Presentation on theme: "Tendonopathy NYSAFP Winter Weekend January 28, 2012"— Presentation transcript:
1Tendonopathy NYSAFP Winter Weekend January 28, 2012 Todd S. Shatynski, MD, CAQSM
2ObjectivesUnderstand the anatomy of a musculo-tendinous unit and locations of injuryReview the process that occurs to cause tendon degenerationEvaluate the current categorization of tendon pathologyAssess the current evidence behind traditional and emerging treatments
3Anatomy of a Tendon Tight, parallel collagen bundles Transmit forces muscle -> boneGreat tensile strengthPoor resistance to compression and shear forcesSurrounded by paratenon +/- sheath
4Anatomy Paratenon – contains tendon vasculature Originates from musculotendinous and bone-tendon junctionsCoiled vasculature allows stretchSheath – avascular tendonsAllows change of direction when crossing over bony prominences
6Tendon Overload/Overuse Tissue deformation begins as strain increases due to friction, torsion, compressionMost common in tendons with large mechanical demands (achilles, patellar)Originally termed “tendonitis” implying inflammatory reactionActually spectrum of injury involving acute and chronic components
7Where’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
8Where is the inflammation? Maybe the paratenon…Ultrasound guided corticosteroid paratenon injection of Achilles, patellar tendonitis (by MRI) provided significant pain relief compared to blind placeboUltrasound guidance used to avoid intratendinous injectionFredberg, Scand J Rheumatol, 2004
9Biochemical Hypothesis Khan, et al. Br J Sports Med, 2000Painful tendon reveals fascicles containing nerve fibers with sympathetic nerve markers (usually only seen in nervous system):Substance PAcetylcholineCatecholamines
10Molecular 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.
12Which 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
13Histopathology Khan, Sports Med, 1999 Tendonitis –Symptomatic degeneration with vascular disruption and inflammatory repair responseCollagen disorientation/disorganization with tear, fibroblastic proliferation, hemorrhage, and organizing granulation tissue+ Inflammatory cellsAnimal models
14Histopathology Tendonopathy Intratendonous degeneration due to aging, microtrauma, or vascular compromiseCollagen disorientation/disorganization with fiber separation by increased mucoid ground substance, possibly neovascularization, focal necrosis or calcificationNo inflammatory cells
15Histopathology Paratenonitis Inflammation of outer layer of the tendon (paratenon)Acute edema and hyperemia of paratenon with infiltration of inflammatory cellsProduction of fibrous exudate in the tendon sheathMild mononuclear infiltrateInflammatory cells in paratenon only
16Histopathology Peratenonitis with tendinosis Intratendinous degenerationParatenonitis with mucoid degeneration and scattered inflammatory cells in paratenon
19General Tendon Injury Ruptures – Male:Female (4-7xs) Wong, et al. Am J Sports Med, 2002Anabolic steroids increase rupture riskMore common in blood type O, less common in type AJosza, et al. JBJS, 1989; Kujala, et al. Injury, 1992; Maffuli, et al. Clin J Sports Med, 2000.Tendon ruptures increased with oral quinolone useKibler, et al. Clinics in Sports Med, 2002
20Exercise ResponseTendonopathy improves with exercise but worsens afterAllows exercise to continueInhibits healing response
21“Tennis elbow” Lateral epicondylitis (-osis) Extensor carpi redialis brevis tendinosis9x more common than medialPain with resisted extensionMore common in older playersOccupational injury very commonIntensity, conditioning, warm-up, training changesGrip size, string tension, racket size/rigidity
22Classic treatment Reduce stresses across tissue RestCounterforce braceImprove quality of tissue and balanceStrength and enduranceEccentric strengtheningBalanced flexibilityOptimize technique, equipment,
24Anti-inflammatory techniques Cryotherapy – acutelyUltrasound guided paratenon and bursal injections of corticosteroid may be temporarily beneficialNever inject corticosteroid into tendonIncreases risk for rupture
25Anti-inflammatory techniques Achilles tendonopathy – oral NSAID (piroxicam) no benefit over placeboAstrom, Westlin, Acta Orthop Scand, 1992.NSAIDS may permit patient to ignore pain and cause further injuryNSAIDS may reduce healing response
26Injected Corticosteroid Well-established efficacy in short term relief of painSafe, limited side effectsLong term degeneration?Ineffective if used in isolation without use of PT modalities
27Topicals Topical Nitric Oxide Not FDA approvedTopical Glyceryl trinitrate with hand rehab81% asymptomatic (vs 60%) at 6 monthsLess pain, improved strengthPaoloni, Am J Sports Med, 2003; Paoloni, JBJS, 2004.
28Newer concepts: Anti-antiinflammatory approach Deep friction massageProlotherapyInjection of blood or plateletsHyperbaric oxygenInjectable growth factorsRadiofrequency coblationExtracoporeal shockwave therapyMinimally invasive release/needle tenotomy/barbotage
29Platelet Rich Plasma NFL, MLB, MLS, PGA Patients own blood extracted, spun in centrifuge and PRP injected into diseased tissueLimited evidence, thus rarely covered by health insurance
30Platelet Rich Plasma (PRP) Peerbooms, et al. Am J Sports Med, 2010DBRCT 100 patients lateral epicondylitisEccentric exercise with PRP or Corticosteroid73% vs 51% improved at 1 year
31PRP Lateral Epicondylitis Hechtman, et al. Orthopedics, 201130 patients, Symptoms >6mos, unresponsive to conservative therapy (inc steroid injection)1 PRP injectionOverall success 90% = 25% reduction in pain scores at 1 year followup
32PRP for Achilles? DeVos, et al. JAMA 2010. DBRCT 54 patients Eccentric exercise with PRP or Saline injectionNo statistical difference in outcomes
33Why the difference? Castillo, et al. AJSM, 2011. >16 different platelet separation systems = different platelet-rich concentratesVarying amount of starting blood volume, spin timesVarying WBC concentrations (↑ or ↓)Thus varying growth factor concentrationsNeeds more study!
34Prolotherapy Sclerosing therapy Reduces neovascularization but not tendon thicknessOhberg, Alfredson, Br J Sports Med, 2002.Review article suggests promise and evidence of effectiveness in tendonopathyDistel, Best, PMR, 2011.