PRP, platelet-rich plasma for patellar tendinopathy: No more effective than saline (in this first study).

"Combined with an exercise-based rehabilitation program, a single injection of LR-PRP or LP-PRP was no more effective than saline for the improvement of patellar tendinopathy symptoms.:"

*this is the First randomized controlled trial comparing PRP (platelet-rich plasma) injection to saline, for patellar tendinopathy.

Platelet-Rich Plasma for Patellar Tendinopathy: A Randomized Controlled Trial of Leukocyte-Rich PRP or Leukocyte-Poor PRP Versus Saline

Alex Scott, PhD*, Robert F. LaPrade, MD, PhD, Kimberly G. Harmon, MD,

Link: https://journals.sagepub.com/doi/abs/10.1177/0363546519837954?journalCode=ajsb&fbclid=IwAR2p8pj3cugbIafBLaUj8zoaKm3hHyBfIIw6m3rBfDVgBDVKBj73s4jaK30

Loading protocols for achilles tendinopathy.

We all know now that the smartest way out of a chronic tendinopathy is painfree, progressive loading. We, as many others have found, that isometrics serve the initial process well because there is no movement through a painful arc, the isometrics can help reduce the neurologic pain loop, and we can more easily find positions where there is no pain in the tendon. This allows us to load the affected tendon, without adding insult to the tendon portion that is injured. It them prepares us for the weeks to months of eccentric and concentric loading that is often necessary to restore function. Keep in mind that some of the literature indicates that some tendons never fully heal, but we replace things with a better functioning of the remaining competent tendon.

This study found that there was an improvement in pain and function as early as 2 weeks. You might find this interesting because on imaging tendon structure does not change within 2 weeks and muscular hypertrophy is not seen for at least 4 weeks following inception of a loading protocol (Murphy). Thus, we all need to continue our education and understanding of central pain mechanisms. Meaning, that these initial early changes, are in part, and maybe a huge part, are neurologic.

Sports Med. 2018 May 15. doi: 10.1007/s40279-018-0932-2. [Epub ahead of print]
Rate of Improvement of Pain and Function in Mid-Portion Achilles Tendinopathy with Loading Protocols: A Systematic Review and Longitudinal Meta-Analysis.
Murphy M1,2,3, Travers M4,5, Gibson W4, Chivers P6,7, Debenham J4, Docking S8, Rio E8,9.

Acute tendon changes in intense CrossFit workouts

Study: Acute tendon changes in intense CrossFit workout

Habitually overloaded tendons often thicken and increase the tendonopathy risks -- nothing new here.
However as this study points out "it remains unknown whether acute overload caused by strenuous, high-intensity exercise will exert changes in tendons and if these changes can be detected and described by ultrasonography."

This study (note: Achilles, and plantaris tendon ultrasounds were performed before and after a specific workout in 34 healthy subjects)
. . . .noted "a significant increase in the thickness of the patellar and Achilles tendons" in response to strenuous, highly intense CrossFit exercises. Cross fit is not the culprit here, it is the load and load rate. None the less, it is good to know that an aggressive workout can leave us more vulnerable. This is why adequate rest and recovery must be part of your regular weekly workouts. One cannot keep fully stomping on the gas pedal over and over, workout after workout, and not expect problems to creep in if adequate recovery time has not been afforded to the working parts. This study showed changes after just one workout. No rocket science here today, we should see changes, load was applied. This is just good old fashioned "well duh, that makes sense". Here is the problem, we don't always listen to logic, nor do our clients who have goals and timeframes. We live in the "more is better" world now, so stay vigilant on logic gang. Dial your foolish clients in a little, save them some grief.  Yes, this goes for runners and all other venues of activity, there is a reason why we see problems in people with speed workouts more frequently than base miles.

Acute tendon changes in intense CrossFit workout: an observational cohort study. F. Y. Fisker et al
http://onlinelibrary.wiley.com/doi/10.1111/sms.12781/full

