Platelet-rich Plasma as an Effective Treatment for

Proximal Hamstring Injuries Robert J. Wetzel, MD Ronak M. Patel, MD Michael A. Terry, MD

ISAKOS Congress – Toronto, Canada May 13th 2013

Disclosures

• Dr. Wetzel has no financial disclosures • Dr. Patel has no financial disclosures • Dr. Terry is a consultant for Smith &

Nephew; fellowship support provided by Mitek

Background • Proximal hamstring injuries are common in endurance sports

and can be disabling when recalcitrant to conservative treatment1-4

• Traditional conservative treatments (TCT) such as physical

therapy, NSAIDs, and corticosteroid injections have all inconsistently reported successful outcomes3, 7-9

• Platelet-rich plasma (PRP) has been reported as safe and effective in pathologies such as lateral epicondylitis

• We present the results of PRP injection into the proximal

hamstrings muscle origin as a novel treatment

Methods • Retrospective chart review of 17 hamstring injuries (15 pts)

• Inclusion criteria: diagnosis of tendinopathy, strain, or partial

hamstring tear made by a Sports Medicine fellowship trained Surgeon confirmed by MRI

• Exclusion criteria: complete tears were excluded

• 12 injuries failed TCT and had persistent pain or incomplete return to pre-injury function and received a PRP injection at the proximal hamstring origin

• 5 injuries were successfully treated with TCT

Methods Pre- and post-treatment Visual Analog Scale (VAS) scores were

compared Functional outcomes were analyzed using the Nirschl Phase Rating

Scale (NPRS)3,13 Return to sport was assessed

Methods • PRP Group – 8 F, 2 M, 9/10 competitive athletes • TCT Group – 4 F, 1 M, 2/5 competitive athletes

• PRP group received one 6cc injection of PRP into the

hamstrings origin near ischial tuberosity

• Activities were limited; hip flexion restricted to 30 degrees for 3 weeks • Mean follow-up:

– 4.5 months in the PRP Group – 2 months in the TCT Group

Results

• A P-value < 0.05 indicated statistical significance • All athletes return to pre-injury level of sport

Age (yrs)

Pre-VAS

Post-VAS

P value

Pre-NPRS

Post-NPRS P value

TCT Group 42.8 8.2 0.7 p=0.06 5.5 1.5 p=0.06

PRP Group 37.1 7.4 1.2 p<0.01 4.4 2 p<0.01

Conclusions

• Treatment of proximal hamstring injuries can be challenging especially in cases refractory to TCT

• Corticosteroids have been shown to provide pain relief but can be complicated by complete tendon rupture4,7,15

• Operative interventions including debridement, tenotomy, and open repair considered last resort and include inherent risks of surgery and anesthesia. – Good to excellent results in 88% of patients4

Conclusions • PRP has been shown to be safe but its efficacy has not yet been

confirmed by long term outcome studies

• Given minimal reported complications, PRP has been advocated for use in promoting tissue healing12 – Rotator cuff repair – Anterior cruciate ligament reconstruction – Achilles’ tendon repair – Lateral epicondylitis of the elbow – Patellar tendonitis – Plantar fasciitis – Osteoarthritis of the knee – Subacromial decompression of the shoulder

• No study has confirmed a specific indication

Conclusions • Our study demonstrates efficacy of PRP in a small retrospective

cases series

• Our data show significantly improved VAS and NRPS scores with PRP injection

• We describe an additional use of PRP in a growing number of

small case series • Limitations include retrospective nature, selection bias, no true

