Dec 15, 2015
Tendonopathy
NYSAFP Winter WeekendJanuary 28, 2012Todd S. Shatynski, MD, [email protected]
Objectives
Understand the anatomy of a musculo-tendinous unit and locations of injury
Review the process that occurs to cause tendon degeneration
Evaluate the current categorization of tendon pathology
Assess the current evidence behind traditional and emerging treatments
Anatomy of a Tendon Tight, parallel
collagen bundles Transmit forces
muscle -> bone Great tensile
strength Poor resistance to
compression and shear forces
Surrounded by paratenon +/- sheath
Anatomy
Paratenon – contains tendon vasculature Originates from musculotendinous and
bone-tendon junctions Coiled vasculature allows stretch
Sheath – avascular tendons Allows change of direction when crossing
over bony prominences
“Tendonitis” Rotator cuff tendonitis Medial epicondylitis (Golfer’s elbow) Lateral epicondylitis (Tennis elbow) Dequervain’s tenosynovitis Hamstring tendonitis Adductor tendonitis Patellar tendonitis (Jumper’s knee) Achilles tendonitis Plantar fasciitis
Tendon Overload/Overuse Tissue deformation begins as strain
increases due to friction, torsion, compression Most common in tendons with large
mechanical demands (achilles, patellar) Originally termed “tendonitis”
implying inflammatory reaction Actually spectrum of injury involving
acute and chronic components
Where’s the inflammation?
“Histologic analysis reveals no inflammatory cells” Nirschl, Clin Sports Med, 1992
“Microdialysis and gene technology has clarified there is no chemical inflammation in Achilles’ tendinosis.” Alfredson, Clin Sports Med, 2003
Where is the inflammation?
Maybe the paratenon… Ultrasound guided corticosteroid
paratenon injection of Achilles, patellar tendonitis (by MRI) provided significant pain relief compared to blind placebo Ultrasound guidance used to avoid
intratendinous injection Fredberg, Scand J Rheumatol, 2004
Biochemical Hypothesis
Khan, et al. Br J Sports Med, 2000 Painful tendon reveals fascicles
containing nerve fibers with sympathetic nerve markers (usually only seen in nervous system): Substance P Acetylcholine Catecholamines
Molecular analysis
IL-1 beta induces expression of cytokines
Cytokines induce matrix destructive enzymes (metalloproteases MMP-1, etc)
Increased lactate (ischemia signal) and glutamate (pain mediator)
Chronic overuse leads to degeneration and premature cell death (apoptosis) Tsuzaki, et al. J Ortho Res, 2003; Cook, et al. Phys Sportsmed, 2000; Capasso, et al.
Sports Exerc Inj, 1997; Arnoczky, et al. J Orthop Res, 2002; Yuan, et al. J Orthop Res, 2002; Alfredson, Clin Sports Med, 2003; Ireland, et al. Matrix Biol, 2001.
Classification
Tendonopathy = chronic tendon pain Tendonitis Tendonosis Paratenonitis Insertional tendonitis
Which one is it?
“…tendinosis was first used by German workers in the 1940’s, its recent usage comes from the work of Giancarro Puddo in the early 1970’s.” N. Maffuli, Clin J Sports Med, 2003
“Degenerative tendinosis occurs over time when tendon damage exceeds the rate of the tendon’s intrinsic ability to heal” Budoff & Nirschl, Op Techniques in Sp Med, 2001
HistopathologyKhan, Sports Med, 1999
Tendonitis – Symptomatic degeneration with vascular
disruption and inflammatory repair response
Collagen disorientation/disorganization with tear, fibroblastic proliferation, hemorrhage, and organizing granulation tissue
+ Inflammatory cells Animal models
Histopathology
Tendonopathy Intratendonous degeneration due to
aging, microtrauma, or vascular compromise
Collagen disorientation/disorganization with fiber separation by increased mucoid ground substance, possibly neovascularization, focal necrosis or calcification
No inflammatory cells
Histopathology
Paratenonitis Inflammation of outer layer of the tendon
(paratenon) Acute edema and hyperemia of paratenon
with infiltration of inflammatory cells Production of fibrous exudate in the
tendon sheath Mild mononuclear infiltrate Inflammatory cells in paratenon only
Histopathology
Peratenonitis with tendinosis Intratendinous degeneration Paratenonitis with mucoid degeneration
and scattered inflammatory cells in paratenon
Appearances…Healthy Glistening white Hierarchical, parallel,
tightly packed collagen fibers
Reflectivity under polarized light
No extracellular matrix Vasculature, tenocytes
inconspicuous
Symptomatic Grey, amorphous Discontinuous,
disorganized collagen fibers
No reflectivity under polarized light
Mucoid ground substance present
Less tenocytes, appear plump
Microscopy
General Tendon Injury Ruptures – Male:Female (4-7xs)
Wong, et al. Am J Sports Med, 2002
Anabolic steroids increase rupture risk More common in blood type O, less
common in type A Josza, et al. JBJS, 1989; Kujala, et al. Injury, 1992;
Maffuli, et al. Clin J Sports Med, 2000.
