Tendonopathy

NYSAFP Winter WeekendJanuary 28, 2012Todd S. Shatynski, MD, CAQSMtshatynski@caportho.com

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.