control group, and low power due to small cohort

References 1. Chakravarthy J, Ramisetty N, Pimpalnerkar A, Mohtadi N. Surgical repair of complete proximal hamstring tendon ruptures in water skiers and bull riders: a report of four cases and review of the literature. British journal of sports medicine. Aug 2005;39(8):569-572. 2. Carlson C. The natural history and management of hamstring injuries. Current reviews in musculoskeletal medicine. Jun 2008;1(2):120-123. 3. Cacchio A, Rompe JD, Furia JP, Susi P, Santilli V, De Paulis F. Shockwave therapy for the treatment of chronic proximal hamstring tendinopathy in professional athletes. The American journal of sports medicine. Jan 2011;39(1):146-153. 4. Lempainen L, Sarimo J, Heikkila J, Mattila K, Orava S. Surgical treatment of partial tears of the proximal origin of the hamstring muscles. British journal of sports medicine. Aug 2006;40(8):688-691. 5. Orchard J, Best TM. The Management of Muscle Strain Injuries: An Early Return Versus the Risk of Recurrence. Clin J Sports Med. 2002;12 (1)(Jan):3-5. 6. Harris JD, Griesser MJ, Best TM, Ellis TJ. Treatment of proximal hamstring ruptures - a systematic review. International journal of sports medicine. Jul 2011;32(7):490-495. 7. Drezner JA. Practical Management: Hamstring Muscle Injuries. Clin J Sports Med. 2003;13(1):48-52. 8. Levine WN, Bergfeld JA, Tessendorf W, Moorman CT. Intramuscular Corticosteroid Injection for Hamstring Injuries: A 13-Year Experience in the National football League. The American journal of sports medicine. 2000;28(3):297-300. 9. Kennedy JC, Willis RB. The effects of local steroid injecions on tendons:a biomechanical and microscopic correlative study. The American journal of sports medicine. 1976;4(1):11-21. 10. Young IJ, van Riet RP, Bell SN. Surgical release for proximal hamstring syndrome. The American journal of sports medicine. Dec 2008;36(12):2372-2378. 11. Hamilton B, Knez W, Eirale C, Chalabi H. Platelet enriched plasma for acute muscle injury. Acta Orthop. Belg. 2010;76(4):443-448. 12. Hall MP, Band PA, Meislin RJ, Jazrawi LM, Cardone DA. Platelet-rich Plasma: Current Concepts and Application in Sports Medicine. J Am Acad Orthop Surg. 2009;17 (10)(Oct):602-608. 13. Nirschl RP, Ashman ES. Elbow tendinopathy: tennis elbow. Clinics in Sports Medicine. 2003;22(4):813-836. 14. De Paulis F, Cacchio A, Michelini O, Damiani A, Saggini R. Sports injuries in the pelvis and hip:diagnostic imaging. Eur J Radiol. 1998;27(Suppl 1):S49-S59. 15. Paavola M, Kannus P, Järvinen TA, Järvinen TL, Józsa L, Järvinen M. Treatment of tendon disorders. Is there a role for corticosteroid injection? Foot Ankle Clin. 2002;7(3)(Sept):501-513.

References 16. Sanchez M, Anitua E, Azofra J, Andia I, Padilla S, Mujika I. Comparison of surgically repaired Achilles tendon tears using platelet-rich fibrin matrices. The American journal of sports medicine. Feb 2007;35(2):245-251. 17. Fleming BC, Spindler KP, Palmer MP, Magarian EM, Murray MM. Collagen-Platelet Composites Improve the Biomechanical Properties of Healing Anterior Cruciate Ligament Grafts in a Porcine Model. The American journal of sports medicine. 2009;37(8):1554-1563. 18. Bava ED, Barber FA. Platelet-Rich Plasma Products in Sports Medicine. Phys Sportsmed. 2011;39 (3)(Sept):94-99. 19. Jo CH, Kim JE, Yoon KS, et al. Does platelet-rich plasma accelerate recovery after rotator cuff repair? A prospective cohort study. The American journal of sports medicine. Oct 2011;39(10):2082-2090. 20. Li W, Enomoto M, Ukegawa M, et al. Subcutaneous injections of platelet-rich plasma into skin flaps modulate proangiogenic gene expression and improve survival rates. Plastic and reconstructive surgery. Apr 2012;129(4):858-866. 21. Li ZJ, Choi HI, Choi DK, et al. Autologous Platelet-Rich Plasma: A Potential Therapeutic Tool for Promoting Hair Growth. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.]. Mar 27 2012. 22. Sanchez M, Azofra J, Anitua E, et al. Plasma rich in growth factors to treat an articular cartilage avulsion: a case report. Medicine and science in sports and exercise. Oct 2003;35(10):1648-1652. 23. Silva A, Sampaio R. Anatomic ACL reconstruction: does the platelet-rich plasma accelerate tendon healing? Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. Jun 2009;17(6):676-682. 24. Mishra A, Woodall J, Vieira A. Treatment of Tendon and Muscle Using Platelet-rich Plasma. Clin J Sports Med. 2009;28:11-125. 25. Arnoczky SP, Caballero O, Yeni YN. On the Horizon From the ORS. J Am Acad Orthop Surg. 2010;18(7):445-448.