Tendinitis, Tendinopathy and Prolotherapy

“Tendinopathy” is an umbrella term for any tendon problem. A tendon injury may start out as a “Tendinitis” (an inflamed tendon), but if it becomes chronic, inflammation is usually no longer present. Actual biopsies of tendons from patients undergoing surgery for “chronic Tendinitis” showed that there was no inflammation present at all! In fact, what was happening was degeneration of the tendon fibers, with an absence of inflammatory cells.[1] The term “tendonosis” is the more accurate term now used for chronic tendon issues to emphasize that inflammation is absent, and what is happening in those tissues is that collagen breakdown is occurring faster than it is being rebuilt; in other words, degeneration of the tissue is occurring, resulting in connective tissue weakness. These injuries have long been a challenge for classic orthopedic medicine because of their poor response to traditional treatment.[2] With Prolotherapy, what we are really trying to do is turn a nonhealing, degenerative tendon back into a Tendinitis, on purpose, in order to stimulate repair and healing.[3] All three of the Prolotherapy formulas have successfully been used to help with healing tendinopathies. Injecting even a low concentration of the traditional Prolotherapy formula, dextrose, into a tendon will stimulate natural growth-factor elevation within minutes to hours.[4] Multiple studies have also shown the effectiveness of Dextrose Prolotherapy for these problems.[5]

How sprains are graded as to severity
Figure 1: Ultrasound of an Achilles tendon tear before and after Biocellular (Stem Cell–Rich) treatment
Adapted from Tate-Oliver K, Alexander RW. Combination of autologous adipose-derived tissue stromal vascular fraction plus high-density platelet rich plasma or bone marrow concentrates in Achilles tendon tear. Journal of Prolotherapy. 2013; 5: e895-912, used with permission.

Both Platelet-rich plasma (PRP) and Biocellular (Stem Cell–Rich) Prolotherapy formulas have been found to be safe and effective treatments for tendinopathies. PRP has been shown to improve quality of tendon repair and reduce pain for many tendon areas, including wrist, rotator cuff (shoulder), knee patella tendon,[6] plantar fasciitis,[7] and other tendinopathies.[8] Biocellular formulas have been used for multiple tendon areas as well, including patellar and achilles tendinopathy.[9]

Of note is a case series (more than one patient case report) describing the use of Biocellular Prolotherapy for severe achilles tendonosis and tears. Improvement was seen as soon as three to four weeks after treatment, and at 12 weeks after treatment all patients returned to full activity without pain or dysfunction. Ultrasound images before and after treatment are noteworthy for dramatic healing of this large tendon tear (see Figure 1: Ultrasound of an Achilles tendon tear before and after Biocellular (Stem Cell-Rich) treatment). During follow-up at three to four years after the procedures, all patients were still symptom-free, with no recurrence of any problems or pain.[10]

Bibliography

[1] Khan KM, Cook JL, Bonar F, Hardcourt P. Histopathology of common overuse tendon conditions: Update and implications for clinical management. Sports Medicine. 1999; 27: 393–408.

[2] Docheva D, Müller SA, Majewski M, Evans CH. Biologics for tendon repair. Advanced Drug Delivery Reviews. 2015 Apr 30; 84: 222–239.

[3] Liu Y. An in situ study of the influence of a sclerosing solution in rabbit medial collateral ligaments and its junction strength. Connective Tissue Research. 1983 Jan 1; 11(2–3):95–102; Maynard J. Morphological and biomechanical effects of sodium morrhuate on tendons. Journal of Orthopaedic Research. 1985; 3(2):236–248.

[4] Reeves KD, Hassanein K. Randomized prospective double-blind placebo-controlled study of dextrose Prolotherapy for knee osteoarthritis with or without ACL laxity. Alternative Therapies. March 2000; 6(2): 68–80.

