General

  • Intra-Articular Injections of Platelet-Rich Plasma versus Hyaluronic Acid in the Treatment of Osteoarthritic Knee Pain: A Randomized Clinical Trial in the Context of the Spanish National Health Care System

    Abstract

    Intra-articular injection of platelet-rich plasma (PRP) has been established as a suitable treatment for knee osteoarthritis. Here, we present a double-blind randomized controlled clinical trial, conducted in a public Hospital of the Spanish National Health Care System, to evaluate the efficacy of injecting autologous PRP versus hyaluronic acid (HA) in knee osteoarthritis. PRP was manufactured in Malaga\'s Regional Blood Center (Spain). Patients that met the eligibility criteria were randomized into a PRP group or a HA group. Pain and functional improvements were assessed pre- and post-treatment (three and six months follow-up) using the Visual Analogue Scale (VAS); the Knee and Osteoarthritis Outcome System (KOOS) scale and the European Quality of Life scale (EUROQOL). Both groups presented pain reduction at six months. The VAS scores for the PRP group improved by at least 50% from their initial value, particularly at three months following the final infiltration, with results resembling those of the HA group at six months. PRP was more effective in patients with lower osteoarthritis grades. Both treatments improved pain in knee osteoarthritis patients without statistically significant differences between them. However, PRP injection was proved to improve pain three months after the final infiltration and to be more effective in lower osteoarthritis grades.

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  • Effective of Platelet-rich plasma injections compared with steroid injetion in treatement of laterat epicondylitis (Tennis Elbow)

    Abstract

    Autologous injection of platelet rich plasma (PRP) stimulates healing process in degenerated tendons. The purpose of this study is to compare the functional outcome of lateral epicondylitis treated with PRP and steroid injection.

    Tennis elbow patients who failed conservative medical therapy were included and were allocated randomly steroid group (n=70) and PRP group (n=63). Data were collected before procedure, at 4, 8, 12 weeks, 1 year and 2 years after procedure. The main outcome measures were visual analogue score, Mayo elbow performance score, DASH score and hand grip strength.

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  • Platelet Rich Plasma and Hyaluronic Acid Blend for the Treatment of Osteoarthritis: Rheological and Biological Evaluation

    Abstract

    Introduction: Osteoarthritis (OA) is the most common musculoskeletal disease. Current treatments for OA are mainly symptomatic and inadequate since none results in restoration of fully functional cartilage. Hyaluronic Acid (HA) intra-articular injections are widely accepted for the treatment of pain associated to OA. The goal of HA viscosupplementation is to reduce pain and improve viscoelasticity of synovial fluid. Platelet-rich plasma (PRP) has been also employed to treat OA to possibly induce cartilage regeneration. The combination of HA and PRP could supply many advantages for tissue repair. Indeed, it conjugates HA viscosupplementation with PRP regenerative properties. The aim of this study was to evaluate the rheological and biological properties of different HA compositions in combination with PRP in order to identify (i) the viscoelastic features of the HA-PRP blends, (ii) their biological effect on osteoarthritic chondrocytes and (iii) HA formulations suitable for use in combination with PRP.

    Materials and Methods: HA/PRP blends have been obtained mixing human PRP and three different HA at different concentrations: 1) Sinovial, 0.8% (SN); 2) Sinovial Forte 1.6% (SF); 3) Sinovial HL 3.2% (HL); 4) Hyalubrix 1.5% (HX). Combinations of phosphate buffered saline (PBS) and the four HA types were used as control. Rheological measurements were performed on an Anton PaarMCR-302 rheometer. Amplitude sweep, frequency sweep and rotational measurements were performed and viscoelastic properties were evaluated. The rheological data were validated performing the tests in presence of Bovine Serum Albumin (BSA) up to ultra-physiological concentration (7%). Primary osteoarthritic chondrocytes were cultured in vitro with the HA and PRP blends in the culture medium for one week. Cell viability, proliferation and glycosaminoglycan (GAG) content were assessed.

