Thank you very much. Okay, so I'm going to go to patellar tendonitis, as Alan mentioned. Okay, thanks, appreciate it. All right, so my disclosures are, like all of ours, in the AOS website. So these are all the options for patella tendonitis. It's a nagging, very difficult problem. Given my patient population, we see a lot of it in not just jumping athletes, but clearly that's a dominant group of patients who present to us. And I always will start with physical therapy, minimal activity modification as needed, anti-inflammatories will do. A show part strap, most athletes I've found do not find particularly effective, and they just don't like it, but some of them can use it. It's a lot like a counterforce brace for lateral epicondylitis. Topicals may be useful, you know, it just gives patients more to do, but they're now very expensive, often unreimbursed. We actually have used Flector and or lidocaine type patches, and that has been reasonably effective subjectively from patients. Have no primary experience with shockwave therapy, although it's an option. We've used plenty of PRP, and then rarely surgery. I think patella tendonitis, especially with bone pain, is a lot like lateral epicondylitis, and these are patients that I will do anything humanly possible to keep out of the operating room. We always talk about complications, and I think the number one complication is not a nerve injury, not an infection, it's just that patients don't get well. So this is one of those conditions where, from a surgical perspective, they just may not get well. We would like to try to keep them out of the operating room for that, if not for any other reason. My algorithm is I will do eccentric exercises, static stretching, core stabilization, always check their glute medius, single leg activities. I will, early on, obviously there's no role for cortisone or steroids in this patient population, and basically this is what everyone gets. If they can respond favorably in six to eight weeks with phase one, then I may not go to PRP, but that is my next line of treatment, and we'll kind of go over the data for that. As a side note, if you do surgery, one of the things I've learned, especially in pretty high level athletes, is that if they have bone pain, and you just do a tendon type procedure, whether it's a minimally invasive one, ultrasound, mechanical debridement, or surgical, don't leave the bone alone. You hardly ever see patella tendonitis after a BTB autographed. So just the lesson learned, if you do surgery, take a small piece of bone with it, as well as a tendon. I'll just use an oscillating saw, much like a BTB, just a very small sliver of bone. So this is a 34-year-old basketball player. He's had chronic patella tendinosis, pain at the inferior pole of the patella. He has no history of a big trauma. That's very common. They sort of have this insidious progression of symptoms. We tried rest, and you can't really afford to rest these guys for a long period of time, and has had all the proper modalities and therapy and so forth. So he ended up getting PRP treatment. I don't know if you saw on the MRI the signal change at the inferior pole. That's the best patient, because sometimes you get these patients where they have no signal change. It's nice to have something that is physiologic by MRI or even ultrasound. So PRP injection, we'll use ultrasound to do that. And this is him at six weeks post-injection. Actually some thickening, and the edema pattern that we had, it looks like they're, I don't know if you call it remodeling or what, but it doesn't look the same. The important thing is what we were striving for is just to get rid of his pain, or certainly improve his pain so that his function improves as well. And you can see the MRI signal change. This is another one, a little bit different story, but some similarities. He actually has bilateral knee pain right worse than left. He played through the previous season. He has pain at the insertion site. He's tried everything, including PRP, in the offseason without relief, and he's unable to play. And what was interesting on x-ray, if you look distally, you don't see much. I don't know how well it projects, but didn't see any real calcification on x-ray. He had sort of this bogginess at the tendon insertion just proximal to the tibial tubicle. And by MRI, had some significant signal change distally, and was rather diffusely tender, but absolutely had point tenderness there as well. And in my mind, having failed everything he failed, we, and at this time, I really wasn't certain if I liked BMAC, if I liked PRP. So like any professional athlete, as long as you don't hurt him, we throw everything at him. And we just did both for whatever that's worth. But most importantly, we excised the tissue. So this is a situation where I don't think non-surgical treatment would have been productive. Whether this helps the early postoperative course, reduction of inflammation and so forth, I can't say. But I will say, Sergio, this is a different patient in that I think surgery absolutely was required. And he had an anatomic lesion and ended up having his other side done and is now just returning playing as a center. So the common question, we don't speak about it much, like we used to, it used to be, look, if there's more platelets, it's better and vice versa. I think in vitro, there was some evidence that that was true, but I would say in vivo, I'm not sure that's, well, we can make that same conclusion. It's an interesting paper. Jorge Hala is one of the challenges. Our current fellow is going to come on board with us next year and has been very prolific, especially in the area of biologics. And it was an interesting systematic review. And the bottom line is when we're looking at the use of PRP, like any biologic, and this is still a problem we have in our contemporary literatures, there's just very little standardization. And there's no consensus out there in terms of the time for spin, the number of RPMs, the number of spin, et cetera, as well as dosage. So we still struggle in that regard. And it becomes difficult for me to speak to another individual and say, we're having a same or similar or different experience. Out of 105 publications, only 11.5% reported what they did on every step. And very few studies actually analyze what's going into these patients. So I think if you guys are interested in this type of research, that's a really important part of the analysis. Not just how they do clinically or with some anatomic endpoint, but it's what we're putting in each individual. So there are some decent studies that have looked at chronic patella tendonitis prospectively. Some have used leukocyte poor. Some have used leukocyte rich. I think there's a narrative we could have and say, look, if it's more acute, maybe you don't want, maybe there's an inflammatory component, you don't want white cells in that setting. But I will admit to you that tendinosis is rarely an inflammatory process. In fact, most histology doesn't have any inflammatory process whatsoever if there's no tenosynovium around it. So tendinosis is a blood problem typically, a dysvascular problem, and not necessarily an inflammatory problem. So I don't know exactly how I feel about leukocyte rich versus poor. My honest answer is I use leukocyte poor because it's less expensive, it's fast, and it's the machine I have. So anecdotally, I'll tell you, it's been working. We have not studied it, but others have. So where are we with the literature? So if you look at the evidence, there's been 19 studies and six randomized studies and four conservative treatment comparisons. And basically, if you sort of want to take the yellow, intermediate grade recommendations, single versus multiple injections showed favorable results, PRP versus shockwave therapy showed favorable results, and PRP, much like Alan just told us, was better than dry needling. I think dry needling makes sense when you think about it simply because if you agree that this is a dysvascular problem, then it kind of makes sense to do something mechanical. There were two surgical trials. One was actually after ACL reconstruction with BTBs, and basically suggesting better pain control and better healing in six months. I think the challenge is that we're dealing with a population of patients that don't have a lot of other options, and we're not going to use steroids, right? So you could look to other mechanical options like shockwave therapy and other, but this has been, I think, very favorable for us. So there's at least a neutral recommendation, in my opinion, to a positive recommendation. I think, I will just tell you anecdotally, from a clinical perspective, it's changed the landscape of my ability to treat these patients, to give them one more thing. And I would say just anecdotally, this is probably 100 or more patients over the last eight years that were doing about 75% good or excellent, and patients who have failed everything else other than surgery. So my personal opinion, and I think the early evidence suggests that PRP is a dominant treatment strategy for recalcitrant patella tendonitis. And I'll just bring you to highlight one course that's going to happen between January 30th and February 3rd. This is the 20th year in the making, and it's going to be very case-based in Park City. So hopefully you'll, I've already seen a number of people attending that course in the past, and would love to see you there in the early spring. Thank you for your attention. Thank you.

patellar tendonitis

treatment options

PRP

eccentric exercises

upcoming course