Tuesday, January 31, 2012

Super Bowl High Ankle Sprain and Platelet Rich Plasma

Rob Gronkowski of the SuperBowl New England Patriots apparently has a "high ankle" sprain.  First let's define a high ankle sprain.  This is a stretching or tearing of the ligaments that connect the two bones of the just above the ankle, the fibula and tibia.  That is why it is called a "high" ankle sprain as opposed to a typical less serious ne that involves the ligaments just below the joint line.  It can lead to significant instability of the ankle that at times requires surgery.  It also takes between 6-8 weeks to heal even if surgery is not needed.  

The details about his injury are little sketchy but here is what I can find so far.   He did not practice on Monday and has been wearing a boot.  He injured it in the AFC championship game 10 days ago.  I think it is possible the doctors may have given him platelet rich plasma to speed the healing of his injury.  There is no published data supporting this application but based on preclinical studies, it may be an effective treatment.  Here is a link to a story that fuels that speculation.    He will also likely to receive game time treatment in the form of tight taping or bracing and perhaps even a pain killing shot into the joint. 

Here is what to watch for.  Will he be able to block and make sharp cuts during his recieving routes?  A high ankle sprain by definition injuries the ligaments that stablize and support these moves.  Can he somehow become the Hines Ward of 2012 and make a catch in the first series that helps his team ultimately win the Super Bowl?  The first quarter of the game will help all of us better understand.  Hopefully, after the game we will learn more about his actual injury and treatment. 

Read more about High Ankle Sprains

Read more this speculation on ESPN

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Saturday, January 21, 2012

Platelet Rich Plasma vs Hyaluronate for Ankle Pain and Disability

Am J Sports Med. 2012 Jan 17. 

Platelet-Rich Plasma or Hyaluronate in the Management of Osteochondral Lesions of the Talus.


Department of Orthopedic Surgery, Meir University Hospital, Kfar-Saba, Israel.



Nonoperative options for osteochondral lesions (OCLs) of the talar dome are limited, and currently, there is a lack of scientific evidence to guide management.


To evaluate the short-term efficacy and safety of platelet-rich plasma (PRP) compared with hyaluronic acid (HA) in reducing pain and disability caused by OCLs of the ankle.


Randomized controlled trial; Level of evidence, 2.


Thirty-two patients aged 18 to 60 years were allocated to a treatment by intra-articular injections of either HA (group 1) or PRP (plasmarich in growth factors [PRGF] technique, group 2) for OCLs of the talus. Thirty OCLs, 15 per arm, received 3 consecutive intra-articular therapeutic injections and were followed for 28 weeks. The efficacy of the injections in reducing pain and improving function was assessed at each visit using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale (AHFS); a visual analog scale (VAS) for pain, stiffness, and function; and the subjective global function score.


The majority of patients were men (n = 23; 79%). The AHFS score improved from 66 and 68 to 78 and 92 in groups 1 and 2, respectively, from baseline to week 28 (P < .0001), favoring PRP (P < .05). Mean VAS scores (1 = asymptomatic, 10 = severe symptoms) decreased for pain (group 1: 5.6 to 3.1; group 2: 4.1 to 0.9), stiffness (group 1: 5.1 to 2.9; group 2: 5.0 to 0.8), and function (group 1: 5.8 to 3.5; group 2: 4.7 to 0.8) from baseline to week 28 (P < .0001), favoring PRP (P < .05 for stiffness, P < .01 for function, P > .05 for pain). Subjective global function scores, reported on a scale from 0 to 100 (with 100 representing healthy, preinjury function) improved from 56 and 58 at baseline to 73 and 91 by week 28 for groups 1 and 2, respectively (P < .01 in favor of PRP).


Osteochondral lesions of the ankle treated with intra-articular injections of PRP and HA resulted in a decrease in pain scores and an increase in function for at least 6 months, with minimal adverse events. Platelet-rich plasma treatment led to a significantly better outcome than HA.

Interesting new data.


Tuesday, January 10, 2012

Platelet Rich Plasma Classification and Tennis Elbow Data

PRP Classification

White Blood Cells
Type 1
Increased over Baseline
Type 2
Increased over Baseline
Type 3
Minimal or No WBCs
Type 4
Minimal or No WBCs

A:  > 5x Platelets
B:  < 5x Platelets

The classification system outlined above has been published in a peer reviewed journal by Mishra et al.  Published Reference

The use of platelet rich plasma has grown significantly worldwide.  Not all PRP, however, is the same.  This is crucial for patients, providers and hospital administrators to understand.  The most studied clinical problem so far is chronic tennis elbow.  Elite data supports the use of PRP that contains white blood cells applied in an unactivated fashion.  This is type 1 PRP according to the classification.  PRP formulations that do not contain white blood cells have NO controlled data supporting their use for chronic tennis elbow.  Below is a list of the PUBLISHED controlled data supporting the use of PRP for tennis elbow.

Gosens et al:  PRP with white blood cells 77% success vs 43% for cortisone at 2 years (p < 0.0001)

Peerbooms et al:  PRP with white blood cells 64% pain improvement vs 24% for cortisone at 1 year ( p < 0.001)

These are level one studies of 100 patients done using the Biomet GPS system.  It is clear from this data that PRP is a better option than cortisone for chronic tennis elbow.  When debating about whether PRP is effective, it is paramount to ask:

What TYPE of PRP?  and for What APPLICATION?

PRP research is continuing to evolve but the debate should take place in the context of data whenever possible.

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