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Inflammatory and Metabolic Alterations of Kager's Fat Pad in Chronic Achilles Tendinopathy. PLoS One 2015; 10:e0127811. [PMID: 25996876 PMCID: PMC4440827 DOI: 10.1371/journal.pone.0127811] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 04/18/2015] [Indexed: 12/14/2022] Open
Abstract
Background Achilles tendinopathy is a painful inflammatory condition characterized by swelling, stiffness and reduced function of the Achilles tendon. Kager’s fat pad is an adipose tissue located in the area anterior to the Achilles tendon. Observations reveal a close physical interplay between Kager’s fat pad and its surrounding structures during movement of the ankle, suggesting that Kager’s fat pad may stabilize and protect the mechanical function of the ankle joint. Aim The aim of this study was to characterize whether Achilles tendinopathy was accompanied by changes in expression of inflammatory markers and metabolic enzymes in Kager’s fat pad. Methods A biopsy was taken from Kager’s fat pad from 31 patients with chronic Achilles tendinopathy and from 13 healthy individuals. Gene expression was measured by reverse transcription-quantitative PCR. Focus was on genes related to inflammation and lipid metabolism. Results Expression of the majority of analyzed inflammatory marker genes was increased in patients with Achilles tendinopathy compared to that in healthy controls. Expression patterns of the patient group were consistent with reduced lipolysis and increased fatty acid β-oxidation. In the fat pad, the pain-signaling neuropeptide substance P was found to be present in one third of the subjects in the Achilles tendinopathy group but in none of the healthy controls. Conclusion Gene expression changes in Achilles tendinopathy patient samples were consistent with Kager’s fat pad being more inflamed than in the healthy control group. Additionally, the results indicate an altered lipid metabolism in Kager’s fat pad of Achilles tendinopathy patients.
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Notarnicola A, Maccagnano G, Tafuri S, Fiore A, Margiotta C, Pesce V, Moretti B. Prognostic factors of extracorporeal shock wave therapy for tendinopathies. Musculoskelet Surg 2015; 100:53-61. [PMID: 25982090 DOI: 10.1007/s12306-015-0375-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 05/06/2015] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Extracorporeal shock wave therapy is very widely used for the management of tendinopathies and plantar fasciitis. AIM The aim of the study is to determine whether there are prognostic factors that may influence the outcome of extracorporeal shock wave therapy for these diseases. METHODS Three hundred fifty-five patients were analyzed 2 months after shock wave treatment for rotator cuff tendinitis, epicondylitis, Achilles tendinopathy, trocanteritis, jumper's knee or plantar fasciitis. We recorded the epidemiological, clinical and treatment protocol, and these data were correlated with treatment outcome. RESULTS Clinical improvement was achieved in 45.9 % of these patients. We discovered that laterality different to the dominant limb (p < 0.0001) and repeated shock wave treatments (p = 0.004) are prognostic factors in an unsuccessful therapy, while being male (p = 0.015) and a high body mass index (p = 0.004) are factors for success. We found no differences in relation to age, diet, blood type, work or sport activity, presence of co-morbidities, drugs, type of tendinopathy, density of energy delivered and other physiotherapy treatment. Knowledge of these prognostic factors may lead to improved insight for physicians and physiotherapists to predict the extent of the recovery and adjust rehabilitation and patient expectations accordingly.
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Affiliation(s)
- A Notarnicola
- Course of Motor and Sports Sciences, Department of Medical Sciences of Basis, Neurosciences and Organs of Sense, Faculty of Medicine and Surgery, University of Study of Bari, Lungomare Starita 1, 70123, Bari, Italy. .,Orthopedics Section, Department of Medical Sciences of Basis, Neurosciences and Organs of Sense, Faculty of Medicine and Surgery, University of Study of Bari, General Hospital, Piazza Giulio Cesare 11, 70124, Bari, Italy.
| | - G Maccagnano
- Orthopedics Section, Department of Medical Sciences of Basis, Neurosciences and Organs of Sense, Faculty of Medicine and Surgery, University of Study of Bari, General Hospital, Piazza Giulio Cesare 11, 70124, Bari, Italy
| | - S Tafuri
- Department of Biomedical Sciences and Human Oncology, Faculty of Medicine and Surgery, University of Study of Bari, General Hospital, Piazza Giulio Cesare 11, 70124, Bari, Italy
| | - A Fiore
- Orthopedics Section, Department of Medical Sciences of Basis, Neurosciences and Organs of Sense, Faculty of Medicine and Surgery, University of Study of Bari, General Hospital, Piazza Giulio Cesare 11, 70124, Bari, Italy
| | - C Margiotta
- Orthopedics Section, Department of Medical Sciences of Basis, Neurosciences and Organs of Sense, Faculty of Medicine and Surgery, University of Study of Bari, General Hospital, Piazza Giulio Cesare 11, 70124, Bari, Italy
| | - V Pesce
- Orthopedics Section, Department of Medical Sciences of Basis, Neurosciences and Organs of Sense, Faculty of Medicine and Surgery, University of Study of Bari, General Hospital, Piazza Giulio Cesare 11, 70124, Bari, Italy
| | - B Moretti
- Course of Motor and Sports Sciences, Department of Medical Sciences of Basis, Neurosciences and Organs of Sense, Faculty of Medicine and Surgery, University of Study of Bari, Lungomare Starita 1, 70123, Bari, Italy.,Orthopedics Section, Department of Medical Sciences of Basis, Neurosciences and Organs of Sense, Faculty of Medicine and Surgery, University of Study of Bari, General Hospital, Piazza Giulio Cesare 11, 70124, Bari, Italy
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Sejersen MHJ, Frost P, Hansen TB, Deutch SR, Svendsen SW. Proteomics perspectives in rotator cuff research: a systematic review of gene expression and protein composition in human tendinopathy. PLoS One 2015; 10:e0119974. [PMID: 25879758 PMCID: PMC4400011 DOI: 10.1371/journal.pone.0119974] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 02/03/2015] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Rotator cuff tendinopathy including tears is a cause of significant morbidity. The molecular pathogenesis of the disorder is largely unknown. This review aimed to present an overview of the literature on gene expression and protein composition in human rotator cuff tendinopathy and other tendinopathies, and to evaluate perspectives of proteomics--the comprehensive study of protein composition--in tendon research. MATERIALS AND METHODS We conducted a systematic search of the literature published between 1 January 1990 and 18 December 2012 in PubMed, Embase, and Web of Science. We included studies on objectively quantified differential gene expression and/or protein composition in human rotator cuff tendinopathy and other tendinopathies as compared to control tissue. RESULTS We identified 2199 studies, of which 54 were included; 25 studies focussed on rotator cuff or biceps tendinopathy. Most of the included studies quantified prespecified mRNA molecules and proteins using polymerase chain reactions and immunoassays, respectively. There was a tendency towards an increase of collagen I (11 of 15 studies) and III (13 of 14), metalloproteinase (MMP)-1 (6 of 12), -9 (7 of 7), -13 (4 of 7), tissue inhibitor of metalloproteinase (TIMP)-1 (4 of 7), and vascular endothelial growth factor (4 of 7), and a decrease in MMP-3 (10 of 12). Fourteen proteomics studies of tendon tissues/cells failed inclusion, mostly because they were conducted in animals or in vitro. CONCLUSIONS Based on methods, which only allowed simultaneous quantification of a limited number of prespecified mRNA molecules or proteins, several proteins appeared to be differentially expressed/represented in rotator cuff tendinopathy and other tendinopathies. No proteomics studies fulfilled our inclusion criteria, although proteomics technologies may be a way to identify protein profiles (including non-prespecified proteins) that characterise specific tendon disorders or stages of tendinopathy. Thus, our results suggested an untapped potential for proteomics in tendon research.
