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CASE PRESENTATION: Ankle injury

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

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CASE PRESENTATION: Ankle injury

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  1. CASE PRESENTATION:Ankle injury Southeast ACSM Conference February 5, 2011 Mandy Huggins, MD Emory Sports Medicine Center

  2. 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

  3. 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

  4. Diagnosis? • Achilles injury

  5. 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

  6. MRI

  7. 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”

  8. Now what? • PRP of course!

  9. Initial ultrasound findings

  10. 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

  11. PRP

  12. 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

  13. 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

  14. Repeat US 9/13

  15. Repeat US 9/13

  16. 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

  17. Repeat US 11/17

  18. Repeat US 11/17

  19. 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.

  20. 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

  21. 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

  22. 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?

  23. Questions?

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