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Southeast ACSM Conference February 5, 2011 Mandy Huggins, MD Emory Sports Medicine Center.

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Presentation on theme: "Southeast ACSM Conference February 5, 2011 Mandy Huggins, MD Emory Sports Medicine Center."— Presentation transcript:

1 Southeast ACSM Conference February 5, 2011 Mandy Huggins, MD Emory Sports Medicine Center

2 HPI 35 year old male corporate banker Very active in kickboxing, weight lifting, running, etc. Presents on 7/15 with history of injury on 6/19 Felt a pop and pain in the posterior ankle of planted right foot while sparring (like someone kicked me) He currently has only mild to no discomfort; reports steady improvement in pain Main reason for presentation is weakness, unable to jump or sprint Continued weight lifting and CrossFit; no kickboxing

3 Physical Exam Height 511 Weight 192 lbs RLE tender at proximal Achilles/musculotendinous junction ? Mild defect here Edema noted Weakly positive Thompsons 4/5 weakness with plantarflexion Distal neurovascular exam intact

4 Diagnosis? Achilles injury

5 Performed 7/17 Full-thickness defect involving the lateral 2/3 of the tendon with a 3.5 cm gap CONCLUSION = high grade partial tear MRI


7 Clinical decision making Referral to orthopedic foot and ankle specialist on 7/20 Recommendation for surgical repair Non-operative course would likely leave him with residual plantar flexion weakness If he needed surgery in the future, it would be difficult and he would have a prolonged recovery But… It will take an act of Congress for me to agree to have surgery

8 Now what? PRP of course!

9 Initial ultrasound findings

10 PRP Performed on 7/21 with ultrasound guidance 10 cc PRP with 1% lidocaine injected into the Achilles proximal tendon near the musculotendinous junction Post-procedural instructions Complete rest and walking boot for 4 days Avoidance of lower extremity activities for at least 2 weeks Gradually increase activity as tolerated Return to clinic in 6 weeks

11 PRP

12 Follow up Patient returned to clinic on 9/13 Denied pain or discomfort Admitted to wearing the boot for only 2 days and rest for only 1 week Returned to most activities at 1 week Has not returned to kickboxing or running Physical exam: no tenderness but mild thickening on palpation, normal strength, negative Thompsons

13 Repeat US 9/13 Improved tendon architecture by comparison Persistent thickening Heterogenous signal c/w partial tear in the proximal tendon and musculotendinous junction Neovessels

14 Repeat US 9/13


16 Second follow up visit 4 month follow up 11/17 No pain reported Running, weight lifting, cross fit without difficulty Repeat ultrasound Persistent thickening of the Achilles tendon from the muscles and junction all the way down to approximately 1 cm proximal to the insertion. Tendon appears to have filled in No gaps seen at all within the tendon itself No neovessels seen

17 Repeat US 11/17


19 Third follow up visit 6 month follow up 2/2/10 Now 6 months post procedure Patient unable to keep appointment (no US pics) Per his report, he was 100% at end of November 4 months after PRP Kickboxing, sprinting, bleachers, jumping, etc.

20 Alternative management Would he have been back this soon after surgery? NWB 2 weeks, boot 3 months, RTS at least 6 months What about non-operative management without PRP? Immobilization for about 8 weeks

21 CONCLUSION Current evidence None to compare PRP vs surgical repair Two compare surgery + PRP to surgery only Sanchez et al 2007 Earlier ROM, earlier RTS Small number Schepull et al 2011 No difference at 1 year – functionally or mechanically Lower rerupture score for PRP (1 rerupture in 16) Concentration higher, PRP storage, longer casting

22 CONCLUSION This case shows a successful outcome of PRP treatment to a near complete Achilles tendon tear that would normally have been treated surgically High level of activity Strength returned Minimal period of immobilization* Still risk of rerupture?

23 Questions?

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