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Affiliation(s)
- Maria Hee Jung Sejersen
- Danish Ramazzini Centre, Department of Occupational Medicine, Regional Hospital West Jutland—University Research Clinic, Herning, Denmark
| | - Poul Frost
- Danish Ramazzini Centre, Department of Occupational Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Torben Bæk Hansen
- Research Unit for Orthopaedics, Holstebro Regional Hospital, Holstebro, Denmark
- Institute of Clinical Medicine, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark
| | | | - Susanne Wulff Svendsen
- Danish Ramazzini Centre, Department of Occupational Medicine, Regional Hospital West Jutland—University Research Clinic, Herning, Denmark
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Pelletier R, Higgins J, Bourbonnais D. Is neuroplasticity in the central nervous system the missing link to our understanding of chronic musculoskeletal disorders? BMC Musculoskelet Disord 2015; 16:25. [PMID: 25887644 PMCID: PMC4331171 DOI: 10.1186/s12891-015-0480-y] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 01/27/2015] [Indexed: 12/22/2022] Open
Abstract
Background Musculoskeletal rehabilitative care and research have traditionally been guided by a structural pathology paradigm and directed their resources towards the structural, functional, and biological abnormalities located locally within the musculoskeletal system to understand and treat Musculoskeletal Disorders (MSD). However the structural pathology model does not adequately explain many of the clinical and experimental findings in subjects with chronic MSD and, more importantly, treatment guided by this paradigm fails to effectively treat many of these conditions. Discussion Increasing evidence reveals structural and functional changes within the Central Nervous System (CNS) of people with chronic MSD that appear to play a prominent role in the pathophysiology of these disorders. These neuroplastic changes are reflective of adaptive neurophysiological processes occurring as the result of altered afferent stimuli including nociceptive and neuropathic transmission to spinal, subcortical and cortical areas with MSD that are initially beneficial but may persist in a chronic state, may be part and parcel in the pathophysiology of the condition and the development and maintenance of chronic signs and symptoms. Neuroplastic changes within different areas of the CNS may help to explain the transition from acute to chronic conditions, sensory-motor findings, perceptual disturbances, why some individuals continue to experience pain when no structural cause can be discerned, and why some fail to respond to conservative interventions in subjects with chronic MSD. We argue that a change in paradigm is necessary that integrates CNS changes associated with chronic MSD and that these findings are highly relevant for the design and implementation of rehabilitative interventions for this population. Summary Recent findings suggest that a change in model and approach is required in the rehabilitation of chronic MSD that integrate the findings of neuroplastic changes across the CNS and are targeted by rehabilitative interventions. Effects of current interventions may be mediated through peripheral and central changes but may not specifically address all underlying neuroplastic changes in the CNS potentially associated with chronic MSD. Novel approaches to address these neuroplastic changes show promise and require further investigation to improve efficacy of currents approaches.
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Affiliation(s)
- René Pelletier
- École de réadaptation, Faculté de médecine, Université de Montréal, C.P. 6128, succursale Centre-ville, Montréal, H3C 3 J7, Québec, Canada.
| | - Johanne Higgins
- École de réadaptation, Faculté de médecine, Université de Montréal, C.P. 6128, succursale Centre-ville, Montréal, H3C 3 J7, Québec, Canada. .,Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Institut de réadaptation Gingras-Lindsay-de-Montréal, Montréal, Québec, Canada.
| | - Daniel Bourbonnais
- École de réadaptation, Faculté de médecine, Université de Montréal, C.P. 6128, succursale Centre-ville, Montréal, H3C 3 J7, Québec, Canada. .,Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Institut de réadaptation Gingras-Lindsay-de-Montréal, Montréal, Québec, Canada.
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Seo JB, Yoo JS, Ryu JW. Sonoelastography findings of supraspinatus tendon in rotator cuff tendinopathy without tear: comparison with magnetic resonance images and conventional ultrasonography. J Ultrasound 2014; 18:143-9. [PMID: 26191102 DOI: 10.1007/s40477-014-0148-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 11/14/2014] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND AND PURPOSE Sonoelastography (SE) is a new technique that can assess differences in tissue stiffness. This study investigated the performance of SE for the differentiation of supraspinatus (SSP) tendon alterations of tendinopathy compared to magnetic resonance imaging (MRI) and conventional ultrasonography (US). METHODS One hundred and eighteen consecutively registered patients with symptoms and MRI findings of SSP tendinopathy were assessed with US and SE. Coronal images of the SSP tendon were obtained using US and SE. Increased signal intensity on T2-weighted images in the coronal planes were graded according to the extent of the signal changes from ventral to dorsal. SE images were evaluated by reviewers using an experimentally proven color grading system. RESULTS Using SE, 7.6 % of the SSP tendons were categorized as grade 0, 30.5 % as grade 1, 19.5 % as grade 2, and 42.4 % as grade 3. Evaluation of the interobserver reliability of the SE findings showed "almost perfect agreement", with a weighted kappa coefficient of 0.83. By comparing the MRI findings with the SE findings, grades of MRI and SE had a positive correlation (r = 0.829, p = <0.001). Furthermore, grades of US and SE also had a positive correlation (r = 0.723, p = <0.001). CONCLUSIONS SE is valuable in the detection of the intratendinous and peritendinous alterations of the SSP tendon and has excellent interobserver reliability and excellent correlation with MRI findings and conventional ultrasonography findings.
