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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