Patellar Tendonitis or Other Tendenopathy.

[JMP8928]

For anyone who has Patellar Tendonitis (jumper's knee) and is having trouble kicking it. You will be interested to read:


Use of platelet-rich plasma for the treatment of refractory
jumper’s knee

Giuseppe Filardo & Elizaveta Kon & Stefano Della Villa &
Ferruccio Vincentelli & Pier Maria Fornasari &
Maurilio Marcacci

Received: 21 June 2009 / Revised: 12 July 2009 / Accepted: 13 July 2009
# Springer-Verlag 2009

Abstract

The aim of this study was to evaluate the efficacy
of multiple platelet-rich plasma (PRP) injections on the
healing of chronic refractory patellar tendinopathy after
previous classical treatments have failed. We treated 15
patients affected by chronic jumper’s knee, who had failed
previous nonsurgical or surgical treatments, with multiple
PRP injections and physiotherapy.

We also compared the
clinical outcome with a homogeneous group of 16 patients
primarily treated exclusively with the physiotherapy approach.
Multiple PRP injections were performed on three
occasions two weeks apart into the site of patellar
tendinopathy. Tegner, EQ VAS and pain level were used
for clinical evaluation before, at the end of the treatment
and at six months follow-up. Complications, functional
recovery and patient satisfaction were also recorded.

A statistically significant improvement in all scores was
observed at the end of the PRP injections in patients with
chronic refractory patellar tendinopathy and a further
improvement was noted at six months, after physiotherapy
was added. Moreover, comparable results were obtained
with respect to the less severe cases in the EQ VAS score
and pain level evaluation, as in time to recover and patient
satisfaction, with an even higher improvement in the sport
activity level achieved in the PRP group. The clinical
results are encouraging, indicating that PRP injections have
the potential to promote the achievement of a satisfactory
clinical outcome, even in difficult cases with chronic
refractory tendinopathy after previous classical treatments
have failed.

[VTechVaulter]

How many injections are you using in your study?
How much time in between injections.

I myself have had a single round of it, however with 5 weeks recovery til full activity after the first round, its something that is not to be taken lightly if multiple rounds are needed. Basically with multiple injections the entire preseason disappears.

[hallvaulter]

what he said

[souleman]

I suffered with jumpers knee all through Jr. high and high school. When I came back to jumping it returned. I was training at Altitude with Attitude in St. Cloud, MN with coach Kevin Hanson early in my come back. He had a therapy machine called an A.R.P. system (the Minnesota Vikings have 11 of them). Kevin did three treatments, one week apart each and after the third one, no more jumpers knee. I've tried to find a web site for the manufacturer of the machine but haven't had much luck. Admittedly I haven't made a career out of it either seeing that I know where one is close to me. Find one, get the treatments and I'll bet your jumpers knee will go away. Later................Mike

[JMP8928]

YO.

Not my study, i found it through the library. let me see if i can post some more of it.

[JMP8928]

Heres the whole shabang. Its long, but heres the link to the PDF if you can access it. if not, full text is there.
http://www.springerlink.com/content/g16 ... lltext.pdf

ORIGINAL PAPER
Use of platelet-rich plasma for the treatment of refractory
jumper’s knee
Giuseppe Filardo & Elizaveta Kon & Stefano Della Villa &
Ferruccio Vincentelli & Pier Maria Fornasari &
Maurilio Marcacci
Received: 21 June 2009 / Revised: 12 July 2009 / Accepted: 13 July 2009
# Springer-Verlag 2009

Abstract The aim of this study was to evaluate the efficacy
of multiple platelet-rich plasma (PRP) injections on the
healing of chronic refractory patellar tendinopathy after
previous classical treatments have failed. We treated 15
patients affected by chronic jumper’s knee, who had failed
previous nonsurgical or surgical treatments, with multiple
PRP injections and physiotherapy. We also compared the
clinical outcome with a homogeneous group of 16 patients
primarily treated exclusively with the physiotherapy approach.
Multiple PRP injections were performed on three
occasions two weeks apart into the site of patellar
tendinopathy. Tegner, EQ VAS and pain level were used
for clinical evaluation before, at the end of the treatment
and at six months follow-up. Complications, functional
recovery and patient satisfaction were also recorded. A
statistically significant improvement in all scores was
observed at the end of the PRP injections in patients with
chronic refractory patellar tendinopathy and a further
improvement was noted at six months, after physiotherapy
was added.