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Affiliation(s)
- Joong-Bae Seo
- Department of Orthopaedic Surgery, Dankook University College of Medicine, 119, Dandae-ro Dongnam-gu, Cheonan-Si, Chungnam 330-715 Republic of Korea
| | - Jae-Sung Yoo
- Department of Orthopaedic Surgery, Dankook University College of Medicine, 119, Dandae-ro Dongnam-gu, Cheonan-Si, Chungnam 330-715 Republic of Korea
| | - Jee-Won Ryu
- Department of Orthopaedic Surgery, Dankook University College of Medicine, 119, Dandae-ro Dongnam-gu, Cheonan-Si, Chungnam 330-715 Republic of Korea
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Valera-Garrido F, Minaya-Muñoz F, Medina-Mirapeix F. Ultrasound-guided percutaneous needle electrolysis in chronic lateral epicondylitis: short-term and long-term results. Acupunct Med 2014; 32:446-54. [PMID: 25122629 PMCID: PMC4283658 DOI: 10.1136/acupmed-2014-010619] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 07/21/2014] [Accepted: 07/24/2014] [Indexed: 01/27/2023]
Abstract
BACKGROUND Ultrasound (US)-guided percutaneous needle electrolysis (PNE) is a novel minimally invasive approach which consists of the application of a galvanic current through an acupuncture needle. OBJECTIVE To evaluate the clinical and ultrasonographic effectiveness of a multimodal programme (PNE, eccentric exercise (EccEx) and stretching) in the short term for patients with chronic lateral epicondylitis, and to determine whether the clinical outcomes achieved decline over time. METHODS A one-way repeated measures study was performed in a clinical setting in 36 patients presenting with lateral epicondylitis. The patients received one session of US-guided PNE per week over 4-6 weeks, associated with a home programme of EccEx and stretching. The main outcome measures were severity of pain, disability (Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire), structural tendon changes (US), hypervascularity and patients' perceptions of overall outcome. Measurements at 6, 26 and 52 weeks follow-up included recurrence rates (increase in severity of pain or disability compared with discharge), perception of overall outcome and success rates. RESULTS All outcome measures registered significant improvements between pre-intervention and discharge. Most patients (n=30, 83.3%) rated the overall outcome as 'successful' at 6 weeks. The ultrasonographic findings showed that the hypoechoic regions and hypervascularity of the extensor carpi radialis brevis changed significantly. At 26 and 52 weeks, all participants (n=32) perceived a 'successful' outcome. Recurrence rates were null after discharge and at follow-up at 6, 26 and 52 weeks. CONCLUSIONS Symptoms and degenerative structural changes of chronic lateral epicondylitis are reduced after US-guided PNE associated with EccEx and stretching, with encouragingly low recurrences in the mid to long term. TRIAL REGISTRATION NUMBER ClinicalTrials.gov identifier: NCT02085928.
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Affiliation(s)
- Fermín Valera-Garrido
- MVClinic, Madrid, Spain
- Fremap Hospital, Majadahonda, Madrid, Spain
- Faculty of Medicine, San Pablo CEU University, Madrid, Spain
| | - Francisco Minaya-Muñoz
- MVClinic, Madrid, Spain
- Fremap Hospital, Majadahonda, Madrid, Spain
- Faculty of Medicine, San Pablo CEU University, Madrid, Spain
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108
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Camargo PR, Alburquerque-Sendín F, Salvini TF. Eccentric training as a new approach for rotator cuff tendinopathy: Review and perspectives. World J Orthop 2014; 5:634-644. [PMID: 25405092 PMCID: PMC4133471 DOI: 10.5312/wjo.v5.i5.634] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 04/29/2014] [Accepted: 07/17/2014] [Indexed: 02/06/2023] Open
Abstract
Excessive mechanical loading is considered the major cause of rotator cuff tendinopathy. Although tendon problems are very common, they are not always easy to treat. Eccentric training has been proposed as an effective conservative treatment for the Achilles and patellar tendinopathies, but less evidence exists about its effectiveness for the rotator cuff tendinopathy. The mechanotransduction process associated with an adequate dose of mechanical load might explain the beneficial results of applying the eccentric training to the tendons. An adequate load increases healing and an inadequate (over or underuse) load can deteriorate the tendon structure. Different eccentric training protocols have been used in the few studies conducted for people with rotator cuff tendinopathy. Further, the effects of the eccentric training for rotator cuff tendinopathy were only evaluated on pain, function and strength. Future studies should assess the effects of the eccentric training also on shoulder kinematics and muscle activity. Individualization of the exercise prescription, comprehension and motivation of the patients, and the establishment of specific goals, practice and efforts should all be considered when prescribing the eccentric training. In conclusion, eccentric training should be used aiming improvement of the tendon degeneration, but more evidence is necessary to establish the adequate dose-response and to determine long-term follow-up effects.
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109
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Heales LJ, Broadhurst N, Mellor R, Hodges PW, Vicenzino B. Diagnostic Ultrasound Imaging for Lateral Epicondylalgia. Med Sci Sports Exerc 2014; 46:2070-6. [DOI: 10.1249/mss.0000000000000345] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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110
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Zhang ZJ, Ng GYF, Lee WC, Fu SN. Changes in morphological and elastic properties of patellar tendon in athletes with unilateral patellar tendinopathy and their relationships with pain and functional disability. PLoS One 2014; 9:e108337. [PMID: 25303466 PMCID: PMC4193737 DOI: 10.1371/journal.pone.0108337] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 08/05/2014] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Patellar tendinopathy (PT) is one of the most common knee disorders among athletes. Changes in morphology and elasticity of the painful tendon and how these relate to the self-perceived pain and dysfunction remain unclear. OBJECTIVES To compare the morphology and elastic properties of patellar tendons between athlete with and without unilateral PT and to examine its association with self-perceived pain and dysfunction. METHODS In this cross-sectional study, 33 male athletes (20 healthy and 13 with unilateral PT) were enrolled. The morphology and elastic properties of the patellar tendon were assessed by the grey and elastography mode of supersonic shear imaging (SSI) technique while the intensity of pressure pain, self-perceived pain and dysfunction were quantified with a 10-lb force to the most painful site and the Victorian Institute of Sport Assessment-patella (VISA-P) questionnaire, respectively. RESULTS In athletes with unilateral PT, the painful tendons had higher shear elastic modulus (SEM) and larger tendon than the non-painful side (p<0.05) or the dominant side of the healthy athletes (p<0.05). Significant correlations were found between tendon SEM ratio (SEM of painful over non-painful tendon) and the intensity of pressure pain (rho = 0.62; p = 0.024), VISA-P scores (rho = -0.61; p = 0.026), and the sub-scores of the VISA-P scores on going down stairs, lunge, single leg hopping and squatting (rho ranged from -0.63 to -0.67; p<0.05). CONCLUSIONS Athletes with unilateral PT had stiffer and larger tendon on the painful side than the non-painful side and the dominant side of healthy athletes. No significant differences on the patellar tendon morphology and elastic properties were detected between the dominant and non-dominant knees of the healthy control. The ratio of the SEM of painful to non-painful sides was associated with pain and dysfunction among athletes with unilateral PT.