What are we listening to this week? The Plantaris…    Thanks to Karly Foster of Twin Bridges Physiotherapy the: Physioedge podcast with David Pope    Imagine if you were able to dedicate a large portion of your life to the study of one individual muscle. That’s exactly what the main person interviewed here has done Dr. Kristof Spang from Sweden has done.  a lot of research on Achilles tendon tendinopathy.This podcast looks at the role of the plantaris muscle in mid tendon tendinopathy,   with an emphasis on anatomy.     This muscle needs to be considered in recalcitrant cases of Achilles tendon apathy which of not respond to conservative means.   Dr Spang goes through some of the anatomical variations of attachment of the plantaris, with 10 to 20% attaching into the Achilles tendon. Since there seems to be at least  nine different anatomical variations in attachment  that can occur; this can often explain the variety of symptoms associated with plantaris issues.  The plantaris attaches from the lateral aspect of the femoral condyle downward to its insertion point within deli near its origin at the knee. The area of attachment distally can be between two and 5 mm and this “area attachment” may be part of the source of the pain. Phylogenetically the tendon attaches into the plantar fashia, similar to the palmaris. One theory is due to the small muscle size it may actually act as a proprioceptive sentinel for the knee and ankle. The peritendonous tissue may interfere with the gliding of the tendon in this is believed to be one of the ideologies of this recalcitrant problem.  Of the diagnostic imaging available,  ultrasound  seems to provide the most clues. In the absence of imaging, recalcitrant medial knee tendon Achilles tendon pain seems to also be a good indicator.   Our takeaway  was that most often the problem seems to be had a conjoined area between the planters and Achilles tendon midcalf lead to most problems. Treatment concentrated in this area may have better results. If this is unsuccessful, surgery (removal of the plantaris, extreme, eh?)  may need to be considered.  Regarding  specific tests  for plantaris involvement,  people who pronate seem to be more susceptible  than those who supinate. This is not surprising since the tendon runs from lateral to medial it would be under more attention during predatory forces  It seems that plantaris tendonopathy  can exist separately from an conjoint tendinopathy and it may be that people of younger age may suffer from plantaris tendinopathy alone. This may indicate that the problem may begin with the plantaris and that the planters is actually stronger and stiffer than the Achilles!  It was emphasized that this condition only exists in a small percentage of mid Achilles tendon apathy patients. And that conservative means should always be exhausted first.     All in all, an interesting discussion for those who are interested in pathoanatomy. Check out part 2 in this series for more.      link to PODcast:  http://physioedge.com.au/physio-edge-041-plantaris-involvement-in-midportion-achilles-tendinopathy/

What are we listening to this week? The Plantaris…

Thanks to Karly Foster of Twin Bridges Physiotherapy the: Physioedge podcast with David Pope


Imagine if you were able to dedicate a large portion of your life to the study of one individual muscle. That’s exactly what the main person interviewed here has done Dr. Kristof Spang from Sweden has done.  a lot of research on Achilles tendon tendinopathy.This podcast looks at the role of the plantaris muscle in mid tendon tendinopathy, with an emphasis on anatomy.

This muscle needs to be considered in recalcitrant cases of Achilles tendon apathy which of not respond to conservative means.

Dr Spang goes through some of the anatomical variations of attachment of the plantaris, with 10 to 20% attaching into the Achilles tendon. Since there seems to be at least nine different anatomical variations in attachment that can occur; this can often explain the variety of symptoms associated with plantaris issues.

The plantaris attaches from the lateral aspect of the femoral condyle downward to its insertion point within deli near its origin at the knee. The area of attachment distally can be between two and 5 mm and this “area attachment” may be part of the source of the pain. Phylogenetically the tendon attaches into the plantar fashia, similar to the palmaris. One theory is due to the small muscle size it may actually act as a proprioceptive sentinel for the knee and ankle. The peritendonous tissue may interfere with the gliding of the tendon in this is believed to be one of the ideologies of this recalcitrant problem.

Of the diagnostic imaging available, ultrasound seems to provide the most clues. In the absence of imaging, recalcitrant medial knee tendon Achilles tendon pain seems to also be a good indicator.

Our takeaway was that most often the problem seems to be had a conjoined area between the planters and Achilles tendon midcalf lead to most problems. Treatment concentrated in this area may have better results. If this is unsuccessful, surgery (removal of the plantaris, extreme, eh?)  may need to be considered.

Regarding specific tests for plantaris involvement, people who pronate seem to be more susceptible than those who supinate. This is not surprising since the tendon runs from lateral to medial it would be under more attention during predatory forces

It seems that plantaris tendonopathy  can exist separately from an conjoint tendinopathy and it may be that people of younger age may suffer from plantaris tendinopathy alone. This may indicate that the problem may begin with the plantaris and that the planters is actually stronger and stiffer than the Achilles!

It was emphasized that this condition only exists in a small percentage of mid Achilles tendon apathy patients. And that conservative means should always be exhausted first.


All in all, an interesting discussion for those who are interested in pathoanatomy. Check out part 2 in this series for more. 


link to PODcast: http://physioedge.com.au/physio-edge-041-plantaris-involvement-in-midportion-achilles-tendinopathy/