Moreover, comparable results were obtained
with respect to the less severe cases in the EQ VAS score
and pain level evaluation, as in time to recover and patient
satisfaction, with an even higher improvement in the sport
activity level achieved in the PRP group. The clinical
results are encouraging, indicating that PRP injections have
the potential to promote the achievement of a satisfactory
clinical outcome, even in difficult cases with chronic
refractory tendinopathy after previous classical treatments
have failed.
Introduction

Jumper’s knee is a disabling and often chronic condition
that affects athletes in many sports, particularly elite
athletes engaged in explosive jumping sports. Epidemiological
evaluations showed that the average duration of
substantial pain problems and reduced function is nearly
three years [1] and that at 15 years’ follow-up 53% of the
subjects reported quitting their sports career due to the
damaged knee [2].

Various therapeutic approaches have been adopted for
the treatment of patellar tendinopathy. The initial treatment
of jumper’s knee typically includes rest, ice, electrotherapy,
massage, taping, anti-inflammatory medication or corticosteroid
injections [3]. Also, physiotherapy, including eccentric
training protocols [4], extra-corporeal shock-wave
therapy [5] and sclerosant injections [6] have been
proposed, but in the difficult cases, where results are poor,
surgical treatment may be considered. Surgery, with
decompression, resection and open stimulation of the
affected tendon, is recommended for athletes whose sports
careers seem to be in danger, and good results have been
reported [7]. However, for the most part, treatment options
are poorly researched and outcomes after both conservative
and surgical treatment may offer incomplete recovery and
difficulties returning to sport [8].

Recent knowledge regarding tissue biology highlights a
complex regulation of growth factors in the normal tissue
structure and in the reaction to tissue damage and shows
an important role and effectiveness for growth factor
application in the healing of damaged tissue. Studies
showed the role of TGF-β in increasing the expression of
procollagen type I and III and improving tendon mechanical
properties [9, 10]. PDGF-BB, IGF-1,VEGF and BFGF
promote tendon cell proliferation and also tendon healing
[11]. It has been demonstrated that the healing tendon is
responsive to the local application of growth factors and
the fact that platelets secrete growth factors and active
metabolites means that their applied use can have a
positive influence on damaged tissues with low healing
potential. Platelet-rich plasma (PRP) is a method which
provides many growth factors in a simple, low cost and
minimally invasive way.

The purpose of our study was to evaluate the therapeutic
effects of multiple PRP injections to promote the healing of
chronic refractory patellar tendinopathy after previous
classical treatments have failed. We also compared the
results obtained in this group of patients with a homogeneous
group of patients, primarily treated exclusively with
the physiotherapy protocol, to understand better the actual
role of PRP in increasing the tendon healing potential.
Materials and methods
Patient selection

Clinical experimentation was approved by the Hospital
Ethics Committee and informed consent of all patients was
obtained. Two groups of patients were enrolled and treated
either with PRP and physiotherapy or with the physiotherapy
approach alone.
In the PRP group, the inclusion criteria used were
history (>3 months) of exercise-associated pain, pain or
tenderness on palpation and imaging findings of degenerative
changes. For this group we enrolled only patients who
had failed previous nonsurgical or surgical treatments,
including all or a combination of rest for at least
two months, conventional stretching exercises and strengthening,
and were classified as grade III-B according to the
criteria originally described by Blanzina and later modified
by Lian et al. [12] (patients unable to participate in sports at
the same level as before the onset of symptoms). Exclusion
criteria were: systemic disorders such as diabetes, rheumatoid
arthritis, coagulopathies, cardiovascular diseases, infections,
immunodepression, patients in therapy with
anticoagulants–antiaggregants, use of NSAIDs in the
five days before blood donation, Hb values of <11 and
platelets values of <150,000/mmc. Fifteen consecutive
patients with refractory jumper’s knee were treated and
prospectively evaluated at a minimum of six months’
follow-up.

