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

2. 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

3. 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

4. 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

5. “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

6. 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

7. 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

8. 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

9. 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

10. 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.

11. Classification Tendonopathy = chronic tendon pain Tendonitis
Tendonosis
Paratenonitis
Insertional tendonitis

12. 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

13. 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

14. 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

15. 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

16. Histopathology Peratenonitis with tendinosis
Intratendinous degeneration
Paratenonitis with mucoid degeneration and scattered inflammatory cells in paratenon

17. 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

18. Microscopy

19. 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

20. Exercise Response
Tendonopathy improves with exercise but worsens after
Allows exercise to continue
Inhibits healing response

21. “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

22. 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,

23. 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

24. 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

25. 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

26. 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

27. 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.

28. 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

29. 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

30. 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

31. 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

32. PRP for Achilles? DeVos, et al. JAMA 2010. DBRCT 54 patients
Eccentric exercise with PRP or Saline injection
No statistical difference in outcomes

33. 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!

34. 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.

35. 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?

36. 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.