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TIME’S UP ON HEEL PAINOPTIONS FOR CHRONIC FASCIAL AND TENDON INJURIES
ERIKA M. SCHWARTZ, DPM
FOOT AND ANKLE SPECIALISTS OF THE MID -ATLANTIC
WASHINGTON DC AND CHEVY CHASE, MD
TENDON INJURY
Tendon injuries are common- affect over 30 million people a year.
Can occur with trauma, overuse, aging
Typically show pain, inflammation and dysfunction
Tendon healing is slow. Acute tendon healing process can take up to 10 weeks in healthy tendons.
TENDINOSIS AND FASCIOSIS
When inflammatory changes are present, but inflammatory mediators are absent
May fail to regain full function with conservative management
Conservative or Surgically, fibrosis and scar tissue = poor tensile strength, prone to re-injury
resultant tendon can be thickened, fibrotic, and less resistant to tensile stress than when preinjury.
Tendons injured with overuse show tendinopathy
Tenocyte depletion
Collagen fiber disorganization
Failure to heal
Results in pain, lower function, and tearing at a lesser threshold.
healthy number of tenocytes decrease.
Inflammatory changes present but inflammatory mediators are absent
THE HEEL
Achilles Tendon and Plantar Fascia
The relatively avascular area 2-6 cm proximal to the Achilles tendon insertion on the calcaneus is the most common site of non insertional tendinopathy
Insertional tendinopathy occurs at the junction of bone and tendon
Medial band of plantar fascia at/distal to the medial calcaneal tuborosity
OPTIONS TO REJOIN HEALING- REGENERATION
Amniotic Membrane Allograft
Platelet-rich plasma injection
High and low frequency extracorporeal shockwave therapy
AMNIOTIC MEMBRANE
Innermost layer of amniotic sac, surrounds fetus
Readily available
No ethical concerns- usually discarded after birth and no harm or danger to fetus and/or mother when extract.
Harvested from consenting donor during scheduled c-section or during an amniocentesis.
AMNIOTIC MEMBRANE ALLOGRAFT
Amniotic Stem Cells
Can develop into many different types of tissue- skin, cartilage, cardiac, nerves, muscle, bone
Synthesizes cytokines and growth factors
Can generate tissue from all three germ layers (mesoderm, endoderm, ectoderm) but do not form teratomas
Amniotic fluid has a heterogeneous mixture of multi-potential stem cells
Immunologically privileged
ADVANTAGES FOR TENDON REPAIR
Amniotic membrane is composed of
extracellular matrix to act as scaffold
for structural support for cells.
Attachment for collagen types I, III,
IV, V, VI, growth factors and hyaluronic
acid.
Has antimicrobial properties
PROCESSING
Cryopreserved- freezing at extreme temperature- viable cells
Lyophilized- freeze drying- viable cells
Dehydrated- non viable cells
5 year shelf life, no special storage requirements
TENDON WRAPPING
INJECTABLE FORM
Flowable Amniotic Stem Cell Allograft
DEHYDRATED HUMAN AMNION/CHORION PRODUCTS
20mg, 40mg and 100mg
Mix with 0.5% Marcaine
Needle size doesn’t matter
Cam Walker type boot, 1 month
Painful injection, pain for 2-3 days following
Avoid NSAIDs
RESULTS
Positive results for tendon use in animal studies
Clinical trials for use in tendons are limited and show “encouraging results”
British Journal of Sports Medicine, 2017- In all literature of randomized and non randomized controlled trials,
cohort studies, and case series, only four trials (total of 79 patients) were found to be eligible for consideration
and all of them were ultimately seen as having high risk of bias.
Foot & Ankle International, 2013- Significant improvement AOFAS hindfoot scores with injection of dehydrated
allograft for plantar fasciitis.
PLATELET-RICH PLASMA
Platelet-rich plasma (PRP)- fractionated plasma
from patient with high level platelets
Platelets contain growth factors
Stimulate healing by recruiting stem cells
Promotes collagen formation and
angiogenesis
PRP- ADVANTAGES AND DISADVANTAGES
Platelet-rich plasma (PRP)- autogenous source growth factors
Considered safe and natural
Less expensive than amniotic stem cell use
Clinical studies have not demonstrated efficacy of PRP alone in enhancing tendon repair
Combination of PRP with stem cells may have enhancing effects
SHOCKWAVE
Extracorporeal Shock
Wave Therapy
MECHANISM OF ACTION- HOW DOES ESWT WORK?