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Affiliation(s)
- Zhi Jie Zhang
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong
- Guangdong-Hongkong Joint Sports Rehabilitation and Research Center, Guangdong Provincial Work Injury Rehabilitation Hospital, Guangzhou, China
| | - Gabriel Yin-fat Ng
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong
| | - Wai Chun Lee
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong
| | - Siu Ngor Fu
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong
- * E-mail:
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Kragsnaes MS, Fredberg U, Stribolt K, Kjaer SG, Bendix K, Ellingsen T. Stereological quantification of immune-competent cells in baseline biopsy specimens from achilles tendons: results from patients with chronic tendinopathy followed for more than 4 years. Am J Sports Med 2014; 42:2435-45. [PMID: 25081311 DOI: 10.1177/0363546514542329] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Limited data exist on the presence and function of immune-competent cells in chronic tendinopathic tendons and their potential role in inflammation and tissue healing as well as in predicting long-term outcome. PURPOSE To quantify subtypes of immune-competent cells in biopsy specimens from nonruptured chronic tendinopathic Achilles tendons and healthy control tendons. In addition, to examine whether findings in baseline cell biopsy specimens can predict the long-term presence of Achilles tendon symptoms. STUDY DESIGN Cross-sectional and case-control study; Level of evidence, 3. METHODS Fifty patients with nonruptured chronic Achilles tendinopathy and 15 healthy participants were included. At time of inclusion, an ultrasound examination was performed immediately before an ultrasound-guided Achilles tendon biopsy specimen was obtained. Tissue samples were evaluated immunohistochemically by quantifying the presence of macrophages (CD68-PGM1(+), CD68-KP1(+)), hemosiderophages (Perls blue), T lymphocytes (CD2(+), CD3(+), CD4(+), CD7(+), CD8(+)), B lymphocytes (CD20(+)), natural killer cells (CD56(+)), mast cells (NaSDCl(+)), Schwann cells (S100(+)), and endothelial cells (CD34(+)) using a stereological technique. A follow-up examination was conducted more than 4 years (range, 4-9 years) after the biopsy procedure to evaluate the long-term presence of Achilles tendon symptoms. RESULTS Macrophages, T lymphocytes, mast cells, and natural killer cells were observed in the majority (range, 52%-96%) of biopsy specimens from nonruptured chronic tendinopathic Achilles tendons. CD68-KP1(+) macrophages (0.29% vs 0; P = .005) and CD34(+) endothelial cells (3% vs 0.97%; P = .04) were significantly more numerous in tendinopathic tendons compared with healthy tendons. The presence of iron(+) hemosiderophages was more frequently observed in biopsy specimens obtained from the group who was asymptomatic at follow-up compared with the symptomatic group (42% vs 5%; P = .02). CONCLUSION This study provides evidence for the presence of immune-competent cells in the majority of biopsy specimens from nonruptured chronic tendinopathic Achilles tendons. Macrophages and endothelial cells were significantly more numerous in tendinopathic tendons than in healthy tendons. The presence of iron(+) hemosiderophages in baseline biopsy specimens was associated with a good prognosis. CLINICAL RELEVANCE New insight into the role of immune-competent cells in chronic Achilles tendinopathy.
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Affiliation(s)
| | - Ulrich Fredberg
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Katrine Stribolt
- Institute of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Knud Bendix
- Institute of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | - Torkell Ellingsen
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark Department of Rheumatology, Odense University Hospital, Odense, Denmark
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Affiliation(s)
- Nicola Maffulli
- Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London E1 4DG, United Kingdom
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Rathleff MS, Mølgaard CM, Fredberg U, Kaalund S, Andersen KB, Jensen TT, Aaskov S, Olesen JL. High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up. Scand J Med Sci Sports 2014; 25:e292-300. [DOI: 10.1111/sms.12313] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2014] [Indexed: 11/30/2022]
Affiliation(s)
- M. S. Rathleff
- Orthopaedic Surgery Research Unit; Aalborg University Hospital; Aalborg Denmark
| | - C. M. Mølgaard
- Department of Occupational and Physiotherapy; Aalborg University Hospital; Aalborg Denmark
| | - U. Fredberg
- Diagnostic Centre; Silkeborg Regional Hospital; Silkeborg Denmark
| | - S. Kaalund
- Elective Surgery Center; Silkeborg Regional Hospital; Silkeborg Denmark
| | - K. B. Andersen
- Diagnostic Centre; Silkeborg Regional Hospital; Silkeborg Denmark
| | - T. T. Jensen
- Elective Surgery Center; Silkeborg Regional Hospital; Silkeborg Denmark
| | - S. Aaskov
- Kaalunds Klinik (Private/Public Orthopaedic Clinic); Aalborg Denmark
| | - J. L. Olesen
- Department of Rheumatology; Aalborg University Hospital; Aalborg Denmark
- Institute of Sports Medicine Copenhagen; Copenhagen University Hospital; Copenhagen Denmark
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de Jesus JF, Spadacci-Morena DD, dos Anjos Rabelo ND, Pinfildi CE, Fukuda TY, Plapler H. Low-level laser therapy in IL-1β, COX-2, and PGE2 modulation in partially injured Achilles tendon. Lasers Med Sci 2014; 30:153-8. [PMID: 25070591 DOI: 10.1007/s10103-014-1636-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 07/16/2014] [Indexed: 12/15/2022]
Abstract
This study evaluated IL-1β, COX-2, and PGE2 modulation in partially injured Achilles tendons treated with low-level laser therapy (LLLT). Sixty-five male Wistar rats were used. Sixty were submitted to a direct injury on Achilles tendon and then distributed into six groups: LASER 1 (a single LLLT application), LASER 3 (three LLLT applications), and LASER 7 (seven LLLT applications) and Sham 1, 3, and 7 (the same injury but LLLT applications were simulated). The five remaining animals were allocated at control group (no procedure performed). LLLT (780 nm) was applied with 70 mW of mean power and 17.5 J/cm(2) of fluency for 10 s, once a day. The tendons were surgically removed and assessed immunohistochemically for IL-1β, COX-2, and PGE2. In comparisons with control (IL-1β: 100.5 ± 92.5 / COX-2: 180.1 ± 97.1 / PGE2: 187.8 ± 128.8) IL-1β exhibited (mean ± SD) near-normal level (p > 0.05) at LASER 3 (142.0 ± 162.4). COX-2 and PGE2 exhibited near-normal levels (p > 0.05) at LASER 3 (COX-2: 176.9 ± 75.4 / PGE2: 297.2 ± 259.6) and LASER 7 (COX-2: 259.2 ± 190.4 / PGE2: 587.1 ± 409.7). LLLT decreased Achilles tendon's inflammatory process.