In the control group, the same inclusion and exclusion
criteria were used for this group of patients affected by
jumper’s knee. The only difference was related to previous
treatments, i.e. for this group we selected patients who had
not undergone any treatment (for at least two months) and
were primarily treated with the physiotherapy protocol
alone. A group of 16 consecutive patients, treated during
the same period by the same surgeons, was enrolled.
The groups were matched for sex, age and sport activity
level; the only differences were regarding previous treatment
(due to the study design) and duration of symptoms,
which was markedly longer in the PRP group (p<0.0005)

(Table 1).
Treatment procedure and follow-up
The procedure described by Kon et al. [13] was used for the
preparation and injection of the platelet concentrate and for
the postinjection phase. The procedure consisted of two
centrifugations (the first at 1800 rpm for 15 minutes and the
second at 3500 rpm for 10 minutes) of a 150-ml venous
blood sample in order to concentrate platelets and produce
20 ml of PRP. The unit of PRP was divided into four small
units of 5 ml each, whereby one unit was sent to the
laboratory for analysis, one unit was used for the first
injection within two hours, and the other two units were
stored at −30°C. The total number of platelets per milliliter
presented a concentration 6.1±1.6 higher compared with
whole blood values, and an average of 6.5±1.5 million
platelets were administered at every injection. Injections
were performed every 15 days. For the second and third
treatments the samples were thawed in a dry-thermostat at
37°C for 30’ just before application. Before every injection,
10% of Ca-chloride (Ca++ = 0.22 mEq x dose) was added
to the PRP concentrate to activate platelets.
After the injection, the patients were sent home with
instructions to limit the use of the leg for at least 24 hours
International Orthopaedics (SICOT)
and to use cold therapy for pain. Between the first and the
second injection rest was indicated. After the second
injection stretching exercises and mild activities (such as
bicycle exercise and mild exercises in a pool) were allowed,
whereas after the third application patients were recommended
to continue with stretching and light activities, and
to begin a strengthening program and proceed gradually
after one month with normal sports or recreational activities
as tolerated. The same physiotherapy protocol was used for
the other group of patients.

