Tendinosis or tendinopathy is a degenerative condition of the tendon caused by repetitive microtrauma and a failed healing response. The tendon is the strong tissue that connects muscle to the bone. It is made of bundles of collagen fibrils. When a tendon is repetitively subjected to loads exceeding its capacity, some of the fibers begin to fail making the whole tendon weaker. The body tries to begin a healing response, but sometimes, because of continued stress, the age of a tendon, or other factors the tendon does not heal.
Tendinosis, sometimes called tendinopathy, is different than "tendonitis." Tendonitis is an acute inflammation of the tendon and occurs in response to a new activity or stress. Tendinitis will typically resolve with rest, ice, and anti-inflammatory medication. Tendinosis, on the other hand, is a long-standing degenerative process, and when tendinopathic tendons are biopsied there are no inflammatory cells present. Instead, the tendon is degenerative and the healing response has failed. Sometimes scar tissue or calcium deposits in the tendon are the result of the failed healing response.
Treatments targeting inflammation have limited effectiveness in the treatment of tendinosis since there is no inflammation present. Anti-inflammatory medications such as ibuprofen, naproxen, and similar prescription medications are good pain relievers which is why people with tendinosis may experience temporary relief when taking them. They will not, however, cure the problem of tendinosis. In fact, anti-inflammatory medication may actually impair tendon recovery as inflammation is the first stage of the healing process.
Newer treatments for tendinosis are all designed to stimulate healing. This can be done in a variety of ways.
Certain types of exercises ("eccentric") or deep tissue massage may stimulate healing in tendons.
Nitroglycerin patches are usually used to lower blood pressure, however, studies have shown that they can have healing effects on tendons. The patch is cut into quarters and applied directly over the tendon. It typically takes 1-2 months to see improvement and works best when combined with eccentric exercises.
Some studies have shown that repetitively poking or needling the tendon and causing it to bleed may induce healing. Blood is made up of several elements. An important element for the healing of tendons are the platelets. Platelets are packed with growth factors that can jump start the stalled healing process in tendinosis. In a tenotomy procedure, the area is numbed with local anesthetic and then the tendon is needled or repeatedly poked to create small fenestrations and cause the tendon to bleed. Tendons are relatively avascular and do not have a lot of blood vessels in them. Sometimes the needling procedure alone is enough to stimulate healing. Sometimes the needling or tenotomy is combined with other procedures.
In autologous blood injections, a small amount of blood (2-3 cc) is taken from the patients arm and injected back into the degenerative portion of the tendon using ultrasound guidance after the tenotomy. The blood contains growth factors which can restart a stalled healing process.
In studies that have looked at autologous blood injections there is a reported 80% - 95% satisfaction rate, and about a 5% - 15% failure rate. In actual practice, around 60% of people improve significantly with two injections. The protocol we use is to do two injections four weeks apart.
Platelet rich plasma has received a significant amount of media attention and is becoming more popular. Initial studies are promising but there is still much to be learned.
In a PRP injection a small amount of patients blood is drawn from the patient, the blood is centrifuged and the platelets are harvested. PRP is then injected back into the degenerative area under ultrasound guidance. PRP has 3 – 9 times the growth factors that whole blood does and can stimulate healing. PRP has been used for over twenty years in dental and maxillofacial procedures. Its use in musculoskeletal injuries is relatively recent.
There are many basic science and animal studies that suggest that PRP is effective. There are also studies in humans suggesting PRP is effective. PRP is not a miracle cure. In chronic injuries it can restart the body's natural healing processes. Progress is usually slow. Typically, people will be about 20% better at 6 weeks and about 80% better at 12 weeks. A second injection is required in about 30% of people. A second injection (if needed) is usually not done until 12 weeks because significant improvement can occur up to that time period.
About 10% of people will not respond to PRP. Almost everybody improves. Not everybody gets back to 100%.
The indication which has been studied the most is for tendinosis or partial tears of most tendons:
There are a few studies which suggest PRP may be effective in osteoarthritis. It is more effective in mild to moderate arthritis and will likely not help severe, degenerative arthritis. Its use in arthritis is experimental and it is unlikely to be covered by insurance.
PRP has not been studied in chronic back or disk injuries and these injections are not done at Hall Health.
Since the PRP is prepared from your own body there is very little risk of infection. With any injection there is always a small risk of infection or bleeding. In addition, tendons which are degenerative may rupture with or without the injection of PRP. Some people will have pain during and after the procedure although this is typically fairly minimal. About 10% of people do not respond to PRP treatment. You may improve but get back to 100% of pre-injury level.
There is a small amount of discomfort when the blood is drawn to prepare the PRP. After the blood is drawn, the skin is cleaned and sterilized and then numbed using local anesthetic similar to the dentist's office. Pain during the procedure is usually minimal, although a minority of people will experience a deep cramping, aching discomfort which typically resolves after 10 – 15 minutes. After the procedure you will be asked to lay still with ice on the affected area for 15 minutes. The pain from the injury may be flared up for a few days to a week.
The actual injection only takes a few minutes. However drawing and preparing the blood, and procedure set-up can take 15 – 30 minutes. After most injections you will be asked to remain still with ice on the area for 15 minutes. You're provider will tell you how long to schedule for your PRP appointment, typically 30 – 60 minutes depending on what you are having done.
You should do only normal activities of daily living for the first two weeks – no additional exercise. Most people can go back to work right away. After two weeks you will begin a slow progression of activity. The exact progression depends on the injury site. For lower extremity injuries a typical progression would be stationary bike or swim at 2 weeks, elliptical trainer or stair stepper at 4 weeks. You will follow up with your provider at 6 weeks.
You can ask your insurance company whether or not it is covered. You will need to provide them with the billing code 0232T and our tax ID # 91-1220843. Most insurers consider it experimental although there is good evidence that it is effective for tendon conditions. You may also check with our billing department, 206-616-1881 to see if your insurance has covered PRP for other patients.
PRP is $800 per injection when ultrasound is used. It is $500 per injection on some joint injections where US is not required.
Cortisone is a potent anti-inflammatory so for acute tendinitis it can be useful. It is also catabolic, meaning it dissolves scar tissue. In tendons where there is a lot of scar tissue, even if there is not inflammation, there may be a role. There is also a role for cortisone in adhesive capsulitis or frozen shoulder. Your doctor can discuss which options are best for your situation.
You should schedule an office visit with one of our providers. You should bring in previous MRIs or x-rays on a CD. You will need to be seen prior to getting your PRP injection to make sure it is the right thing for you. If you are a good candidate for PRP therapy you can schedule for the injection after that.
Yes! We are a full service sports medicine clinic!
At Hall Health, musculoskeletal ultrasound is used to diagnose tendinopathy, target treatment and follow the progress of tendons. Physicians at Hall Health have been on the forefront of this emerging technology. Ultrasound is used to visualize the tendinopathic region of the tendon in order to more accurately focus treatment.
Some injections, like cortisone, do not have to be placed at the exact site on injury because the medication diffuses. With a biologic treatment, like PRP, it is important to get the substance at the exact site of injury or degeneration.
Ultrasound can also be used to diagnose problems and follow the progress of a healing tendon.