Tendinopathy: Current and Evolving Treatments Kenzie Johnston, MD, CAQSM

Objectives Review the science of tendons Discuss the confusing vocabulary surrounding tendinopathy Touch on proposed pathology Discuss escalating nonsurgical management and evidence (or lack there) for these interventions

Just a quick reminder Tendons connect muscle to bone and allow transmission of forces generated by muscle to move bone They save energy and improve power (The patella tendon is actually a ligament)

Common tendinopathies Rotator cuff tendinopathy Lateral and medial epicondylitis Patella tendinopathy Achilles tendinopathy Gluteal tendinopathy

How much does it matter? Tendinopathy probably accounts for 30% of all running related injuries 40% of tennis players may have/had tennis elbow Also affects people in the workforce - ex: mechanics with tennis elbow Has anyone here never seen tennis elbow, jumpers knee, or Achilles tendinopathy

Some vocab Tendons respond to repetitive overload beyond physiologic threshold with either inflammation of their sheath or degeneration of their body or both Tendinopathy and Tenosynovitis Tendinosis and Tendinitis are histologic terms and should not be used unless talking about histology

On a cellular level Basic cell biology of tendon is poorly understood Oxygen consumption is 7.5 times lower than skeletal muscle allowing them to retain tension without risk of ischemia

Tendinopathy Extrinsic factors Biomechanics (ROM of the extremity) Training type and training errors (surfaces, overload or underload) Fluroquinolones… Intrinsic factors Age Genetics Extrinsic – load, surfaces, ROM of the extremity Interesting, cipro and fluroquinolones induce cytokines and inflammatory PG, they also inhibit tenocyte metabolism

3 big theories Mechanical Vascular Neuro Tendon overload or nonuniform stress resulting in microtrauma or some cellular process (apoptosis, influx of cytokines, shift in proteolytic enzymes) Underuse or underloading may also be bad Hyperthermia (stored energy during locomotion) Vascular Poor blood supply and hypoxia resulting in tenocyte death Oxidative stress from reperfusion (oxygen free radicals) Neuro Disruption of normal neural signaling resulting in abnormal cell metabolism, pain signaling, and blood flow

Healing Done intrinsically (tenocytes) and extrinsically (invasion of cells from sheath and synovium) Intrinsic is better as it results in better biomechanics Extrinsic results in more scar tissue. This type of healing prevails in RTC

These are removed and normal collagen returns Injury occurs Acute factors migrate to site 24-48 hrs These are replaced by proliferative factors: abnormal collagen, nerves, and blood vessels 6-12 weeks These are removed and normal collagen returns

Histology of tendinopathy shows disordered haphazard healing with scattered vascular growth (neovascularization) and absence of or minimal inflammatory cells Inflammation only seen with the most acute protocols (so maybe it kicks it off) Macroscopically there is a color change and tendon thickening occurs On ultrasound we see thickening, calcifications, small tears, neovascularization

Without inflammation why is there pain? Increase in chemical irritants and neurotransmitters? Lactate Substance P Glutamate

Diagnosis Clinical diagnosis Pain with palpation of affected tendon Pain with tendon loading No systemic causes Less than 3 months we consider in acute phase and more than 3 months is considered chronic phase

Management Subjectivity of signs and symptoms associated with tendinopathy makes research difficult Little uniform in comparison intervention, duration of treatment, dosage or kit used in intervention, acuity of the condition, and measurement of efficacy

Bracing Thought to change fulcrum of force or shutdown repetitive movements or perhaps enhance proprioception Little evidence to support most of what we use (Elbow strap, patella strap, wrist brace, air heel, night splint or orthotic) But overall low risk and usually low cost Maybe if early enough can change or stop the process and allow tendon to make it through healing process? Weak evidence showed that foot orthoses were equivalent to physical therapy, and equivalent to no treatment. Very weak evidence supported the use of adhesive taping alone or when combined with foot orthoses. Moderate evidence showed that the AirHeel™ brace was as effective as a calf muscle eccentric exercise programme, and weak evidence showed that this intervention was not beneficial when added to a calf muscle eccentric exercise programme. Weak evidence showed that an ankle joint dorsiflexion night splint was equally effective to a calf muscle eccentric exercise programme, and strong evidence showed that this intervention was not beneficial when added to a calf muscle eccentric exercise programme. Counterforce bracing of lateral epicondylitis: a prospective randomized double blinded placebo clinical trial suggests that along with a exercise program a counterforce brace may be beneficial in terms of pain and function in the acute setting