Patients were clinically prospectively evaluated before, at
the end of the treatment and at six months follow-up.
Participants with bilateral jumper’s knee were asked to select
the most symptomatic knee. Tegner, EQ VAS and pain level
were used for clinical evaluation. Complications, functional
recovery and patient satisfaction were also recorded.
Statistical methods
All continuous data are expressed in terms of mean ± SD.
Categorical variables are expressed as proportions or
percentages. The Kolmogorov-Smirnov test was performed
to test normality of continuous variables. For the nonnormal
distribution of evaluated variables non-parametric
tests were used. The Wilcoxon test was used for paired
comparisons and the Mann Whitney test was used to
investigate data differences between the two groups.
Pearson’s Chi square test was performed to investigate the
relationships between grouping variables. For all tests p<
0.05 was considered significant.
Results
No complications related to the injections or severe adverse
events were observed during the treatment and follow-up
period.
PRP group Statistical analysis showed a significant improvement
in the EQ VAS (p=0.004) from basal evaluation
(52.7±22.0) to the end of the injection cycle (68.0±13.9),
and a further improvement was present at six months’
follow-up (78.3±13.3) (p=0.007) (Fig. 1). Similarly, a
significant decrease in the pain level (p=0.002) was
achieved from basal evaluation (6.6±1.4) to the end of
the PRP injections (4.3±1.7), and a further improvement
was present at six months’ follow-up (3.1±1.2) (p=0.02)
(Fig. 2). Sport activity, which was evaluated using the
Tegner score, showed an improvement (p=0.001) from pretreatment
level (3.7±1.8) to six months’ follow-up (6.6±
2.4); most of the patients returned to their sport, with a
lower score, which was not significantly different compared
to the previous activity level (7.5±1.6) (Fig. 3). Evaluation
of the functional recovery showed five patients with a
complete recovery, six with a marked improvement, and
two with a mild improvement. There was a mean return-tosport
time of 3.0±1.1 months, whereas in two cases we did
not obtain any improvement, thus the patient satisfaction
was 86.7% (13/15).
Control group Statistical analysis showed a significant
improvement in the EQ VAS (p=0.006) from basal
Characteristic Platelet-rich plasma (PRP) group Control group
Number of patients 15 16
Age 28.8±8.5 25.5±9.2
Sex Male Male
Bilateral 5 1
Sports activity level 7.5±1.6 7.8±1.3
Duration of symptoms (mo) 24.1±19.9 8.4±4.1
Previous treatments 15 7
Rest (at least 2 mo) 15 0
Stretching exercises 15 0
Strengthening exercises 15 2
Ultrasound therapy 10 1
Shock wave therapy 7 0
Laser therapy 7 7
Deep tendon massage 6 1
Corticosteroids injections 3 0
Sclerotherapy 1 0
Surgery 5 0
Pain level 6.6±1.4 6.7±1.5
EQ VAS score 52.7±22.2 50.6±22.3
Table 1 Comparison of the
characteristics of the two
groups of patients evaluated and
treated
International Orthopaedics (SICOT)
evaluation (50.6±22.3) to the end of the therapy (72.5±
24.7), and the results remained stable at six months’
follow-up (73.5±26.3) (Fig. 1). Similarly, a significant
decrease in the pain level (p=0.001) was achieved from
basal evaluation (6.7±1.5) to the end of therapy (3.2±2.4)
and six months’ follow-up (3.7±2.8) (Fig. 2). The sport
activity showed an improvement (p<0.0005) from pretreatment
level (5.3±2.0) to six months’ follow-up (6.8±
1.6); most of the patients returned to their sport, but with a
mean lower score with respect to the previous activity level
(7.8±1.3) (p=0.01) (Fig. 3). The evaluation of the
functional recovery showed four patients with a complete
recovery, four with a marked improvement, and five with a
mild improvement. There was a mean return-to-sport time
of 3.2±1.6 months, whereas in three cases we did not
obtain any improvement. The patient satisfaction was
68.8% (11/16).
When comparing the two groups, no statistically
significant differences were obtained with the EQ VAS
and pain level evaluation, as with time-to-recover and
patient satisfaction, whereas a greater improvement in the
sport activity level was achieved in the PRP group
(percentage improvement, 39±22%) with respect to the
control group (20±27%) (p=0.048) (Fig. 4).
Discussion
Jumper’s knee is a common overuse injury in athletes that
occurs because of the high chronic repetitive loading that
Fig. 1 Comparison of the health status, evaluated with EQ-VAS, in the platelet-rich plasma (PRP) and control groups
Fig. 2 Comparison of the pain level, evaluated on a 1–10 scale, in the platelet-rich plasma (PRP) and control groups
International Orthopaedics (SICOT)
surpasses the adaptive abilities of the tendon and causes
micro tears and degeneration in the tendon substance.
Many factors have been suspected to predispose patients
to this condition [2] by increasing the patellar tendon
overload. The high chronic repetitive loading stimulates the
local release of cytokines, with an autocrine and paracrine
modulation of cell activity [14], that fails to adapt to
continued abusive load and irritation and leads to intratendinous
damage. The poor regeneration capacity of
tendons, explained by the poor vascularity, oxygenation
and nutrition of this tissue, cannot cope with the applied
forces and explains the low healing potential and the
difficulties in the treatment of this chronic tendon disease
[14].
Recently, some authors [15, 16] have postulated that
autologous blood injections might provide the necessary
cellular and humoral mediators to induce the healing
cascade and promote tendon repair. The rationale was
based on the mitomorphogenic activity of blood growth
factors and the inflammatory response induced in an
otherwise degenerative process, leading to strengthening
of the tendon through the formation of granulation tissue
and tissue regeneration, in a tendon with an increased
healing potential. The effect of autologous blood injections
into the tendon have been evaluated in vitro and in vivo,
whereby an increase in rabbit patellar tendon strength has
been assessed [15]. Clinical applications for the treatment
of chronic tendinopathies have also showed good results
[16–19].
The benefits are the result of some kind of bleeding,
which stimulates the healing response through chemical
modifiers of cellular activity contained in the blood. In
cases of injury, platelets are the first cells carried to the
lesion site and, in fact, they play a key role in mediating
healing of the damaged tissue because of the capacity to
release growth factors from their α-granules [20]. Platelets
contain storage pools of growth factors including PDGF,
TGF-β, VEGF, IGF-1, FGF, and cytokines, chemokines
and metabolites [20]. Platelet-rich plasma is a concentrate
of platelets and therefore autologous growth factors.
Fig. 3 Comparison of the sports
activity level, evaluated with the
Tegner score, in the platelet-rich
plasma (PRP) and control
groups
Fig. 4 A 22-year-old soccer
