Tendonopathy NYSAFP Winter Weekend January 28, 2012 Todd S. Shatynski, MD, CAQSM tshatynski@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

Histopathology Khan, 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.