When doing my blog posts, I always like to go off what I am seeing within the community, the research, and also the questions I get asked by my clients. There are a lot of procedures that can be offered in the assistance of tendon related pain (tendinopathy). Platelet rich plasma (PRP) injections are just one of these that are highly sought after as a "natural" way of going about it. In today's post, I will go over not only whether PRP injections actually help but also break things down further. While this discussion will lean into runners and endurance athletes, active adults can definitely benefit highly from the read as well.
What is Achilles Tendinopathy?
When most people talk about an injury to a tendon, they are more than likely referring to tendinitis. However, an injury to a tendon is more of a progression and is where the term tendinopathy stems. Tendinitis is just the start.
Basically, tendinitis is the irritation of a tendon in the acute sense. This may occur when you perform a task that requires more force than what the tissue can tolerate, you run more miles than you usually do (and/or at a greater intensity), or in some cases when there is direct trauma to the tendon. This part of the progression can last anywhere from a day to a week or two.
If you have tenderness, pain, or discomfort in a tendon for longer than a couple of weeks, that’s when tendinosis appears. Tendinosis is a progressive condition that can last anywhere from a month to years. The longer this occurs without alleviation then, of course, the worse it is. Tendinosis involves a gradual and overall change in the normal tissue of the tendon, converting from healthy tissue that is aligned with the appropriate protein chains holding it together into an irregular, protein poor, and scar tissue-laden tendon.
Usually, tendinitis is an inflammatory condition but once it progresses more to a chronic stage, it is no longer inflammatory and instead becomes one involving decreased oxygen and lack of healing properties/chemicals required for healing. There may be an attempt by the body to lay down more tissue in the form of scar tissue which may cause swelling of the tendon at the site of injury. The longer this occurs before getting assistance, the longer and harder it can be to recover.
If left unchecked for an extended period, you can progress to a tendon rupture which will ultimately require surgical repair. But enough about worrying about whether this is in your future and let’s get to figuring out how to help you out and get you out of this mess. Let's talk about what PRP injections are, if and how they can help, and what else is available as there is no one size fits all plan for everyone.
What Is Platelet Rich Plasma (PRP)? Why Is It Used as An Injection?
Platelet Rich Plasma is a recent innovation in the treatment of tendon, joint, and ligament injuries that was developed as a more "natural" way of healing the body from pain and/or injury (I will explain why I put the quotations around natural as we go along). Basically, in this procedure, your MD will draw a specific amount of blood from your own body. The blood will then be placed inside of centrifuge and spun until the particulates of your blood are separated (much like how you see when you have vinegar and oil separate in salad dressing). From here, the MD or the lab will extract the middle portion between the plasma (i.e., water portion of your blood) that does not have your platelets and the red blood cells.
Prior to extraction of this sample, your MD will decide if he would like to include or exclude white blood cells in the treatment (this does matter and one of the questions you should ask...keep reading to find out more). After extraction and preparation in the syringe, you will receive the therapy as an injection into the affected tendon, ligament or joint as an attempt to use your own body's cells to cause healing.
This is where the "natural" component comes into, as you are using your own body's cells to heal yourself better and faster. However, the unnatural part is the procedure and the fact that it needs to be injected back into you. Hence the quotations.
The ability for this procedure to exist makes it a viable way of being able to reintroduce or restart inflammation directly at the site of a chronic tendon issue (remember, once it goes chronic there is no healing the inflammatory process for recovery). As described above, I mentioned that the MD can include to use your white blood cells (WBCs) or exclude them. You want to include them if you want to restart or cause inflammation-like in a ligament or tendon, but you do not want to cause inflammation in any sense within a joint such as with knee osteoarthritis. Causing inflammation within a joint will only facilitate dysfunction, pain, and decreased activity.
The idea behind using PRP is to create an environment that would best allow healing when other treatments may not. The injection itself will allow for new blood vessel formation (angiogenesis), migration of and activation of healing factors, and the establishment of new tissue to create a strong structure. If you have tried taking a break from the painful activity, medications, other injections, PRP may be a good supplement when paired with physical therapy.