    Results: PRP addition to HA leads to a decrease of viscoelastic shear moduli and increase of the crossover point, due to a pure dilution effect. For viscosupplements with HA concentration below 1% the viscoelasticity is mostly lost. Results were validated also in presence of proteins, which in synovial fluid are more abundant than HA.

    Chondrocytes proliferated overtime in all different culture conditions. The proliferation rate was higher in chondrocytes cultured in the media containing PRP compared to the cultures with different HA alone. GAG content was significantly higher in chondrocytes cultured in PRP and HL blend.

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  • Leukocyte-Rich Platelet-Rich Plasma Injections Do Not Up-Modulate Intra-Articular Pro-Inflammatory Cytokines in the Osteoarthritic Knee

    Abstract

    Introduction: The presence of leukocytes in platelet concentrates is deemed to cause deleterious effects when injected intra articularly. The aim of this study is to analyse both local and systemic effects induced by leukocyte-rich Platelet-rich Plasma (PRP) injections through a proteomic characterization of serial synovial fluid and blood samples obtained from subjects treated for knee OA. Secondary aim was to compare the effects on knee homeostasis and systemic response with those obtained with visco-supplementation.

    Methods: Thirty-six OA patients treated either by autologous L-PRP or HA intra-articular knee injections, administered in series of three at one-week intervals, were analyzed. Just before the injection, 1 ml of synovial fluid was collected through the same needle way. In the same time, a peripheral blood sample was obtained and plasma separated. A further peripheral blood sample was collected at 2, 6, and 12 months. L-PRP, plasma and synovial fluid were tested by multiplex bead-based sandwich immunoassay by means of the Bio-Plex suspension array system (Bio-Rad Laboratories) for the presence of pro- and anti-inflammatory cytokines (IL-1beta, IL-6, IL-8, IL-17 and IL-4, IL-10, IL-13) and growth factors (FGF-b, HGF, PDGF-AB/BB).

    Results: In general, pro-inflammatory cytokine levels were similar at basal condition and after treatment whereas anti-inflammatory ones were nearly undetectable. L-PRP administration did not modulate significant changes of cytokine concentrations either in synovial fluid or plasma, whatever the time points analyzed. No different trend was observed between L-PRP and HA administration in terms of pro- and anti-inflammatory cytokines, as well as growth factors.

    Conclusions: In contrast with the evidence reported by \"in vitro\" studies, where a cellular pro-inflammatory response appears to be induced by the presence of leukocytes, these results suggest that the presence leukocyte-rich PRP doesn\'t induce a relevant in vivo up regulation of pro-inflammatory mediators.

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  • Percutaneous Ultrasound-Guided Hydrodissection of a Symptomatic Sural Neuroma.

    Abstract

    Symptomatic neuromas of the sural nerve are a rare but significant cause of pain and debilitation in athletes. Presentation is usually in the form of chronic pain and dysesthesias or paresthesias of the lateral foot and ankle. Treatment traditionally ranges from conservative measures, such as removing all external compressive forces, to administration of nonsteroidal anti-inflammatory drugs, vitamin B6, tricyclic antidepressants, antiepileptics, or topical anesthetics. This article reports a case of sural nerve entrapment in a 34-year-old male triathlete with a history of recurrent training-induced right-sided gastrocnemius strains. The patient presented with numbness in the right lateral foot and ankle that had persisted for 3 months, after he was treated unsuccessfully with extensive nonoperative measures, including anti-inflammatory drugs, activity modification, and a dedicated physical therapy program of stretching and strengthening. Orthopedic assessment showed worsening pain with forced passive dorsiflexion and manual pressure applied over the distal aspect of the gastrocnemius. Plain radiographs showed normal findings, but in-office ultrasound imaging showed evidence of sural nerve entrapment with edema and neuromatous scar formation in the absence of gastrocnemius or soleus pathology. Percutaneous ultrasound-guided hydrodissection of the sural nerve at the area of symptomatic neuroma and neural edema was performed the same day. The patient had complete relief of symptoms and full return to the preinjury level of participation in competitive sports. This case report shows that hydrodissection, when performed by an experienced physician, can be an effective, minimally invasive technique for neurolysis in the setting of sural nerve entrapment, resulting in improvement in clinical symptoms.