Tendon ruptures increased with oral quinolone use Kibler, et al. Clinics in Sports Med, 2002
Exercise Response
Tendonopathy improves with exercise but worsens after
Allows exercise to continue Inhibits healing response
“Tennis elbow” Lateral epicondylitis (-osis) Extensor carpi redialis brevis tendinosis 9x more common than medial Pain with resisted extension More common in older players
Occupational injury very common
Intensity, conditioning, warm-up, training changes
Grip size, string tension, racket size/rigidity
Classic treatment
Reduce stresses across tissue Rest Counterforce brace
Improve quality of tissue and balance Strength and endurance Eccentric strengthening Balanced flexibility
Optimize technique, equipment,
Treatment NSAIDS and Corticosteroids? Prolotherapy (irritant injection)
Dextrose, Sodium morrhuate Blood
Injectable healing factors Platelet rich plasma (PRP) Stem cells
Mechanical adjuvants Deep massage Extracorporeal Ultrasound Needle tenotomy
Surgery
Anti-inflammatory techniques
Cryotherapy – acutely Ultrasound guided paratenon and
bursal injections of corticosteroid may be temporarily beneficial
Never inject corticosteroid into tendon Increases risk for rupture
Anti-inflammatory techniques
Achilles tendonopathy – oral NSAID (piroxicam) no benefit over placebo Astrom, Westlin, Acta Orthop Scand, 1992.
NSAIDS may permit patient to ignore pain and cause further injury
NSAIDS may reduce healing response
Injected Corticosteroid
Well-established efficacy in short term relief of pain
Safe, limited side effects Long term degeneration? Ineffective if used in isolation without
use of PT modalities
Topicals
Topical Nitric Oxide Not FDA approved
Topical Glyceryl trinitrate with hand rehab
81% asymptomatic (vs 60%) at 6 months
Less pain, improved strength Paoloni, Am J Sports Med, 2003; Paoloni, JBJS, 2004.
Newer concepts: Anti-antiinflammatory approach
Deep friction massage Prolotherapy Injection of blood or platelets Hyperbaric oxygen Injectable growth factors Radiofrequency coblation Extracoporeal shockwave therapy Minimally invasive release/needle
tenotomy/barbotage
Platelet Rich Plasma
NFL, MLB, MLS, PGA Patients own blood extracted, spun in
centrifuge and PRP injected into diseased tissue
Limited evidence, thus rarely covered by health insurance
Platelet Rich Plasma (PRP)
Peerbooms, et al. Am J Sports Med, 2010
DBRCT 100 patients lateral epicondylitis Eccentric exercise with PRP or
Corticosteroid
73% vs 51% improved at 1 year
PRP Lateral Epicondylitis
Hechtman, et al. Orthopedics, 2011 30 patients, Symptoms >6mos,
unresponsive to conservative therapy (inc steroid injection)
1 PRP injection Overall success 90% = 25% reduction
in pain scores at 1 year followup
PRP for Achilles?
DeVos, et al. JAMA 2010. DBRCT 54 patients Eccentric exercise with PRP or Saline
injection No statistical difference in outcomes
Why the difference?Castillo, et al. AJSM, 2011.
>16 different platelet separation systems = different platelet-rich concentrates
Varying amount of starting blood volume, spin times
Varying WBC concentrations (↑ or ↓) Thus varying growth factor
concentrations Needs more study!
Prolotherapy
Sclerosing therapy Reduces neovascularization but not
tendon thickness Ohberg, Alfredson, Br J Sports Med, 2002.
Review article suggests promise and evidence of effectiveness in tendonopathy Distel, Best, PMR, 2011.
Extracorporeal Shockwave Therapy (ESWT)
Approved for multiple locations Review article (patellar tendon)
Van Leeuwen, et al. Br J Sports Med, 2009.
Variable treatment protocols Positive outcomes – safe, effective Uncertain mechanism Availability?
Minimally Invasive Release
Dry needling, Needle tenotomy Saline barbotage for calcifications Percutaneous longitudinal tenotomy
Maffuli, Am J Sports Med, 1999; Wilder, Clin Sports Med, 2004.