Mechanism uncertain, but several theories-
Increasing pressure in calcium deposition- causing fragmentation.
Induction of an inflammatory response- inflammatory mediated healing process
Neovascularization- enhancing angiogenesis to increase blood flow to the treated site
Analgesic effect- inhibits activation of serotonergic system
Peripheral denervation
ESWT AND EPAT
Extracorporeal Shock Wave Therapy is high energy
Extracorporeal Pulse Activated Therapy is low energy.
Low energy shock wave therapy- no need for local/regional anesthesia, but need three-four applications
RESULTS OF ESWT AND EPAT
2015 J. Orthopaed Traumatol study showed significant AOFAS score increase when used for chronic Achilles and best results were seen at weeks 8 and 12 weeks after use.
Multiple other studies (including Rasmussen in 2008) have found better results at 8 and 12 weeks follow up.
2012 Foot Ankle Int study demonstrated a 1.3mm decrease in thickness of the plantar fascia after EPAT treatment, seen on ultrasonographic measurement.
July/August 2018 J of Foot & Ankle Surgery demonstrated 63% and 79% reduction in pain in active and non-active duty military, respectively.
EPAT
Avoid NSAIDs
Energy Level
Pulse Number
Pulse Frequency
Applicators
Standard
Deep impact
Oscillating
TREATMENT CHOICE- WHICH ONE IS RIGHT FOR THE PATIENT?
CHOOSING TREATMENT
Efficacy
Immobilization/Restrictions
Cost
Availability
REFERENCES
1. Larson, A and Gallicchio, VS; Amniotic Derived Stem Cells: Role and Function in Regenerative Medicine, Journal of Cell Science & Therapy, May 14, 2017
2. Rasmussen S, Christensen M, Mathiesen I, Simonson O, Shockwave therapy for chronic Achilles tendinopathy: a double-blind, randomized clinical trial of efficacy, Acta Orthop. 2008;79(2):249-256
3. Young, M; Stem Cell Applications in Tendon Disorders: A Clinical Perspective, Stem Cells Int. 2012
4. Po, P and Lui, Y; Stem cell technology for tendon regeneration: current status, challenges, and future research directions, Stem Cells Cloning, Dec 2015, 163-174
5. Carulli, C, Tonelli, F, Innocenti, M, Gambardells, B, Muncibi, F, Effectiveness of extracorporeal shockwave therapy in three major tendon diseases, J Orthopaed Traumatol, 2016; 15-20
6. Wilson, M, Stacy, J; Shock wave therapy for Achilles Tendinopathy, Curr Rey Musculoskelet Med, 2011 Mar; 4(1) 6-10
7. Liu, L, Hindieh, J, Leong, D, Sun, H; Advances of stem cell based-therapeutic approaches for tendon repair, Journal of Orothopaedic Translation (2017) 9, 69-75
8. Haiko, IMF, Pas, L, Maarten, HM, Hidde, JH, Winters, M, No Evidence of the Use of Stem Cell Therapy for Tendon Disorders, Br J Sports Med, 2017;51 (13):996-1002
9. Andres, BM and Murrell, GAC, Treatment of Tendinopathy: What Works, What Does Not, and What is on the Horizon, Clin Orthop Relat Res. 2008 July; 466(7): 1539-1554
10. Zelen, CM, Poka, A, Andrews, J, Prospective, Randomized, Blinded, Comparative Study of Injectable Micronized Dehydrated Amniotic/Chorionic Membrane Allograft for Plantar Fasciits- A Feasibility Study, Foot Ankle Int 2013 34:1332
11. Mamidi, MK, Singh, G, Husin JM, Nathan, KG, Sasidharan, G, Zakaria, Z, Majumdar, AS, Das, AK, Impact of passing mesenchymal stem cells through smaller bore size needles for subsequent use in patients for clinical or cosmetic indications, J Transl Med. 2012; 10:229.
12. Rodriguez-Ares, MT, Lopez-Valadares MJ, Tourino R, Vieites, B, Gude, F, Silva, MT, Couceiro, J, Effects of Lyophilization on human amniotic membrance, Acta Ophthalmol. 2009 Jun;87(4):396-403
13. Purcell RL, Schroeder, IG, Keeling, LE, Formby PM, Eckel, TT, Shawen SB, Clincial Outcomes After Extracorporeal Shock Wave Therapy for Chronic Plantar Fasciitis in a Predominantly Active Duty Population, J of Foot & Ankle Surgery, Jul/August 2018;57(4):654-657
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