The question and the real thing you have been waiting for while reading this is...will it work for you???....Let's get into it.
Does Platelet Rich Plasma Injections Really Work?
Just like with everything we consume, take, obtain, or go through in healthcare to treat or manage what we deal with in life, we always want to make sure that IT WORKS...so do PRP injections actually do what they say??? Well...let's take a closer look and see what the research says.
In a research study conducted in 2018 by Martinez-Martinez, Ruiz-Santiago, and Garcia-Espinosa, several randomized controlled trials and systematic reviews were examined to determine the effectiveness and current level of evidence. They discovered that there was Level 1a (very high level) evidence showing that PRP would be helpful in lateral epicondylitis (tennis elbow), knee osteoarthritis, plantar fasciitis, and rotator cuff tendinopathy while there was Level 1b (slightly less effective than 1a) evidence for patellar tendinopathy and hip osteoarthritis.
In another study conducted by Chun-Jie Liu et al. in 2019, PRP injections were examined to see if they assisted in directly treating chronic Achilles tendinopathy using a meta-analysis. While at the 6-week and 24-week point of analysis the data showed there was no significant difference between the pain scores and tendon thickness, the 12-week mark did show there was significant difference. Based on this, it was concluded that there was not superior evidence to determine that PRP injections were effective for Achilles tendinitis when compared to a placebo or sham injection of saline.
Lastly, a 2020 study conducted by Everts et al., examined the literature available for PRP injections, closely examining what PRP injections achieve or hope to achieve. If you have the time and do not mind significant amounts of medical jargon, please feel free to use the references below to read the study yourself in its entirety. Despite the major innovations and advances that have been made in PRP research, the study concluded that more researched is needed to clearly understand PRP’s efficacy and the conditions it can best help. They also mentioned that there has yet to be a standardization to preparation and bio-formulations for maximal effectiveness.
So...Is Getting a PRP Injection Right for You?
Despite the lack of evidence mentioned above, I have personally seen some patients do well with PRP injections and others who have had little improvement. Additionally, I have seen the overall cost to the patient go down for these injections; once priced at several thousand dollars, the out-of-pocket cost for the preparation and PRP procedure now only cost several hundred dollars.
In my area of medicine and field of health and wellness, I’m all for trying different techniques and procedures, but I do always recommend going from least invasive to most invasive. Before relying on injections and even surgery, rest and taking it easy with moderate exercise and activity is recommended. However, if your Achilles Tendinitis becomes chronic, an active approach is recommended in hopes of preventing the pain from coming back; sometimes injections, especially in this case, can be a good adjunct to an active approach but this is more of a case-by-case scenario.
In another research study I have read recently (couldn't find it), they stated that there was no difference in the efficacy in physical therapy alone versus physical therapy with PRP injections over the period of the intervention but both groups did note improvement. Regardless of whether getting a PRP injection or not, restoration of normal function (especially if you have been resting) is vital to ensure you have no worries or issues with this tendinitis coming back.
When seeing a physical therapist for this issue, you want to make sure he is exposing you to forces that are similar to your daily life. For example, if you are on your feet for work, your physical therapist should have you work on strength and high endurance activities. If you are an athlete, you should be exposed to activities or forces that are found within your sport. If you are seeing a PT who either does not take you off the table nor does he incorporate activities that replicate your daily life, ask questions. Ask when you are going to get to those types of activities. If he doesn’t have an answer or plan for that, then you may be seeing the wrong person and may need a change in provider.
If you are dealing with acute or chronic Achilles Tendon issue, are an endurance athlete, or an active adult and would love to get back to doing activities which you miss doing, please feel free to contact me at rberghorn@ascentphysicaltherapyny.com or call me at (516) 387-4669 to book a FREE non-obligation Discovery Visit. I can help to determine the cause of your pain and what it will take to get your goals achieved.
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