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Affiliation(s)
- Julio Fernandes de Jesus
- Interdisciplinary Surgical Science Program, Universidade Federal de São Paulo-UNIFESP, São Paulo, SP, 04021-001, Brazil,
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Baroneza JE, Godoy-Santos A, Ferreira Massa B, Boçon de Araujo Munhoz F, Diniz Fernandes T, Leme Godoy dos Santos MC. MMP-1 promoter genotype and haplotype association with posterior tibial tendinopathy. Gene 2014; 547:334-7. [PMID: 24995609 DOI: 10.1016/j.gene.2014.07.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 06/16/2014] [Accepted: 07/01/2014] [Indexed: 01/22/2023]
Abstract
PURPOSE Posterior tibial tendon (PTT) is particularly vulnerable and its insufficiency is recognized as the main cause of adult acquired flatfoot. Some patients have a predisposition without clinically recognized cause, suggesting that individual characteristics play an important role in tendinopathy. The objective of the present study is to investigate the association of -519 (rs1144393) matrix metalloproteinase-1 (MMP-1) polymorphism and the -1607 (rs1799750) and -519 MMP-1 haplotypes and risk of PTT dysfunction. METHODS The test group included 50 females who presented PTT dysfunction Grade 2 or 3, and who were submitted to surgical treatment, with histopathological examination of the tendon and magnetic resonance image (MRI) confirming tendinopathy, while the control group was 100 asymptomatic women who present intact PTT at MRI. We analyzed functional polymorphisms MMP-1 and their haplotypes using polymerase chain reaction and restriction fragment length analysis. RESULTS There was a significant difference in the presence of the different alleles and genotypes between the control group and test group for the MMP-1 gene (p≤0.01). The G allele of the -519 MMP-1 polymorphism increased susceptibility to degeneration in the PTT tendon and seems to be a genetic risk factor. Global haplotype analysis indicated a significant difference between both groups (p<0.0001). Haplotypes G-2G and A-2G had statistically significant risk effect on PTT insufficiency. G-2G, p<0.001; OR=5.72 (CI, 2.84-11.52) and A-2G p=0.002, OR=3.95 (CI, 1.65-9.44). CONCLUSION According to our results, -519 MMP-1 isolated and -1607/-519 MMP-1 haplotypes are associated to tendinopathy in posterior tibial tendon.
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Affiliation(s)
| | - Alexandre Godoy-Santos
- Department of Orthopedics and Traumatology, University of São Paulo, São Paulo, SP, Brazil
| | - Bruno Ferreira Massa
- Department of Orthopedics and Traumatology, University of São Paulo, São Paulo, SP, Brazil
| | | | - Túlio Diniz Fernandes
- Department of Orthopedics and Traumatology, University of São Paulo, São Paulo, SP, Brazil
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Kjaer M, Heinemeier KM. Eccentric exercise: acute and chronic effects on healthy and diseased tendons. J Appl Physiol (1985) 2014; 116:1435-8. [DOI: 10.1152/japplphysiol.01044.2013] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Eccentric exercise can influence tendon mechanical properties and matrix protein synthesis. mRNA for collagen and regulatory factors thereof are upregulated in animal tendons, independent of muscular contraction type, supporting the view that tendon, compared with skeletal muscle, is less sensitive to differences in type and/or amount of mechanical stimulus with regard to expression of collagen, regulatory factors for collagen, and cross-link regulators. In overused (tendinopathic) human tendon, eccentric exercise training has a beneficial effect, but the mechanism by which this is elicited is unknown, and slow concentric loading appears to have similar beneficial effects. It may be that tendinopathic regions, as long as they are subjected to a certain magnitude of load at a slow speed, independent of whether this is eccentric or concentric in nature, can reestablish their normal tendon fibril alignment and cell morphology.
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Affiliation(s)
- Michael Kjaer
- Institute of Sports Medicine, Department of Orthopedic Surgery M, Bispebjerg Hospital, and Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Katja M. Heinemeier
- Institute of Sports Medicine, Department of Orthopedic Surgery M, Bispebjerg Hospital, and Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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117
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Andia I, Latorre PM, Gomez MC, Burgos-Alonso N, Abate M, Maffulli N. Platelet-rich plasma in the conservative treatment of painful tendinopathy: a systematic review and meta-analysis of controlled studies. Br Med Bull 2014; 110:99-115. [PMID: 24795364 DOI: 10.1093/bmb/ldu007] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Platelet-rich plasma (PRP) seeks to meet the multifaceted demand of degenerated tendons providing several molecules capable of boosting healing. AREAS TIMELY FOR DEVELOPING RESEARCH PRP is used for managing tendinopathy, but its efficacy is controversial. SOURCES OF DATA Electronic databases were searched for clinical studies assessing PRP efficacy. Methodological quality was evaluated using the methods described in the Cochrane Handbook for systematic reviews. AREAS OF AGREEMENT Thirteen prospective controlled studies, comprising 886 patients and diverse tendons were included; 53.8% of studies used identical PRP protocol. AREAS OF CONTROVERSY Sources of heterogeneity included different comparators, outcome scores, follow-up periods and diverse injection protocols, but not PRP formulation per se. GROWING POINTS Pooling pain outcomes over time and across different tendons showed that L-PRP injections ameliorated pain in the intermediate-long term compared with control interventions, weighted mean difference (95% CI): 3 months, -0.61 (-0.97, -0.25); 1 year, -1.56 (-2.27, -0.83). However, these findings cannot be applied to the management of individual patients given low power and precision. RESEARCH Further studies circumventing heterogeneity are needed to reach firm conclusions. Available evidence can help to overcome hurdles to future clinical research and bring forward PRP therapies.
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Affiliation(s)
- I Andia
- Regenerative Medicine Laboratory, BioCruces Health Research Institute, Cruces University Hospital, 48903 Barakaldo, Spain
| | - P M Latorre
- Primary Care Research Unit of Bizkaia, BioCruces Health Research Institute, Bilbao, Spain
| | - M C Gomez
- Primary Care Research Unit of Bizkaia, BioCruces Health Research Institute, Bilbao, Spain
| | - N Burgos-Alonso
- Primary Care Research Unit of Bizkaia, BioCruces Health Research Institute, Bilbao, Spain
| | - M Abate
- Department of Medicine and Science of Aging, University G. d'Annunzio, Chieti-Pescara, Chieti Scalo, Italy
| | - N Maffulli
- Center for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Mile End Hospital, 275 Bancroft Road, London E1 4DG, UK
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de Girolamo L, Stanco D, Galliera E, Viganò M, Lovati AB, Marazzi MG, Romeo P, Sansone V. Soft-focused extracorporeal shock waves increase the expression of tendon-specific markers and the release of anti-inflammatory cytokines in an adherent culture model of primary human tendon cells. ULTRASOUND IN MEDICINE & BIOLOGY 2014; 40:1204-1215. [PMID: 24631378 DOI: 10.1016/j.ultrasmedbio.2013.12.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 09/26/2013] [Accepted: 12/05/2013] [Indexed: 06/03/2023]
Abstract
Focused extracorporeal shock waves have been found to upregulate the expression of collagen and to initiate cell proliferation in healthy tenocytes and to positively affect the metabolism of tendons, promoting the healing process. Recently, soft-focused extracorporeal shock waves have also been found to have a significant effect on tissue regeneration. However, very few in vitro reports have dealt with the application of this type of shock wave to cells, and in particular, no previous studies have investigated the response of tendon cells to this impulse. We devised an original model to investigate the in vitro effects of soft-focused shock waves on a heterogeneous population of human resident tendon cells in adherent monolayer culture. Our results indicate that soft-focused extracorporeal shock wave treatment (0.17 mJ/mm(2)) is able to induce positive modulation of cell viability, proliferation and tendon-specific marker expression, as well as release of anti-inflammatory cytokines. This could prefigure a new rationale for routine employment of soft-focused shock waves to treat the failed healing status that distinguishes tendinopathies.