player with a three year history
of refractory jumper’s knee who
failed both non-operative treatments
and surgery. The patient
returned to previous activity
level after four months; MRI
shows the patellar tendon before
treatment (a) and the improvement
of the tendon structure
after the platelet-rich plasma
(PRP) injections at six months’
follow-up (b)
International Orthopaedics (SICOT)
Additionally, their administration in the form of platelet gel
provides an adhesive support that can confine secretion to a
chosen site.
As in the earlier described technique based on the
injection of autologous blood, PRP injections combine the
dry needling stimulus, which may induce internal haemorrhage
and consequently an inflammatory response and a
repair process, with the biological stimulus of the injected
platelet growth factors. Releasate from platelet-rich plasma
has been seen to activate circulation-derived cells [21] that
play a crucial role in the tissue healing process and
stimulate gene expression of the matrix molecules, collagen
production and tendon cell proliferation [22]. In vitro
studies demonstrated this mitogenic activity and that the
stimulated tenocytes synthesise VEGF and HGF, thus
suggesting a beneficial effect for the treatment of tendon
injuries by inducing cell proliferation and promoting the
synthesis of angiogenic factors during the healing process.
An animal model has also confirmed the usefulness of
platelet concentrate for the treatment of tendon damage
[23], with an increased tendon callus strength and stiffness
after percutaneous injections in transacted tendons; a more
rapid recovery in surgically repaired tendons has also been
seen in a human study [24]. Currently, PRP is widely used
experimentally in different fields of medicine, but the
evidence base for the clinical use of PRP is still in its
infancy. Only a few articles specifically address treatment
applications in the orthopaedic field and, to our knowledge,
only one study has been published regarding the treatment
of tendinopathy through PRP injections. Mishra treated
patients affected by severe chronic tennis elbow and
reported promising results [25], with improvement in pain
and function and no complications. The purpose of our
study was to investigate this novel approach for the
treatment of severe chronic patellar tendinopathy. We
recruited and evaluated prospectively athletes who failed
classical therapies. The rationale of the study was to test the
use of PRP only in failed cases and compare the results
achieved by treating recalcitrant tendinopathy through PRP
injections and physiotherapy with those obtained in a
homogeneous group of patients with jumper’s knee
primarily treated only with the physiotherapy protocol. It
was difficult to have a control group for this study, because
it was impossible and unethical to have a group of patients
who had just failed previous physiotherapy, to be treated
once again with classical therapies for control. However,
the non-homogeneous control group represents one of the
main biases of this study. The fact that patients were
subjected to two therapies simultaneously represents another
limitation of our study, since we do not know the relative
importance and the real contributions of PRP and physiotherapy
to the therapeutic outcome. However, all the
patients treated with PRP had previously failed the
physiotherapy treatments, and therefore we believe that
the PRP injection may have increased the tissue reparative
capability and may have played an important role in the
tendon reparative process. Other weak points of this study
are represented by the lack of randomisation (not usable in
this case due to the pre-determined different selection
criteria) and the small number of patients treated; nonetheless,
this study shows interesting results that deserve to be
elaborated and confirmed in wider randomised studies.
After evaluating the safety and feasibility of this
procedure in a preliminary study [13], we used this
biological approach to treat 15 patients affected by pain
and tenderness at the inferior pole of the patella (in most of
the cases the proximal–central part of the tendon also
presented degenerative changes and was symptomatic) for
more than three months despite rest and classical therapies.
In our previous study we underlined the necessity to
combine PRP treatment with physiotherapy, i.e. after
injections, the patients followed a standardised physiotherapy
protocol to aid rehabilitation before returning to full
sporting activity. Stretching and strengthening therapies
play a key role after the PRP injections, due to the interplay
between biological and mechanical stimulation, as shown in
an animal model [23]. On the other hand, the better
function of the extensor apparatus may reduce the overload,
thus aiding healing of the tendon and maintaining the
results over time.
We observed a statistically significant improvement in
all scores evaluated at the end of the therapy and at
six months’ follow-up. Knee function and quality of life
markedly improved, and the majority of the patients had a
good recovery, returned to their previous sporting activity
level and were satisfied with the results of the treatment.
The analysis showed comparable results with the control
group, with an even higher improvement in sports activity
level in the PRP group. In other words, patients with a long
history (much longer with respect to that of the control
group) of chronic refractory jumper’s knee, who had
previous failed nonsurgical or even surgical treatments,
were able, through the combination of multiple PRP
injections and physiotherapy, to achieve the same results
obtainable in less severe cases. This was probably due to an
increased tendon healing potential, but needs to be verified
through imaging and histological evaluation.
Conclusions
This report investigates the use of autologous growth
factors through platelet-rich plasma injections as a treatment
for jumper’s knee. The clinical results of our study are
encouraging and suggest this method can be useful for the
treatment of chronic patellar tendinopathy, even in difficult
International Orthopaedics (SICOT)
cases with refractory tendinopathy where the only physiotherapy
approach had failed.
Acknowledgments Thanks go to M. Lo Presti, M. Delcogliano, S.
Zaffagnini, A. Bondi, A. Di Martino, and S. Bassini from the IX
Division – Biomechanics Lab, Rizzoli Orthopedic Institute, Bologna,
Italy; to A. Cenacchi, F. Pieretti, A. Gabriele, M. Vaccari, A.M. Del
Vento, M. Zagarella, V. Roverini, I. Brognara, L. D’Amato and S.
Ardone from the Immunohematology and Transfusion Medicine
Service, Rizzoli Orthopedic Institute, Bologna, Italy; to E. Pignotti,
and K. Smith from Task Force, Rizzoli Orthopedic Institute, Bologna,
Italy; and to G. Nanni from Isokinetic, Education Research Department,
Bologna, Italy.
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International Orthopaedics (SICOT)

