Platelet Rich Plasma Therapy to Treat Bilateral Patellar Tendonitis in Female Collegiate Soccer Athlete: A Case Study

Nalepa AV*, Bains KH†, Bennett, JP*: *Chapman University, Orange, CA, †Santiago Canyon College, Orange, CA.
Background:
• 15-year-old high school female soccer athlete diagnosed with bilateral patellar tendonitis in 2005 and did rehabilitation with her high school athletic trainer • 2005 - 2008: Rehabilitation included general quadriceps, hamstring, and gluteal strengthening while participating in soccer and track & field • 2008: Orthopedic specialist diagnosed her with patellar tendonitis, plica inflammation, and chondromalacia • Athlete discontinued activity from Dec 2008 to Aug 2009 and was referred to physical therapist •Therapy included home exercise program to assist in strengthening hip abductors, pelvic stabilizers and knee flexors •Exercises included bridges, hamstring curls and marches on the Swiss Ball • Complained of 8/10 pain at the beginning of the 2009 soccer season while attempting to play soccer

Treatment:
• September 23, 2009 athlete (age 19) received PRP therapy • Athlete took two weeks off to allow proper recovery • Week 1: Ice, stretch, gradually increase walking • Week 2: Progressive Resistive Exercises including: Straight Leg Raises, Mini-squats, light jogging • Overall pain decreased to 2/10 three weeks post -injection

Athlete's Pain Scale
10 8 6 4 2 0 -15 -10

-5

0

5

10

15

20

25

30

Days Pre Therapy, Day of Therapy (0), and Days Post Therapy

What is Platelet Rich Plasma Therapy? What is Patellar Tendonitis?
• Chronic condition involving a failure of normal tendon repair mechanism associated with angiofibroblastic degeneration(2) • Often occurs with activities such as jumping, cutting, going up and down stairs, and running • Incomplete structural disruption of the tendon occurs, which results in vascular damage (3) • Initially used 20 years ago to help dental patients recover from jaw reconstruction • Accelerated the remodeling and angiogenesis in the injured matrix • Platelets contain growth factors that proliferate human osteoblast-like and fibroblast cells • Increase the production of both collagen I and collagen III (4) • Normal Blood Concentration= 200,000 platelets/l; PRP Therapy= 4x (~ 1 million platelet/l)(1) • The PRP is then diluted with 8.4% bicarbonate and injected into the patellar tendon and surrounding areas including the fat pad behind the tendon and the tendon sheath.

How is Patellar Tendonitis treated?
• Conservative (3) • Stretching and strengthening exercises • Applying heat before and ice after exercise • NSAIDS • Patellar strap • Aggressive Treatments (3) • Corticosteroids • Platelet Rich Plasma (PRP) Therapy • Nitric Oxide

Differential Diagnosis:
• Patellofemoral pain syndrome • Osteochondral defect • Meniscus tear • Pes anserine bursitis • Osgood schlatter’s disease • Tibial plateau stress fracture

Uniqueness:
• No previous reports of PRP therapy done bi-laterally in a lower extremity • No previous reports of PRP therapy done in an athlete during the middle of his or her season • Only a handful of patients have received this treatment • Finding appropriate rehabilitation protocols to follow after the injection was difficult
References: 1.Sampson, et al. "Platelet rich plasma injection grafts for musculoskeletal injuries: a review." Current Reviews in Musculoskeletal Medicine 1.3-4 (2008): 165-74. 2.Mishra, Allan, and Terri Pavelko. "Treatment of Chronic Elbow Tendinosis With Buffered Platelet-Rich Plasma." American Journal of Sports Medicine 34 (2006): 1774-78. 3.Kaeding, Christopher, and Thomas M. Best. "Tendinosis: Pathophysiology and Nonoperative Treatment." Sports Health: A Multidisciplinary Approach 1 (2009): 284-92. 4.Klein, et al. "Flexor tendon healing in vitro: Effects of TGF-[beta] on tendon cell collagen production." The Journal of Hand Surgery 27.4 (2002): 615-20. 5.de Vos, et al. "Platelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial." JAMA 303.2 (2010): 144-49.

Results/Conclusions:
• Athlete returned to play on October 8, 2009, 15 days after therapy with 2/10 pain • PRP therapy appeared successful in treating chronic tendonitis for this patient • While this patient showed positive results of PRP therapy, recent random controlled trials of PRP for Achilles’ tendon injection showed no significant benefit over the placebo saline injection (5) • Athletic trainers should be aware of a new treatment possibility called Platelet Rich Plasma (PRP) therapy which may increase the rate of healing and recovery