another Knee Arthritis Treatment

KobeTeam.com

Kobe Bryant returned to Germany this past week to be treated with a blood derived treatment (Orthokine) again for his knee.  He has had this treatment in the past at least twice before.  It involves drawing blood and incubating it over a 24 hour period and then reinjecting a component of blood that has anti-inflammatory properties.  It is similar but not exactly the same as platelet-rich plasma therapy.  It would be most interesting to learn about how this has helped him over the years and in what specific ways. He clearly has thousands of miles of basketball on his knees and is also recovering from multiple other injuries.  We do not, however, have any data about the status of his knee cartilage or joint before or after any of these treatments.  Here is a detailed description of the "Orthokine" treatment.  

Kobe has with his travel and his wallet voted in favor of this treatment.  It will be quite interesting to see how he plays this year in the NBA.   It will also be instructive to follow Kobe's future medical interventions as a way of measuring the value of the one he just had in Germany.

AM

TotalTendon

Why patients are seeking out platelet rich plasma and other biologic treatments.

Platelet rich plasma (PRP) and adult stem cell treatments derived from bone marrow are rapidly evolving into the mainstream of medicine.  As you can see from the chart above, the number of hits for "platelet rich plasma" is rising dramatically.  There are also over 7400 PRP references on PubMed.org.  Let's explore why.

Patients are seeking out less invasive treatments.  When presented with the option of surgery or an office procedure, patients typically will choose the office procedure.  Surgery often carries significant more risk and certainly more cost.

Patients want to return to sports, work or life as quickly as possible.
Botox and Lasik eye surgery provide patients with almost immediate improvement for wrinkles and vision.  Patients now expect other specialities to deliver similar almost instantaneous success.   Elite athletes are especially interested in returning to the highest level of function as quickly as possible.  They have been one of the primary drivers of PRP and other biologic treatments.

Patients are dissatisfied with the surgical treatments we have been offering them.
This is particularly true when it comes to knee arthritis.  Presently, there is very little definitive evidence supporting the use of many common treatments and there is a Grand Canyon size hole in our ability to effectively manage tens of millions of patients.  Biologic therapies will likely fill this void within the next five years.

Patients intuitively understand the regenerative abilities of your own blood and bone marrow.  Evidence is mounting across a several specialties supporting the use of blood and bone marrow to treat a variety of conditions.  A new study will begin this fall evaluating the utility of giving Alzheimer's patients blood transfusions from healthy volunteers under 30.  (Stanford Blood-Alzheimer's study)

Patients are willing to be treated without perfect supporting data.

Patients do not often understand the need for large clinical trials and are impatient with the time and effort it takes to generate meaningful clinical data.  The use of their own blood (PRP) or bone marrow simply make sense to them and they are willing and often eager to try a new treatment instead of undergo surgery.

We are presently scrambling to figure out how to develop, execute and pay for the clinical trials needed to best understand how to utilize biologic orthopedic therapies.  The good news is:  hundreds of clinicians, researchers and medical device professionals are working diligently on dozens of new treatment options.

Please post any comments about why you may think patients and clinicians are using PRP, stem cells or other biologic treatments.

AM   (@BloodCure on Twitter)
TotalTendon

Biologic Orthopedic Society crosses over 2500 Member Mark

The Biologic Orthopedic Society (BOS) is a group of professionals dedicated to the research and development of biologic treatments for musculoskeletal injuries and disorders.  This group has now grown to over 2500 members worldwide.  Much of the group's focus has been on the use of platelet rich plasma, stem cells and bone marrow concentrate (BMC) for tendonitis, arthritis and degenerative spinal disc disease.

The growth of the Biologic Orthopedic Society (BOS) is a testimony to the rapidly rising interest in biologic solutions to difficult musculoskeletal problems.  Significant progress has been made in terms of better published data supporting the use of biologic therapies in the last 2-3 years.  Clearly, more information and research is still needed.  As the group continues to grown, more and more connections are being made.  Ideas and projects are advancing.  All of this should give hope to those patients in search of better treatments.  Many hard working professionals are striving to deliver better biologic options.  

I'll predict within another 5-10 years, we will be staggered by how much will be accomplished.

Thanks to my many colleagues and friends within the BOS for a fantastic journey so far.