NSAIDs Little evidence to no evidence Possibly just analgesia and perhaps could interfere with healing process Likely to be less effective in those with long standing pain

Exercise The most common intervention Eccentric has been long prescribed (active lengthening) but we may be questioning Strengthening program for rotator cuff It may just be loading the tendon that is important EE only produced good or excellent results in less than 60% of patients Greatest evidence if with midsubstance lesions of the Achilles tendon (less so for insertional) Some evidence for EE with patella tendinopathy and small evidence for lateral epicondylitis

Nitroglycerin Patches May be of benefit Well designed studies looking at Achilles, supraspinatus, and forearm extensors Decreased pain with activities of daily living after 6 weeks Perhaps nitrous oxide plays a role Risk for headache (2/2 low BP)

My nitroglycerin directions 1. Use 0.2 mcg/24 hr patch 2. For the first week cut the patch into 1/8th and use that to reduce risk of headache 3. Place patch over painful area and change daily after shower 4. Increase to 1/4th a patch after one week, do not use more than 1/4th 5. Must use consistently for 6-8 weeks to start to notice a difference

Steroid injections Highly contentious and may put at risk of rupture Effective for first 2-6 weeks but no long term benefit and perhaps less effective in long term than doing nothing or exercise (worse in pain and function for lateral epicondylitis)

When do I use steroid injections? Rotator cuffs that have already tried several weeks of PT or are too painful to participate in PT Once or twice for glute med/min with point tenderness Only once for elbows if they have an upcoming event or competition Only use with fat pad hydro dissection for patella (and only inject into fat pad) Never for Achilles Only if cannot tolerate PT for Plantar Fasciitis No more than 3 in one spot is the unwritten rule Did not show overall worse outcomes with SA injections

Fenestration Also known as partial tenotomy, dry needling Theory: convert chronic into acute PRP and Autologous blood often include this Consider avoiding ASA and NSAIDs prior to and after procedure Small studies have shown that this may improve pain and function for patients for various tendons, best studies have been with elbow, no good studies for the cuff Billable and covered by insurance https://doi.org/10.7863/jum.2009.28.9.1187 Cuff no good studies – perhaps because these people tend to do well with surgery

Tenex device

Autologous Blood Platelets in blood would release growth factors Early studies showed improvement in both pain and function but some recent studies comparing to steroid or saline have shown little difference As effective as PRP at 6 mo in tennis elbow in 1 study 2011 Single blind randominized control trial

PRP Platelets release growth factors that aid in wound healing Similar to autologous blood but more concentrated so perhaps better clinical response Better than steroid but perhaps no better than saline Great variance in type of PRP produced (leukocyte rich vs poor, concentration) and number of injections Suggestions that leukocyte rich, high cell PRP with little anesthetic may be good for tendons Metaanalysis of RCTs in PRP for various tendinopathies published in American Journal of Sports Medicine in 2016 Not covered by insurance (range anywhere 500 – 2000 a shot)

My proposed management algorithm Pain less than 2-3 months? Consider referral to sports med Yes No Modify activity Consider brace Start PT Steroid injection for painful cuff or troch bursa 3-6 mo > 6 mo and has failed PT Modify activity PT Steroid injection for painful cuff or troch bursa Nitroglycerin for elbows, Achilles, patella Consider fenestration vs Autologous Blood vs PRP for glutes, Achilles, elbow, PF, and patella and restart PT after a period of rest For cuffs, consider PRP vs surgery * Recommend confirmation of tendinopathy with MRI in all but elbow and PF

ESWT Extracorporeal shock wave therapy may be useful in insertional and calcific tendinopathy but should only be considered if more traditional treatment as failed

Stem cells May be promising in animal studies

We need better studies! IMPROVE Study underway looking at PRP vs autologous blood vs fenestration vs PT Alone on Pain and Quality of Life in Tennis Elbow

Thank you! Kenzie.Johnston@duke.edu

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