[5] Seven MM, Ersen O, Akpancar S, Ozkan H, Turkkan S, Yıldız Y, Koca K. Effectiveness of prolotherapy in the treatment of chronic rotator cuff lesions. Orthopaedics & Traumatology: Surgery & Research. 2017 May 31; 103(3): 427–433; Chan O, Havard B, Morton S, Pritchard M, Maffulli N, Crisp T, Padhiar, N, Perry, JD, King, J, Morrissey, D. Outcomes of prolotherapy for intra-tendinous Achilles tears: a case series. Muscles, Ligaments and Tendons Journals. 2017; 7(1): 78–87; Morath O, Kubosch EJ, Taeymans J, Zwingmann J, Kostantinidis L, Südkamp NP, Hirschmüller A. The effect of sclerotherapy and prolotherapy on chronic painful Achilles tendinopathy–a systematic review including meta‐analysis. Scandinavian Journal of Medicine & Science in Sports. 2017; 1–12; Hauser RA, Lackner JB, Steilen-Matias D, Harris DK. A systematic review of dextrose prolotherapy for chronic musculoskeletal pain. Clinical Medicine Insights. Arthritis and Musculoskeletal Disorders. 2016; 9: 139–159; Lee DH, Kawck KS, Rah UW, Yoon SH. Prolotherapy for refractory rotator cuff disease: retrospective case-control study of 1-year follow up. Archives of Physical Medicine and Rehabilitation. 2015; 96(11): 2027–2032; Bertrand H, Reeves KD, Bennett CJ, Bicknell S, Cheng A. Dextrose prolotherapy versus control injections in painful rotator cuff tendinopathy. Archives of Physical Medicine and Rehabilitation. 2016; 97(1): 17–25; Rabago D, Yelland M, Patterson JJ, Zgierska A. Prolotherapy for chronic musculoskeletal pain. American Family Physician. 2011; 84(11): 1208–1210

[6] Filardo G, Kon E, Di Matteo B, Pelotti P, Di Martino A, Marcacci M. Platelet-rich plasma for the treatment of patellar tendinopathy: clinical and imaging findings at medium-term follow-up. International Orthopaedics. 2013 Aug 1; 37(8): 1583–1589.

[7] Kadam R, Vijay S, Chhallani A, Pandhare S, Gupta A, Singh RS. Efficacy of platelet rich plasma injection in treatment of plantar fasciitis. International Journal of Research in Orthopaedics. 2017 Apr 25;3(3): 451–455; Baz AA, Gad AM, Waly MR. Ultrasound guided injection of platelet rich plasma in cases of chronic plantar fasciitis. The Egyptian Journal of Radiology and Nuclear Medicine. 2017 Mar 31; 48(1): 125–132; Papalia R, Zampogna B, Vadala G, Di Martino A, Nobile C, Del Buono A, Torre G, Tirindelli, C, Maffulli, N, Denaro, V. Are Platelet Rich Plasma Injections More Effective in Tendinopathy or Enthesopathy? Journal of Pain & Relief. 2017; 6(288): ISSN 2167-0846.

[8] Mautner K, Colberg RE, Malanga G, Borg-Stein JP, Harmon KG, Dharamsi AS, Chu S, Homer P. Outcomes after ultrasound-guided platelet-rich plasma injections for chronic tendinopathy: a multicenter, retrospective review. PM & R. 2013; 5(3): 169–175; Fitzpatrick J, Bulsara M, Zheng MH. The effectiveness of platelet-rich plasma in the treatment of tendinopathy: a meta-analysis of randomized controlled clinical trials. American Journal of Sports Medicine. 2017 Jan; 45(1): 226–233; Sahu A, Singh PK, Khan S, Singhania S, Gudhe M, Mundada G, Gawande V. Ultrasound-guided platelet-rich plasma infiltration: A stupendous treatment for chronic tendinopathy. Saudi Journal of Sports Medicine. 2016 Sep 1;16(3):185.

[9] Pascual-Garrido C, Rolón A, Makino A. Treatment of chronic patellar tendinopathy with autologous bone marrow stem cells: a 5-year-followup. Stem Cells International. 2012: Article ID 953510, 5 pages; de Girolamo L, Grassi M, Viganò M, Orfei CP, Montrasio UA, Usuelli F. Treatment of achilles tendinopathy with autologous adipose-derived stromal vascular fraction: Results of a randomized prospective clinical trial. Orthopaedic Journal of Sports Medicine. 2016 Jul 18; 4(7) Suppl 4.

[10] Oliver KS, Alexander RW. Combination of autologous adipose-derived tissue stromal vascular fraction plus high density platelet-rich plasma or bone marrow concentrates in Achilles tendon tears. Journal of Prolotherapy. 2013; 5: e89–e912.