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  • Ultrasound-Guided Percutaneous Injection, Hydrodissection, and Fenestration for Carpal Tunnel Syndrome: Description of a New Technique

    Abstract

    Objective: Carpal tunnel syndrome, caused by compression of the median nerve deep to the flexor retinaculum, is the most common entrapment neuropathy. Most patients are initially treated with conservative mea-sures such as splinting. When conservative measures fail, interventional techniques are considered the next step. Many studies have appeared comparing open surgical flexor retinaculum release to blind injections of corticosteroids into the carpal tunnel, but neither technique has proven superior to the other. Advantages of injection are: lower level of invasiveness, faster recovery, and ease of the technique. Occasional failures and complications occur with all techniques.

    Conclusion: Ultrasound-guided hydrodis section and fenestration is a viable, easy, relatively non-invasive therapy for carpal tunnel syndrome that can result in pro longed symptom relief, and may be a way to postpone, or even obviate the need for, open release.

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  • Assesing the cytokine content of human platelet-rich plasma

    Abstract

    Human platelet-rich plasma (PRP) is plasma that is enriched with thrombocytes at a concentration of 1000 * 109 per litre, higher than normal (150 - 350 * 109 per litre). Thrombocytes are known to contain growth factors including IGF, PDGF, EGF, FGF, TGF-li, PDEGF, VEGF or PDAF as well as thrombospondin and osteonectin. The release of these growth factors is induced by thrombocyte activation resulting from their exposure to a variety of substances such as thrombin, Calciom chloride or collagen. Growth factors are found in higher concentrations in PRP than in blood, and could be used to facilitate wound healing at a faster rate. Currently, PRP is employed in dentistry, dermatology, traumatology and orthopedics. In developed countries, PRP is also actively used in treating acute and chronic skin lesions. Though commercial devices for clinical preparation of autologous PRP are available, standardized PRP-preparation protocols are yet to be developed. Furthermore, only a handful of research work is aimed at optimizing methods of obtaining platelet-rich plasma. Therefore, two different modifications of the Araki et al method, the most standardized of all available methods, were used to prepare high cytokine-containing platelet-rich plasma.

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  • A New Treatment Option in Osteoarthritis: Prolotherapy Injections

    Abstract

    Osteoarthritis is the most common degenerative disorder, and one of the major causes of physical disability in adults. Unfortunately many people experience arthroplasty or other major surgeries, in spite of improvements of the conservative options. There is a need for efficient treatment methods in this group of patients. Prolotherapy is one of the simple and safe injection-based complementary method and it\'s efficiency was proved in the musculoskeletal problems. The aim of this article is to present current perspectives of prolotherapy in osteoarthritis.

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  • Effects of ozone therapy on facial nerve regeneration

    Abstract

    Introduction: Ozone may promote moderate oxidative stress, which increases antioxidant endogenous systems. There are a number of antioxidants that have been investigated therapeutically for improving peripheral nerve regeneration. However, no previous studies have reported the effect of ozone therapy on facial nerve regeneration.

    Objective: We aimed to evaluate the effect of ozone therapy on facial nerve regeneration.

    Methods: Fourteen Wistar albino rats were randomly divided into two groups with experimental nerve crush injuries: a control group, which received saline treatment post-crush, and an experimental group, which received ozone treatment. All animals underwent surgery in which the left facial nerve was exposed and crushed. Treatment with saline or ozone began on the day of the nerve crush. Left facial nerve stimulation thresholds were measured before crush, immediately after crush, and after 30 days. After measuring nerve stimulation thresholds at 30 days post-injury, the crushed facial nerve was excised. All specimens were studied using light and electron microscopy.

    Results: Post-crushing, the ozone-treated group had lower stimulation thresholds than the saline group. Although this did not achieve statistical significance, it is indicative of greater functional improvement in the ozone group. Significant differences were found in vascular congestion, macrovacuolization, and myelin thickness between the ozone and control groups. Significant differences were also found in axonal degeneration and myelin ultrastructure between the two groups.

    Conclusions: We found that ozone therapy exerted beneficial effect on the regeneration of crushed facial nerves in rats.