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Affiliation(s)
- Laura de Girolamo
- Orthopaedic Biotechnology Laboratory, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.
| | - Deborah Stanco
- Orthopaedic Biotechnology Laboratory, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Emanuela Galliera
- Dipartimento di Scienze Biomediche, Chirurgiche ed Odontoiatriche, Università degli Studi di Milano, Milan, Italy; IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Marco Viganò
- Orthopaedic Biotechnology Laboratory, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Arianna Barbara Lovati
- Cell and Tissue Engineering Laboratory, Gruppo Ospedaliero San Donato Foundation, Milan, Italy
| | - Monica Gioia Marazzi
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy
| | - Pietro Romeo
- Orthopaedic Department, Istituto Ortopedico Galeazzi, Milan, Italy
| | - Valerio Sansone
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy; Orthopaedic Department, Istituto Ortopedico Galeazzi, Milan, Italy
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119
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Sonoelastography findings of biceps tendinitis and tendinosis. J Ultrasound 2014; 17:271-7. [PMID: 25368684 DOI: 10.1007/s40477-014-0075-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 02/06/2014] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE The purpose of this study was to evaluate sonoelastography (SE) in the assessment of the long head of biceps tendon (LHBT) in patients with symptoms of biceps tendinitis or tendinosis and in patients without biceps lesion. The findings were compared with those obtained at clinical examination, using ultrasonography (US). MATERIALS AND METHODS 36 shoulders of 34 consecutively registered patients with clinical symptoms and US findings of biceps tendinitis or tendinosis, and 114 shoulders of 98 patients without biceps lesions were assessed with SE. Transverse and longitudinal images of LHBT were obtained using SE. SE images were evaluated by reviewers using an experimentally proven color grading system. RESULTS The transverse images of SE showed a mean sensitivity of 69.4 %, a mean specificity of 95.6 % and a mean accuracy of 89.3 %. Good correlation of conventional ultrasound findings was found (p < 0.001, r = 0.763). The longitudinal images of SE showed a mean sensitivity of 94.4 %, a mean specificity of 92.1 % and a mean accuracy of 92.7 %. Good correlation of conventional ultrasound findings was found (p < 0.001, r = 0.585). Inter-observer reliability of SE was in "almost perfect agreement" with a weighted kappa coefficient of 0.84. CONCLUSIONS SE has potential to be clinically useful in the detection of the intratendinous and peritendinous alterations of LHBT and has excellent accuracy and excellent correlation with conventional ultrasound findings.
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120
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Grigg NL, Wearing SC, O'Toole JM, Smeathers JE. Achilles tendinopathy modulates force frequency characteristics of eccentric exercise. Med Sci Sports Exerc 2013; 45:520-6. [PMID: 23073214 DOI: 10.1249/mss.0b013e31827795a7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Previous research has demonstrated that ground reaction force (GRF) recorded during eccentric ankle exercise is characterized by greater power in the 8- to 12-Hz bandwidth when compared with that recorded during concentric ankle exercise. Subsequently, it was suggested that vibrations in this bandwidth may underpin the beneficial effect of eccentric loading in tendon repair. However, this observation has been made only in individuals without Achilles tendinopathy. This research compared the force frequency characteristics of eccentric and concentric exercises in individuals with and without Achilles tendinopathy. METHODS Eleven male adults with unilateral midportion Achilles tendinopathy and nine control male adults without tendinopathy participated in the research. Kinematics and GRF were recorded while the participants performed a common eccentric rehabilitation exercise protocol and a concentric equivalent. Ankle joint kinematics and the frequency power spectrum of the resultant GRF were calculated. RESULTS Eccentric exercise was characterized by a significantly greater proportion of spectral power between 4.5 and 11.5 Hz when compared with concentric exercise. There were no significant differences between limbs in the force frequency characteristics of concentric exercise. Eccentric exercise, in contrast, was defined by a shift in the power spectrum of the symptomatic limb, resulting in a second spectral peak at 9 Hz, rather than 10 Hz in the control limb. CONCLUSIONS Compared with healthy tendon, Achilles tendinopathy was characterized by lower frequency vibrations during eccentric rehabilitation exercises. This finding may be associated with changes in neuromuscular activation and tendon stiffness that have been shown to occur with tendinopathy and provides a possible rationale for the previous observation of a different biochemical response to eccentric exercise in healthy and injured Achilles tendons.
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Affiliation(s)
- Nicole L Grigg
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Queensland, Australia.
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121
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Dean BJF, Lostis E, Oakley T, Rombach I, Morrey ME, Carr AJ. The risks and benefits of glucocorticoid treatment for tendinopathy: a systematic review of the effects of local glucocorticoid on tendon. Semin Arthritis Rheum 2013; 43:570-6. [PMID: 24074644 DOI: 10.1016/j.semarthrit.2013.08.006] [Citation(s) in RCA: 117] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 08/27/2013] [Accepted: 08/28/2013] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Our primary objective was to summarise the known effects of locally administered glucocorticoid on tendon tissue and tendon cells. METHODS We conducted a systematic review of the scientific literature using the PRISMA and Cochrane guidelines of the Medline database using specific search criteria. The search yielded 50 articles, which consisted of 13 human studies, 36 animal studies and one combined human/animal study. RESULTS Histologically, there was a loss of collagen organisation (6 studies) and an increase in collagen necrosis (3 studies). The proliferation (8 studies) and viability (9 studies) of fibroblasts was reduced. Collagen synthesis was decreased in 17 studies. An increased inflammatory cell infiltrate was shown in 4 studies. Increased cellular toxicity was demonstrated by 3 studies. The mechanical properties of tendon were investigated by 18 studies. Descriptively, 6 of these studies showed a decrease in mechanical properties, 3 showed an increase, while the remaining 9 showed no significant change. A meta-analysis of the mechanical data revealed a significant deterioration in mechanical properties, with an overall effect size of -0.67 (95% CI = 0.01 to -1.33) (data from 9 studies). CONCLUSIONS Overall it is clear that the local administration of glucocorticoid has significant negative effects on tendon cells in vitro, including reduced cell viability, cell proliferation and collagen synthesis. There is increased collagen disorganisation and necrosis as shown by in vivo studies. The mechanical properties of tendon are also significantly reduced. This review supports the emerging clinical evidence that shows significant long-term harms to tendon tissue and cells associated with glucocorticoid injections.
