Advances in the Treatment of Tendon Injuries Rishi Sharma, MD, Sports Medicine www.SpringfieldClinic.com
Jan 14, 2015
Advances in the Treatment of Tendon InjuriesRishi Sharma, MD, Sports Medicine
www.SpringfieldClinic.comwww.SpringfieldClinic.com
Common Tendon Problems
• Shoulder
• Elbow
• Wrist
• Hip
• Knee
• Ankle & Foot
Tendon: What is it?
• Fibrous connective tissue that connects muscle to bone
Tendon: What is the function?
• Acts as a spring to collect and release force
Common Names for Tendinopathy
• Tendonitis
• Peritendonitis
• Tendinopathy
• Tenosynovitis
• Apophysitis
• Insertitis
• Bursitis
• Enthesopathy
How is it injured?
• Tendinopathy– Degeneration of
the tendon
• Tendinitis– Overuse
• Tendon Tears– Injury
Microscopic Tendon
RUPTURED TENDON
ACHILLES TENDINOPATHY
NORMAL TENDON
ROTATOR CUFF TENDINOPATHY
Can the tendon heal itself?
• Depends– Full-thickness
• usually no
– Tendinopathy• usually yes
How does tendinopathy heal?
• Inflammation
• Repair
• Remodeling
How does tendinopathy heal?
• Inflammation
• Repair
• Remodeling
How does tendinopathy heal?
• Inflammation
• Repair
• Remodeling
What is the problem with the tendon?
• Tendinopathy
• Full-thickness tear
Etiology of Tendon Disorders
• Repetitive and prolonged exertion
• Sudden increase in training
• Pre-existing tendinosis
• Acute trauma
Shoulder
• Rotator Cuff Tendon– Continuum from:
• Tendinopathy to Full-thickness Rotator Cuff Tear
• Biceps Tendon
Rotator Cuff Pain
• Insidious onset of pain
• Middle aged
• Increasing pain with activity
• Can have decreased range of motion or weakness
Elbow
Elbow
• Tennis Elbow– Lateral Epicondylitis
• Golfer’s Elbow– Medial Epicondylitis
Tennis Elbow
Tennis Elbow
• Common extensor tendon
Golfer’s Elbow
Wrist
• DeQuervain’s tenosynovitis
Hip
• Trochanteric Bursitis
Hip
• Hamstring
• Hip Flexors
Knee
• Quadriceps tendon
• Patellar tendon
Foot & Ankle
• Achilles tendon
• Peroneal tendon
• Tibialis posterior tendon
• Tibialis anterior tendon
Medications
Bracing
Physical Rehabilitation
Corticosteroid Injections
Topaz - Radiocoblation
Surgical Treatment
• Achilles Tendinopathy
Emerging Treatments
• Topical Glycerol Trinitrate
• Proliferation Therapy
• Botulinium Toxin A
• Acupuncture
• Low Level Laser Therapy
• Platelet Rich Plasma
Platelet-Rich Plasma
• Sample of blood with a platelet concentration of at least 1,000,000 platelets/micromLin 5 mL of plasma
Platelet-Rich Plasma
Types of Platelet Rich Plasma
• Tier One– Arteriocyte Magellan– Harvest SmartPRep– Biomet GPS II
• 4-5 x’s baseline platelet concentration
• Tier Two– Arthrex– Cascade
• 2-3 x’s baseline concentration
Tier One: PRP
• Arteriocyte Magellan
Tier Two
• Arthrex
Platelet-Rich Plasma
• What do platelets contain?– alpha granules
• PDGF • VEGF• EGF• IGF-1
How do we know where to inject?
Ultrasound
• Patellar tendinopathy
Ultrasound
• Achilles tendinopathy
Rotator Cuff Disorders
• Diagnostic Ultrasound– Partial and Full thickness tears– Tendinopathy
Evidence of PRP
• Double blind randomized study showed PRP better than corticosteroid at 26 and 52 weeks
– AJSM Feb 2010
PRP Evidence
• Mishra, et. al; in a pilot study; has had success in the management of chronic elbow tendinosis with PRP
• Scarpone, et. al; showed statistical significance in pain scores for the management of rotator cuff tendonipathy with PRP
• Barret, et. al. had found significant symptom relief in patients with plantar facciitis who underwent PRP therapy.
May not work for everyone