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Autologous Blood Injections

Autologous Blood Injection for the Treatment of Tendinopathy

Tendinosis is thought to be secondary to degeneration of the tendon at its insertion. It is now accepted that there is little inflammation involved but a fibroblastic and neovascularisation (new blood vessel formation) response. Repeated injuries and microtrauma lead to further degeneration. A cycle of degeneration and repair follows with resulting weakening of the tendon with chronic pain and the potential for tendon rupture.

Steroid injections have been used for many years under the assumption that an inflammatory process is involved. They provide symptomatic pain relief but there is no evidence that they promote healing. Any other treatments which involve immobilisation may have a deleterious effect on the long term strength of the tendon rather than helping the condition. Surgical treatments have been described such as "tenotomy" but the associated risks of scarring and bleeding result in this treatment not being frequently used.

Autologous Blood Injection (ABI) has recently been described for the treatment of lateral epicondylosis. Several recent studies have demonstrated its effectiveness for tennis elbow and also for the treatment of other tendonoses such as plantar fasciitis and patella tendinosis. It is assumed that ABI works via Transforming Growth Factor Beta and Basic Fibroblast Growth Factor carried in the blood will acting as mediators to induce a "healing cascade". The mechanism of short term relief following steroid injection or needling is not understood but it may be that trauma to the area of tendinosis with the needle may promote a healing cascade within the tendon.

Neovascularisation has been postulated as a cause for the symptom of pain in tendinosis but clearly the cause of patients symptoms are more complex than can be attributed purely to the new vessel formation, involving inflammation and the stimulation of local pain fibres.

Using ultrasound scanning, it has been seen that following autologous blood injection there is a reduction in tendon thickness and inflammatory changes seen with the tendon. There is also a partial resolution of tendon tears following injection. One of the first studies by Edwards and Calandruccio showed that after an average follow up of 9.5 months there was an improvement in pain and movement in 22 out of 28 patients.

We routinely perform one injection initially and there may occasionally be a requirement of a second injection four weeks later. Most pain relief occurs within the first 4-6 weeks. Patient selection and an accurate diagnosis is critical to the success of the procedure.

From recent studies it would appear that autologous blood injections have a more permanent effect on long-term benefit than that achieved with injection of corticosteroid (cortisone injections). This is probably related to the healing benefits of ABI causing the tendon to return to its pre-injury state rather than simply relying on the anti-inflammatory action of corticosteroid injections.

References:

Sheth U, Simunovic N, Klein G, Fu F, Einhorn TA, Schemitsch E, Ayeni OR, Bhandari M. Efficacy of autologous platelet-rich plasma use for orthopaedic indications: A meta-analysis. J Bone Joint Surg Am 2012 Jan 11.

Creaney L, Wallace A, Curtis M, Connell D. Growth factor-based therapies provide additional benefit beyond physical therapy in resistant elbow tendinopathy: a prospective, single-blind, randomised trial of autologous blood injections versus platelet-rich plasma injections. Br J Sports Med 2011;45:966-971.

Van Ark M, Zwerver J, Van den Akker-Scheek I. Injection treatments for patellar tendinopathy. Br J Sports Med 2011;45:1068-1076

Edwards SG, Calandruccio JH... Autologous blood injections for refractory lateral epicondylitis. J Hand Surg 2003;28A:272-278

Iwasaki M, Nakahara H, Nakata K, Nakase T, Kimura T, Ono K. Regulation of proliferation and osteochondrogenic differentiation of periosteum-derived cells by transforming growth factor-β and basic fibroblast growth factor. J Bone Joint Surg 1995;77A:543-554.

Connell D, Burke F, Coombes P, McNealy S, Freeman D, Pryde D, Hoy G. Sonographic examination of lateral epicondylitis. AJR 2001;176:777-782

Kraushaar BS, Nirschl RP. Tendinosis of the elbow (Tennis Elbow). Clinical features and findings of histological, immunohistochemical and electron microscopy studies. J Bone Joint Surg 1999;81-A:269-278.

Lian O, Holken KJ, Engebrestson L, Bahr R. Relationship between symptoms of jumper's knee and the ultrasound characteristics of the patellar tendon among high level male volleyball players. Scand J Med Scit Sports 1996;6:291-296

Khan KM, Cook, JK. Overuse tendon injuries. Clinical Sports Medicine, McGraw-Hill 2nd edition January 2001.