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Affiliation(s)
- Benjamin John Floyd Dean
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Botnar Research Centre, Institute of Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Windmill Rd, Oxford OX3 7LD, UK.
| | - Emilie Lostis
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Botnar Research Centre, Institute of Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Windmill Rd, Oxford OX3 7LD, UK
| | - Thomas Oakley
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Botnar Research Centre, Institute of Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Windmill Rd, Oxford OX3 7LD, UK
| | - Ines Rombach
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Botnar Research Centre, Institute of Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Windmill Rd, Oxford OX3 7LD, UK
| | - Mark E Morrey
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Botnar Research Centre, Institute of Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Windmill Rd, Oxford OX3 7LD, UK
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Botnar Research Centre, Institute of Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Windmill Rd, Oxford OX3 7LD, UK
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122
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McCreesh K, Lewis J. Continuum model of tendon pathology - where are we now? Int J Exp Pathol 2013; 94:242-7. [PMID: 23837792 DOI: 10.1111/iep.12029] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 04/16/2013] [Indexed: 12/01/2022] Open
Abstract
Chronic tendon pathology is a common and often disabling condition, the causes of which remain poorly understood. The continuum model of tendon pathology was proposed to provide a model for the staging of tendon pathology and to assist clinicians in managing this often complex condition (Br. J. Sports Med., 43, 2009, 409). The model presents clinical, histological and imaging evidence for the progression of tendon pathology as a three-stage continuum: reactive tendinopathy, tendon disrepair and degenerative tendinopathy. It also provides clinical information to assist in identifying the stage of pathology, in addition to proposed treatment approaches for each stage. The usefulness of such a model is determined by its ability to incorporate and inform new and emerging research. This review examines the degree to which recent research supports or refutes the continuum model and proposes future directions for clinical and research application of the model.
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Affiliation(s)
- Karen McCreesh
- Department of Clinical Therapies, University of Limerick, Limerick, Ireland
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123
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Shepherd JH, Screen HRC. Fatigue loading of tendon. Int J Exp Pathol 2013; 94:260-70. [PMID: 23837793 DOI: 10.1111/iep.12037] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 06/12/2013] [Indexed: 12/28/2022] Open
Abstract
Tendon injuries, often called tendinopathies, are debilitating and painful conditions, generally considered to develop as a result of tendon overuse. The aetiology of tendinopathy remains poorly understood, and whilst tendon biopsies have provided some information concerning tendon appearance in late-stage disease, there is still little information concerning the mechanical and cellular events associated with disease initiation and progression. Investigating this in situ is challenging, and numerous models have been developed to investigate how overuse may generate tendon fatigue damage and how this may relate to tendinopathy conditions. This article aims to review these models and our current understanding of tendon fatigue damage. We review the strengths and limitations of different methodologies for characterizing tendon fatigue, considering in vitro methods that adopt both viable and non-viable samples, as well as the range of different in vivo approaches. By comparing data across model systems, we review the current understanding of fatigue damage development. Additionally, we compare these findings with data from tendinopathic tissue biopsies to provide some insights into how these models may relate to the aetiology of tendinopathy. Fatigue-induced damage consistently highlights the same microstructural, biological and mechanical changes to the tendon across all model systems and also correlates well with the findings from tendinopathic biopsy tissue. The multiple testing routes support matrix damage as an important contributor to tendinopathic conditions, but cellular responses to fatigue appear complex and often contradictory.
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Affiliation(s)
- Jennifer H Shepherd
- Institute of Bioengineering, School of Engineering and Materials Science, Queen Mary, University of London, London E1 4NS, UK.
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124
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Dean BJF, Franklin SL, Carr AJ. The peripheral neuronal phenotype is important in the pathogenesis of painful human tendinopathy: a systematic review. Clin Orthop Relat Res 2013; 471:3036-46. [PMID: 23609815 PMCID: PMC3734433 DOI: 10.1007/s11999-013-3010-y] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 04/16/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND The pathogenesis of tendinopathy is complex and incompletely understood. Although significant advances have been made in terms of understanding the pathological changes in both the extracellular matrix and the cells involved, relatively little is known about the role of neuronal regulation in tendinopathy. The frequent mismatch between tendon pathology and pain may be explained, in part, by differences in the peripheral neuronal phenotype of patients. QUESTIONS/PURPOSES The primary purpose of this review was to determine whether evidence exists of changes in the peripheral neuronal phenotype in painful human tendinopathy and, if so, to identify the associated histological and molecular changes. The secondary purpose was to determine if any changes in the peripheral neuronal phenotype reported correlate with pain symptoms. METHODS We conducted a systematic review of the scientific literature using the PRISMA and Cochrane guidelines. The Medline and Embase databases were searched using specific search criteria. Only studies analyzing the peripheral tissue of patients with the clinical diagnosis of tendinopathy were included. Inclusion was agreed on by two independent researchers on review of abstracts or full text. RESULTS Overall in the 27 included studies, there was clear evidence of changes in the peripheral neuronal phenotype in painful human tendinopathy. The excitatory glutaminergic system was significantly upregulated in seven studies, there was a significant increase in sensory neuropeptide expression in four studies, and there were significant changes in the molecular morphology of tenocytes, blood vessels, and nerves. In rotator cuff tendinopathy, substance P has been shown to correlate with pain and the neural density in the subacromial bursa has been shown to correlate with rest pain. CONCLUSIONS The peripheral neuronal phenotype is an important factor in the pathogenesis of painful human tendinopathy. Further research in this area specifically correlating tissue changes to clinical scores has great potential in further developing our understanding of the disease process.
