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?