If you are a professional working in the area, please consider joining the group.  

Biologic Orthopedic Society

AM

Total Tendon

Hamstring Injuries Treated with Platelet Rich Plasma Return to Play Faster than Rehab Alone

Hamstring muscle injuries are very common in a variety of sports including track, soccer, football and basketball.  A recently published study in the American Journal of Sports Medicine (AJSM) found athletes that were treated with platelet rich plasma (PRP) injections returned faster to their sport when compared to rehabilitation alone.  In the study, the PRP patients returned at an average of 26.7 days compared to 42.5 days in the control group (P = .02).  (reference) This greater than two week difference in time to return to play after this common injury is clinically and competitively important.

Another recently published in the New England Journal of Medicine (NEJM) found no difference between PRP injections (2 injections spaced about a week apart) and a control group.  Interestingly, both groups in this study returned to play at 42 days, very similar to the control group in the AJSM study.  (reference)

Why are these results conflicting?

One important difference between the two studies is the type of PRP used to treat the patients.  In the study that did show a difference, white blood cell enriched PRP (leukocyte enriched PRP) was used.  In the study that did not show a difference, white blood cell  poor PRP (leukocyte poor PRP) was used.  This is a clear example of why PRP formulation matters.

The data published in elite, peer reviewed journals suggests leukocyte enriched PRP helps return athletes more than two weeks faster than rehabilitation alone after an acute hamstring injury.  No difference in return to play can be expected if leukocyte poor PRP is used in this patient population.

As PRP and other cell therapies continue to evolve, it will become increasingly clear that formulations much match indication.  Patients, researchers, and clinicians need to realize not all PRP is the same.

AM
TotalTendon

Platelet Rich Plasma Helps for "High" Ankle Sprains

"High" ankle sprains are significant injuries that typically result in prolonged recovery and time away from sports.  This type of injury involves the strong ligaments that connect two of the major bones of the ankle.  They are also known as syndesmotic injuries.

A recent randomized, controlled trial found that athletes that were treated with ultrasonic guided injections returned to play faster and has less pain than a control group.  Return to play was almost 20 days faster for the PRP group.  (40.8 days vs 59.6 days, p = 0.006)  (See abstract below)

This data supports the use of PRP for athletes with this type of injury.  Further studies will help confirm this value.

AM
TotalTendon

Knee Surg Sports Traumatol Arthrosc. 2014 Jun 18. [Epub ahead of print]

Plasma rich in growth factors (PRGF) as a treatment for high ankle sprain in elite athletes: a randomized control trial.

Laver L1, Carmont MR, McConkey MO, Palmanovich E, Yaacobi E, Mann G, Nyska M, Kots E, Mei-Dan O.

Author information

Abstract

PURPOSE:

Syndesmotic sprains are uncommon injuries that require prolonged recovery. The influence of ultrasound-guided injections of platelet-rich plasma (PRP) into the injured antero-inferior tibio-fibular ligaments (AITFL) in athletes on return to play (RTP) and dynamic stability was studied.

METHODS:

Sixteen elite athletes with AITFL tears were randomized to a treatment group receiving injections of PRP or to a control group. All patients followed an identical rehabilitation protocol and RTP criteria. Patients were prospectively evaluated for clinical ability to return to full activity and residual pain. Dynamic ultrasound examinations were performed at initial examination and at 6 weeks post-injury to demonstrate re-stabilization of the syndesmosis joint and correlation with subjective outcome.

RESULTS:

All patients presented with a tear to the AITFL with dynamic syndesmosis instability in dorsiflexion-external rotation, and larger neutral tibia-fibula distance on ultrasound. Early diagnosis and treatment lead to shorter RTP, with 40.8 (±8.9) and 59.6 (±12.0) days for the PRP and control groups, respectively (p = 0.006). Significantly less residual pain upon return to activity was found in the PRP group; five patients (62.5 %) in the control group returned to play with minor discomfort versus one patient in the treatment group (12.5 %). One patient in the control group had continuous pain and disability and subsequently underwent syndesmosis reconstruction.

CONCLUSIONS:

Athletes suffering from high ankle sprains benefit from ultrasound-guided PRP injections with a shorter RTP, re-stabilization of the syndesmosis joint and less long-term residual pain. LEVEL OF EVIDENCE: II.