[bel142]

Whoa, come on JMP, lets take a step back before we have every high school-er on this web sight going out for knee injections.

In terms of the make up of the human knee, there is poor circulation/vascular blood movement in and around the knee. The reason why damageable knees take so long to heal (if ever) is because the healing property of blood isn't there, to get the healing cells in and carry away the damaged tissues... (More or less)

Me taking another look at this, the standard practice for ITS/Tendinitis and yadda, in general is to decrease activity, ice, anti inflammatory drugs, they did that then added the additional factor of the platelet injections, and had some success. So let us all understand this is for extreme cases where careers are being threatened, not for "casual" knee pain... because as a collegian/post collegiate athlete try explaining to the NCAA/USADA that you took venous blood out of your body and injected it back into yourself... Shot in the dark they are not going to be look favorably upon you... Although, this is not how, specifically, blood doping works it seems to me, to be walking that line and may be still too experimental for you to hop back on the runway.

...but in my opinion, all in all, a fun read...

[MattM]

I suffered from Patellar Tendonitis all through the past two years of competition, and am glad to say that I have not had any problems with it since the beginning of fall. The secret to my healing was this: progression. I found that if I ever took a break off from exercising, my pain would return. What I did that prevented it from hurting me, was exercising every day. You don't need to do a huge exercise, or even a mundane one, just do a little jog. Even one mile run a day was enough to keep it from hurting when I would jump into competition! (pun intended.)

[Erica]

Platelet-derived preparations (Platelet Rich Plasma, “blood spinning”) are on the World Anti-doping Agency prohibited list. MAKE SURE YOU KNOW WHAT IS ON THE BANNNED LIST IF YOU ARE A HIGH SCHOOL, COLLEGE, OR ELITE ATHLETE! Just because you don't know doesn't mean you are innocent. Your ADD meds or inhaler may also be banned in competitions. You don't want to find out what is banned by testing positive for something at Jr. Nats.

[JMP8928]

oooooh good point erica

But it might be a good idea to check with WADA for therapudic uses of PRP.

[VTechVaulter]

Erica

Question for you. Do you know the specifics of the PRP ban? Im familiar with the concept of blood doping, but taking your own blood and returning less of it within 5 minutes time doesn't seem to constitute at blood doping. Theres no time for the body to create more and then be overloaded. The doctors at VT have prescribed it to 100s of athletes in the last few years, both ncaa, usatf, and more. They say they have already checked with WADA and USADA and that it is within the rules.

[Erica]

Cut and Pasted from the WADA prohibited list:

Platelet-derived preparations (e.g. Platelet Rich Plasma, “blood
spinning”) administered by intramuscular route. Other routes of
administration require a declaration of Use in accordance with the
International Standard for Therapeutic Use Exemptions.

and other substances with similar chemical structure or similar biological
effect(s).

Basically this means "other routes" like injection in tendons, joints, or ligaments requires a TUE in order to be allowable.

This is the first year that Platelet Rich PLasma has been on the banned list. Before this point, there was no ruling against it. It is a pretty new procedure, and is effective. I guess since more athletes were using it, they felt they needed to control it more so it doesn't get out of hand. Who knows how good athletes could be if they got intramuscular PRP every day? Someone would probably try it if it wasn't banned.