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  • Hypertonic dextrose injections (prolotherapy) in the treatment of symptomatic knee osteoarthritis: A systematic review and meta-analysis

    Abstract

    Hypertonic dextrose injections (prolotherapy) is an emerging treatment for symptomatic knee osteoarthritis (OA) but its efficacy is uncertain. We conducted a systematic review with meta-analysis to synthesize clinical evidence on the effect of prolotherapy for knee OA. Fifteen electronic databases were searched from their inception to September 2015. The primary outcome of interest was score change on the Western Ontario and McMaster Universities Arthritis Index (WOMAC). Three randomized controlled trials (RCTs) of moderate risk of bias and one quasi-randomized trial were included, with data from a total of 258 patients. In the meta-analysis of two eligible studies, prolotherapy is superior to exercise alone by a standardized mean difference (SMD) of 0.81 (95% CI: 0.18 to 1.45, p = 0.012), 0.78 (95% CI: 0.25 to 1.30, p = 0.001) and 0.62 (95% CI: 0.04 to 1.20, p = 0.035) on the WOMAC composite scale; and WOMAC function and pain subscale scores respectively. Moderate heterogeneity exists in all cases. Overall, prolotherapy conferred a positive and significant beneficial effect in the treatment of knee OA. Adequately powered, longer-term trials with uniform end points are needed to better elucidate the efficacy of prolotherapy.

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  • Hypertonic dextrose injection (prolotherapy) for knee osteoarthritis: Long term outcomes

    Abstract

    Objective: Knee osteoarthritis (OA) is a common, debilitating chronic disease. Prolotherapy is an injection therapy for chronic musculoskeletal pain. Recent 52-week randomized controlled and open label studies have reported improvement of knee OA-specific outcomes compared to baseline status, and blinded saline control injections and at-home exercise therapy (p<0.05). However, long term effects of prolotherapy for knee OA are unknown. We therefore assessed long-term effects of prolotherapy on knee pain, function and stiffness among adults with knee OA.

    Design: Post clinical-trial, open-label follow-up study.

    Setting: Outpatient; adults with mild-to-severe knee OA completing a 52-week prolotherapy study were enrolled.

    Intervention And Outcome Measures: Participants received 3-5 monthly interventions and were assessed using the validated Western Ontario McMaster University Osteoarthritis Index, (WOMAC, 0-100 points), at baseline, 12, 26, 52 weeks, and 2.5 years.

    Results: 65 participants (58

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  • Role of PRP in the Treatment of Knee Osteoarthritis

    Abstract

    Platelet-rich plasma (PRP) is one of the many new therapeutic approaches that continues to evolve in the field of general musculoskeletal medicine, sports medicine, and orthopedic medicine. There has been increasing amount of interest particularly in knee osteoarthritis as it is the most common degenerative disease encountered in clinical practice. PRP injections have been found in the majority of recent clinical studies to be helpful for pain and function. The purpose of this article was to provide the readers with the historical perspective of PRP and the most current literature on the use of PRP for the treatment of knee OA.

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  • Effectiveness and relevant factors of platelet?rich plasma treatment in managing plantar fasciitis: A systematic review

    Abstract

    Background: Plantar fasciitis (PF) is a common foot complaint, affects both active sportsmen and physically inactive middle age group. It is believed that PF results from degenerative changes rather than inflammation. Platelet?rich plasma (PRP) therapy has been introduced as an alternative therapy for PF. This study is aimed to systematically review to the effectiveness and relevant factors of PRP treatment in managing PF. Materials and Methods: A search was conducted in electronic databases, including PubMed,Scopus, and Google Scholar using different keywords. Publications in English?language from 2010 to 2015 were included. Two reviewers extracted data from selected articles after the quality assessment was done. Results: A total of 1126 articles were retrieved,but only 12 articles met inclusion and exclusion criteria. With a total of 455 patients, a number of potentially influencing factors on the effectiveness of PRP for PF was identified. In all these studies, PRP had been injected directly into the plantar fascia, with or without ultrasound guidance. Steps from preparation to injection were found equally crucial. Amount of collected blood, types of blood anti?coagulant, methods in preparing PRP, speed, and numbers of time the blood samples were centrifuged, activating agent added to the PRP and techniques of injection, were varied between different studies. Regardless of these variations, superiority of PRP treatment compared to steroid was reported in all studies. Conclusion: PRP therapy might provide an effective alternative to conservative management of PF with no obvious side effect or complication. The onset of action after PRP injection also greatly depended on the degree of degeneration.