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Affiliation(s)
- Benjamin John Floyd Dean
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, Institute of Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Windmill Road, Oxford, OX3 7LD UK
| | - Sarah L. Franklin
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, Institute of Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Windmill Road, Oxford, OX3 7LD UK
| | - Andrew Jonathan Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, Institute of Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Windmill Road, Oxford, OX3 7LD UK
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Gajhede-Knudsen M, Ekstrand J, Magnusson H, Maffulli N. Recurrence of Achilles tendon injuries in elite male football players is more common after early return to play: an 11-year follow-up of the UEFA Champions League injury study. Br J Sports Med 2013; 47:763-8. [PMID: 23770660 DOI: 10.1136/bjsports-2013-092271] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND There is limited information about Achilles tendon disorders in professional football. AIMS To investigate the incidence, injury circumstances, lay-off times and reinjury rates of Achilles tendon disorders in male professional football. METHODS A total of 27 clubs from 10 countries and 1743 players have been followed prospectively during 11 seasons between 2001 and 2012. The team medical staff recorded individual player exposure and time-loss injuries. RESULTS A total of 203 (2.5% of all injuries) Achilles tendon disorders were registered. A majority (96%) of the disorders were tendinopathies, and nine were partial or total ruptures. A higher injury rate was found during the preseason compared with the competitive season, 0.25 vs 0.18/1000 h (rate ratio (RR) 1.4, 95% CI 1.1 to 2.0; p=0.027). The mean lay-off time for Achilles tendinopathies was 23±37 (median=10, Q1=4 and Q3=24) days, while a rupture of the Achilles tendon, on average, caused 161±65 (median=169, Q1=110 and Q3=189) days of absence. Players with Achilles tendon disorders were significantly older than the rest of the cohort, with a mean age of 27.2±4 years vs 25.6±4.6 years (p<0.001). 27% of all Achilles tendinopathies were reinjuries. A higher reinjury risk was found after short recovery periods (31%) compared with longer recovery periods (13%) (RR 2.4, 95% CI 2.1 to 2.8; p<0.001). CONCLUSIONS Achilles tendon disorders account for 3.8% of the total lay-off time and are more common in older players. Recurrence is common after Achilles tendinopathies and the reinjury risk is higher after short recovery periods.
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Affiliation(s)
- Mariann Gajhede-Knudsen
- Division of Community Medicine, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
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126
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Roberts DB, Kruse RJ, Stoll SF. The Effectiveness of Therapeutic Class IV (10 W) Laser Treatment for Epicondylitis. Lasers Surg Med 2013; 45:311-7. [DOI: 10.1002/lsm.22140] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2013] [Indexed: 12/17/2022]
Affiliation(s)
| | | | - Stephen F. Stoll
- Diagnostic Radiologist; Toledo Radiological Associates; Toledo Ohio 43606
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127
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Krogh TP, Bartels EM, Ellingsen T, Stengaard-Pedersen K, Buchbinder R, Fredberg U, Bliddal H, Christensen R. Comparative effectiveness of injection therapies in lateral epicondylitis: a systematic review and network meta-analysis of randomized controlled trials. Am J Sports Med 2013; 41:1435-46. [PMID: 22972856 DOI: 10.1177/0363546512458237] [Citation(s) in RCA: 142] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Injection therapy with glucocorticoids has been used since the 1950s as a treatment strategy for lateral epicondylitis (tennis elbow). Lately, several novel injection therapies have become available. PURPOSE To assess the comparative effectiveness and safety of injection therapies in patients with lateral epicondylitis. STUDY DESIGN Systematic review and meta-analysis. METHODS Randomized controlled trials comparing different injection therapies for lateral epicondylitis were included provided they contained data for change in pain intensity (primary outcome). Trials were assessed using the Cochrane risk of bias tool. Network (random effects) meta-analysis was applied to combine direct and indirect evidence within and across trial data using the final end point reported in the trials, and results for the arm-based network analyses are reported as standardized mean differences (SMDs). RESULTS Seventeen trials (1381 participants; 3 [18%] at low risk of bias) assessing injection with 8 different treatments-glucocorticoid (10 trials), botulinum toxin (4 trials), autologous blood (3 trials), platelet-rich plasma (2 trials), and polidocanol, glycosaminoglycan, prolotherapy, and hyaluronic acid (1 trial each)-were included. Pooled results (SMD [95% confidence interval]) showed that beyond 8 weeks, glucocorticoid injection was no more effective than placebo (-0.04 [-0.45 to 0.35]), but only 1 trial (which did not include a placebo arm) was at low risk of bias. Although botulinum toxin showed marginal benefit (-0.50 [-0.91 to -0.08]), it caused temporary paresis of finger extension, and all trials were at high risk of bias. Both autologous blood (-1.43 [-2.15 to -0.71]) and platelet-rich plasma (-1.13 [-1.77 to -0.49]) were also statistically superior to placebo, but only 1 trial was at low risk of bias. Prolotherapy (-2.71 [-4.60 to -0.82]) and hyaluronic acid (-5.58 [-6.35 to -4.82]) were both more efficacious than placebo, whereas polidocanol (0.39 [-0.42 to 1.20]) and glycosaminoglycan (-0.32 [-1.02 to 0.38]) showed no effect compared with placebo. The criteria for low risk of bias were only met by the prolotherapy and polidocanol trials. CONCLUSION This systematic review and network meta-analysis of randomized controlled trials found a paucity of evidence from unbiased trials on which to base treatment recommendations regarding injection therapies for lateral epicondylitis.
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128
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Davezies P. Souffrance au travail, répression psychique et troubles musculo-squelettiques. PERSPECTIVES INTERDISCIPLINAIRES SUR LE TRAVAIL ET LA SANTÉ 2013. [DOI: 10.4000/pistes.3376] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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129
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Wearing SC, Hooper SL, Grigg NL, Nolan G, Smeathers JE. Overweight and obesity alters the cumulative transverse strain in the Achilles tendon immediately following exercise. J Bodyw Mov Ther 2012; 17:316-21. [PMID: 23768275 DOI: 10.1016/j.jbmt.2012.11.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Revised: 10/26/2012] [Accepted: 11/07/2012] [Indexed: 11/20/2022]
Abstract
This research evaluated the effect of obesity on the acute cumulative transverse strain of the Achilles tendon in response to exercise. Twenty healthy adult males were categorized into 'low normal-weight' (BMI <23 kg m(-2)) and 'overweight' (BMI >27.5 kg m(-2)) groups based on intermediate cut-off points recommended by the World Health Organization. Longitudinal sonograms of the right Achilles tendon were acquired immediately prior and following weight-bearing ankle exercises. Achilles tendon thickness was measured 20-mm proximal to the calcaneal insertion and transverse tendon strain was calculated as the natural log of the ratio of post- to pre-exercise tendon thickness. The Achilles tendon was thicker in the overweight group both prior to (t18 = -2.91, P = 0.009) and following (t18 = -4.87, P < 0.001) exercise. The acute transverse strain response of the Achilles tendon in the overweight group (-10.7 ± 2.5%), however, was almost half that of the 'low normal-weight' (-19.5 ± 7.4%) group (t18 = -3.56, P = 0.004). These findings suggest that obesity is associated with structural changes in tendon that impairs intra-tendinous fluid movement in response to load and provides new insights into the link between tendon pathology and overweight and obesity.
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Affiliation(s)
- Scott C Wearing
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland 4229, