Synergistic activity of platelet rich plasma and high volume image guided injection for patellar tendinopathy

  • Michele Abate
  • Luigi Di Carlo
  • Sandra Verna
  • Patrizia Di Gregorio
  • Cosima Schiavone
  • Vincenzo Salini



Platelet rich plasma and high volume image guided injections of saline have been used in the treatment of patellar tendinopathy with positive results. As the different mechanisms of action do not interfere each other, it can be hypothesized that they can be used in combination. Aim of this study was twofold: first, to evaluate the efficacy of these two treatments in the management of patellar tendinopathy; second, to verify whether the combination of these therapies could provide further advantages.


Fifty-four patients suffering from patellar tendinopathy were enrolled. After clinical (VAS and VISA-P) and sonographic evaluation, two ultrasound guided injections (2 weeks apart) of platelet rich plasma, high-volume image-guided injections of saline, or both in association were performed. The VAS and VISA-P scores obtained from the three treatments groups (18 patients in each group) were compared across the different follow-up times (3 and 6 months).


In the short term both treatments showed comparable efficacy, whereas in the medium term the positive effects of high-volume image-guided injections gradually diminished and platelet rich plasma showed greater efficacy. Better results (reduced pain, improved function and increased number of subjects who exhibited optimal recovery [> 20 points in VISA-P score]) were observed when both procedures were associated.


The contemporaneous administration of platelet rich plasma and high volume image guided injections of saline treatments, which influence tendon repair by means of different mechanisms, grants a greater improvement for patellar tendinopathy. This finding has clinical relevance, given that this condition has a substantial impact on sports and work performance.

Level of evidence



High volume image-guided injections Patellar tendon Platelet rich plasma Tendinopathy 



The Authors declare that no funding was received for this study.

Compliance with ethical standards

Conflict of interest

The authors declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.


  1. 1.
    Abate M, Schiavone C, Pelotti P, Salini V (2011) Limited joint mobility (LJM) in elderly subjects with type II diabetes mellitus. Arch Gerontol Geriatr 53:135–140CrossRefPubMedGoogle Scholar
  2. 2.
    Abate M, Schiavone C, Salini V, Andia I (2013) Occurrence of tendon pathologies in metabolic disorders. Rheumatology 52:599–608CrossRefPubMedGoogle Scholar
  3. 3.
    Abate M, Di Gregorio P, Schiavone C et al (2012) Platelet rich plasma in tendinopathies: how to explain the failure. Int J Immunopathol Pharmacol 25:325–334CrossRefPubMedGoogle Scholar
  4. 4.
    Abate M, Silbernagel KG, Siljeholm C et al (2009) Pathogenesis of tendinopathies: inflammation or degeneration? Arthritis Res Ther 11:235–249CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Alfredson H, Ohberg L (2005) Neovascularisation in chronic painful patellar tendinosis—promising results after sclerosing neovessels outside the tendon challenge the need for surgery. Knee Surg Sports Traumatol Arthrosc 3:74–80CrossRefGoogle Scholar
  6. 6.
    Allison GT, Purdam C (2009) Eccentric loading for Achilles tendinopathy—strengthening or stretching? Br J Sports Med 43:276–279CrossRefPubMedGoogle Scholar
  7. 7.
    Andia I, Abate M (2013) Platelet-rich plasma: underlying biology and clinical correlates. Regen Med 8:645–658CrossRefPubMedGoogle Scholar
  8. 8.
    Andia I, Latorre PM, Gomez MC et al (2014) Platelet-rich plasma in the conservative treatment of painful tendinopathy: a systematic review and meta-analysis of controlled studies. Br Med Bull 110:99–115CrossRefPubMedGoogle Scholar
  9. 9.
    Anitua E, Sanchez M, Nurden AT et al (2006) Autologous fibrin matrices: a potential source of biological mediators that modulate tendon cell activities. J Biomed Mater Res A 77:285–293CrossRefPubMedGoogle Scholar
  10. 10.
    Barker-Davies RM, Nicol A, McCurdie I et al (2017) Study protocol: a double blind randomised control trial of high volume image guided injections in Achilles and patellar tendinopathy in a young active population. BMC Musculoskelet Disord 18(1):204CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Bar-Or D, Rael LT, Brody EN (2017) Use of saline as a placebo in intra-articular injections in osteoarthritis: potential contributions to nociceptive pain relief. Open Rheumatol J 11:16–22CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Bi Y, Ehirchiou D, Kilts TM et al (2007) Identification of tendon stem/progenitor cells and the role of the extracellular matrix in their niche. Nat Med 13:1219–1227CrossRefPubMedGoogle Scholar
  13. 13.
    Bode G, Hammer T, Karvouniaris N et al (2017) Patellar tendinopathy in young elite soccer—clinical and sonographical analysis of a German elite soccer academy. BMC Musculoskelet Disord 18:344CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Boesen AP, Hansen R, Boesen MI et al (2017) Effect of high-volume injection, platelet-rich plasma and sham treatment in chronic midportion Achilles tendinopathy; a randomized double-blinded prospective study. Am J Sports Med 45:2034–2043CrossRefPubMedGoogle Scholar
  15. 15.
    Cook JL, Malliaras P, De Luca J et al (2005) Vascularity and pain in the patellar tendon of adult jumping athletes: a 5 month longitudinal study. Br J Sports Med 39(7):458–461CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Crisp T, Khan F, Padhiar N et al (2008) High volume ultrasound guided injections at the interface between the patellar tendon and Hoffa’s body are effective in chronic patellar tendinopathy: a pilot study. Disabil Rehabil 30:1625–1634CrossRefPubMedGoogle Scholar
  17. 17.
    de Mos M, van der Windt AE, Jahr H et al (2008) Can platelet-rich plasma enhance tendon repair? A cell culture study. Am J Sports Med 36:1171–1178CrossRefPubMedGoogle Scholar
  18. 18.
    Dean BJ, Franklin SL, Carr AJ (2013) The peripheral neuronal phenotype is important in the pathogenesis of painful human tendinopathy: a systematic review. Clin Orthop Relat Res 471:3036–3046CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    De Vries AJ, Koolhaas W, Zwerver J et al (2017) The impact of patellar tendinopathy on sports and work performance in active athletes. Res Sports Med 25:253–265CrossRefPubMedGoogle Scholar
  20. 20.
    Di Matteo B, Filardo G, Kon E, Marcacci M (2015) Platelet-rich plasma: evidence for the treatment of patellar and Achilles tendinopathy—a systematic review. Musculoskelet Surg 99:1–9CrossRefPubMedGoogle Scholar
  21. 21.
    Dragoo JL, Wasterlain AS, Braun HJ, Nead KT (2014) Platelet-rich plasma as a treatment for patellar tendinopathy: a double-blind, randomized controlled trial. Am J Sports Med 42:610–618CrossRefPubMedGoogle Scholar
  22. 22.
    Dupley L, Charalambous CP (2017) Platelet-rich plasma injections as a treatment for refractory patellar tendinosis: a meta-analysis of randomised trials. Knee Surg Relat Res 29(3):165–171CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Ferrero G, Fabbro E, Orlandi D et al (2012) Ultrasound-guided injection of platelet-rich plasma in chronic Achilles and patellar tendinopathy. J Ultrasound 15:260–266CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Filardo G, Di Matteo B, Kon E et al (2016) Platelet-rich plasma in tendon-related disorders: results and indications. Knee Surg Sports Traumatol Arthrosc. Google Scholar
  25. 25.
    Kaux JF, Bruyere O, Croisier JL et al (2015) One-year follow-up of platelet-rich plasma infiltration to treat chronic proximal patellar tendinopathies. Acta Orthop Belg 81:251–256PubMedGoogle Scholar
  26. 26.
    Khan KM, Maffulli N, Coleman BD et al (1998) Patellar tendinopathy: some aspects of basic science and clinical management. Br J Sports Med 32:346–355CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Kıraç FS (2013) Is ethics approval necessary for all trials? A clear but not certain process. Mol Imaging Radionucl Ther 22:73–75CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Kruckeberg BM, Chahla J, Ferrari MB et al (2017) Open patellar tendon tenotomy, debridement, and repair technique augmented with platelet-rich plasma for recalcitrant patellar tendinopathy. Arthrosc Tech 6:e447–e453CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Lian OB, Engebretsen L, Bahr R (2005) Prevalence of jumper’s knee among elite athletes from different sports: a cross-sectional study. Am J Sports Med 33:561–567CrossRefPubMedGoogle Scholar
  30. 30.
    Liddle AD, Rodríguez-Merchán EC (2015) Platelet-rich plasma in the treatment of patellar tendinopathy: a systematic review. Am J Sports Med 43:2583–2590CrossRefPubMedGoogle Scholar
  31. 31.
    Maffulli N, Del Buono A, Oliva F et al (2016) High-volume image-guided injection for recalcitrant patellar tendinopathy in athletes. Clin J Sport Med 26:12–16CrossRefPubMedGoogle Scholar
  32. 32.
    Maffulli N, Longo UG, Testa V et al (2008) VISA-P score for patellar tendinopathy in males: adaptation to Italian. Disabil Rehabil 30:1621–1624CrossRefPubMedGoogle Scholar
  33. 33.
    Maffulli N, Longo UG (2008) How do eccentric exercises work in tendinopathy? Rheumatology 47:1444–1445CrossRefPubMedGoogle Scholar
  34. 34.
    Malliaras P, Barton CJ, Reeves ND, Langberg H (2013) Achilles and patellar tendinopathy loading programmes: a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med 43:267–286CrossRefPubMedGoogle Scholar
  35. 35.
    Morton S, Chan O, King J et al (2014) High volume image-guided injections for patellar tendinopathy: a combined retrospective and prospective case series. Muscles Ligaments Tendons J 4:214–219PubMedPubMedCentralGoogle Scholar
  36. 36.
    Ohberg L, Alfredson H (2004) Effects on neovascularisation behind the good results with eccentric training in chronic mid-portion Achilles tendinosis? Knee Surg Sports Traumatol Arthrosc 12:465–470CrossRefPubMedGoogle Scholar
  37. 37.
    Ohberg L, Lorentzon R, Alfredson H (2001) Neovascularisation in Achilles tendons with painful tendinosis but not in normal tendons: an ultrasonographic investigation. Knee Surg Sports Traumatol Arthrosc 9:233–238CrossRefPubMedGoogle Scholar
  38. 38.
    Rompe JD, Nafe B, Furia JP, Maffulli N (2007) Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial. Am J Sports Med 35:374–383CrossRefPubMedGoogle Scholar
  39. 39.
    Sanli I, Morgan B, van Tilborg F et al (2016) Single injection of platelet-rich plasma (PRP) for the treatment of refractory distal biceps tendonitis: long-term results of a prospective multicenter cohort study. Knee Surg Sports Traumatol Arthrosc 24: 2308–2312CrossRefPubMedGoogle Scholar
  40. 40.
    Sunding K, Fahlström M, Werner S et al (2016) Evaluation of Achilles and patellar tendinopathy with greyscale ultrasound and colour Doppler: using a four-grade scale. Knee Surg Sports Traumatol Arthrosc 24:1988–1996CrossRefPubMedGoogle Scholar
  41. 41.
    Tempfer H, Wagner A, Gehwolf R et al (2009) Perivascular cells of the supraspinatus tendon express both tendon- and stem cell-related markers. Histochem Cell Biol 131:733–741CrossRefPubMedGoogle Scholar
  42. 42.
    Vetrano M, Castorina A, Vulpiani MC et al (2013) Platelet-rich plasma versus focused shock waves in the treatment of jumper’s knee in athletes. Am J Sports Med 41:795–803CrossRefPubMedGoogle Scholar
  43. 43.
    Zayni R, Thaunat M, Fayard JM et al (2015) Platelet-rich plasma as a treatment for chronic patellar tendinopathy: comparison of a single versus two consecutive injections. Muscles Ligaments Tendons J 5:92–98PubMedPubMedCentralGoogle Scholar
  44. 44.
    Zwerver J, Bredeweg SW, van den Akker-Scheek I (2011) Prevalence of Jumper’s knee among non-elite athletes from different sports: a cross-sectional survey. Am J Sports Med 39:1984–1988CrossRefPubMedGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2018

Authors and Affiliations

  • Michele Abate
    • 1
  • Luigi Di Carlo
    • 1
  • Sandra Verna
    • 2
  • Patrizia Di Gregorio
    • 2
  • Cosima Schiavone
    • 1
  • Vincenzo Salini
    • 1
  1. 1.Department of Medicine and Science of AgingUniversity G. d’Annunzio, Chieti-PescaraChietiItaly
  2. 2.Immunohaematology and Transfusional Medicine Service“SS. Annunziata” HospitalChietiItaly

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