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  • Sciatica: Treatment with intradiscal and intraforaminal injections of steroid and oxygen-ozone versus steroid only

    Abstract

    Purpose:

    To prospectively compare the clinical effectiveness of intraforaminal and intradiscal injections of a mixture of a steroid, a local anesthetic, and oxygen-ozone (O(2)-O(3)) (chemodiscolysis) versus intraforaminal and intradiscal injections of a steroid and an anesthetic in the management of radicular pain related to acute lumbar disk herniation.

    Materials And Methods: Medical Ethical Committee approval and informed consent were obtained. One hundred fifty-nine patients (86 men, 73 women; age range, 18-71 years) were included and were randomly assigned to two groups. Seventy-seven patients (group A) underwent intradiscal and intraforaminal injections of a steroid and an anesthetic, and 82 patients (group B) underwent the same treatment with the addition of an O(2)-O(3) mixture. Procedures were performed with computed tomographic guidance. An Oswestry Low Back Pain Disability Questionnaire was administered before treatment and at intervals, the last at 6-month follow-up. Patients and clinicians were blinded as to which treatment was performed. Results were compared with the chi(2) test.

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  • The Efficacy of Platelet-Rich Plasma in the Treatment of Rib Fractures.

    Abstract

    Background: €ƒRib fracture is the most common result of thoracic traumas. Intrapulmonary shunt, alveolar capillary membrane damage, intra-alveolar hemorrhage, and hypoxia may develop following rib fractures. Therefore, prompt treatment is important. The aim of this experimental study was to analyze the effects of platelet-rich plasma (PRP) on rib fractures to secure a speedier and more efficient treatment method. Materials and Methods €ƒThe study involved 18 New Zealand white rabbits, randomly divided into three groups as Group 1, the sham group with no surgical intervention; Group 2, the control group in which simple rib fractures were applied and no treatment; and Group 3, in which rib fractures were applied and then PRP treatment was administered. Results €ƒThe mean recovery plate thickness measurements were found to be statistically significantly higher in the PRP group compared with the other groups (p < 0.005). A thicker fibrotic cell proliferation and the formation of many capillaries were observed around the growth plate in the PRP group compared with the other groups. These structures were lesser in the control group compared with the PRP group and at the lowest level in the sham group. Larger and distinct callus formation was observed and a new intramedullary field in the PRP group. Conclusions €ƒPRP is a reliable and effective autologous product with minimal side effects, which can be considered as an alternative treatment in patients with rib fractures and used easily in pseudoarthrosis, surgical fracture, or flail chest.

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  • Hypertonic dextrose injections (prolotherapy) in the treatment of symptomatic knee osteoarthritis: A systematic review and meta-analysis

    Abstract

    Hypertonic dextrose injections (prolotherapy) is an emerging treatment for symptomatic knee osteoarthritis (OA) but its efficacy is uncertain. We conducted a systematic review with meta-analysis to synthesize clinical evidence on the effect of prolotherapy for knee OA. Fifteen electronic databases were searched from their inception to September 2015. The primary outcome of interest was score change on the Western Ontario and McMaster Universities Arthritis Index (WOMAC). Three randomized controlled trials (RCTs) of moderate risk of bias and one quasi-randomized trial were included, with data from a total of 258 patients. In the meta-analysis of two eligible studies, prolotherapy is superior to exercise alone by a standardized mean difference (SMD) of 0.81 (95% CI: 0.18 to 1.45, p = 0.012), 0.78 (95% CI: 0.25 to 1.30, p = 0.001) and 0.62 (95% CI: 0.04 to 1.20, p = 0.035) on the WOMAC composite scale; and WOMAC function and pain subscale scores respectively. Moderate heterogeneity exists in all cases. Overall, prolotherapy conferred a positive and significant beneficial effect in the treatment of knee OA. Adequately powered, longer-term trials with uniform end points are needed to better elucidate the efficacy of prolotherapy.

