Transcript CASE PRESENTATION: Ankle injury

Southeast ACSM Conference
February 5, 2011
Mandy Huggins, MD
Emory Sports Medicine Center
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
Physical Exam
 Height 5’11” Weight 192 lbs
 RLE tender at proximal Achilles/musculotendinous
junction
 ? Mild defect here
 Edema noted
 Weakly positive Thompson’s
 4/5 weakness with plantarflexion
 Distal neurovascular exam intact
Diagnosis?
 Achilles injury
MRI
 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
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”
Now what?
 PRP of course!
Initial ultrasound findings
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
PRP
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 Thompson’s
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
Repeat US 9/13
Repeat US 9/13
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
Repeat US 11/17
Repeat US 11/17
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.
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
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
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?
Questions?