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  • Platelet-rich Plasma and Bone Marrow-derived Mesenchymal Stem Cells in Sports Medicine

    Abstract

    Regenerative medicine is a fast-growing field in orthopedic sports medicine. Platelet-rich plasma contains multiple factors that have been shown to augment healing, thereby stimulating its use in multiple areas of acute and chronic injuries. Mesenchymal stem cells have pluripotent potential to form into tissues pertinent to orthopedics, such as cartilage and bone. As such, there is been a surge in the research directed toward steering those stem cells into a particular lineage as part of treatment for a variety of soft-tissue, cartilage, and bone pathologies. Overall, there are promising reports of their potential success, but there is a need for continued investigation into the efficacy of platelet-rich plasma and stem cells in sports medicine.

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  • Impact of platelet-rich plasma injection timing on healing of Achilles tendon injury in a rat model.

    Abstract

    Objective: The aim of this study was to evaluate the impact of the timing of platelet-rich plasma (PRP) application on the healing of Achilles tendon injury in a rat model.

    Methods: Fifty-four female Sprague-Dawley rats were divided into 4 groups: PRP preparation group (n=6); Achilles tendon tear and 150

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  • Efficacy of Platelet-Rich Plasma versus Hyaluronic Acid for treatment of Knee Osteoarthritis: A systematic review and meta-analysis

    Abstract

    Introduction: Knee osteoarthritis is a very common chronic degenerative disease that could impose significant costs to the health system. Although osteoarthritis can affect all joints, knee osteoarthritis is the most common type among adolescents. Non-surgical treatments include corticosteroids injection, hyaluronic acid, and platelet-rich plasma. The aim of this study was to investigate the efficiency of platelet-rich plasma versus hyaluronic acid for the treatment of knee osteoarthritis.

    Methods: Pubmed, Cochran library, Scopus and Ovid databases were investigated to identify related studies from 2000 through August 2015. To study the efficiency, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) outcome using the Standard Mean Difference (SMD) index was calculated using a random model and a confidence interval of 95%. In addition, sensitivity and cumulative analysis were conducted. The data were analyzed using RevMan 5.3.5 and Stata 12 software.

    Results: Seven studies with 722 subjects (364 participants in PRP and 358 participants in the HA group) were analyzed. The WOMAC PRP compared to HA, SMD = −0.75 (95% CI: −1.33 to −0.18, I2 = 92.6%) in treatment of knee osteoarthritis was statistically significant and PRP was more effective.

    Conclusion: The results of this meta-analysis two years after PRP injection showed the efficacy of PRP versus HA. However, further studies are required to determine the longer-term effects.

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  • Good prognosis factors after a platelet rich plasma (PRP) injection for tendinopathies ?

    Abstract

    Introduction : Platelet-rich plasma injections are a recent treatment for chronic tendinopathies. However, this theraeutic remains controversed in litterature. Up to now, there is no prognosis factors identified to predict a good evolution after injection of PRP.

    Purpose: The aims of this study were to evaluate the effect of PRP injection followed by a standardized reeducation protocol among patients suffering from different tendinopathies and to determine the good prognosis factors, if any.

    Methods : 51 patients suffering from different tendinopathies and refractory to conventional physiotherapy were treated with a PRP injection. Prior to the injection, a blood sample was drawn and some biological parameters (glycemia, cholesterol level, ...). A pain assessment was then made using a visual analog scale (VAS) and a pressure algometer. The same assessment was carried out after 6 weeks and 12 weeks when possible.

    Results : There is an overall significant improvement VAS score at the end of the 12 weeks follow- up. However, no correlation was found between the evolution of the clinical scores and the biological parameters measured.

    Discussion and Conclusions : A PRP injection followed by a program of eccentric rehabilitation positively affects the algo-functional scores of patients with tendinopathie who were refractory to conventional physiotherapy, whatever their initial biological parameters.

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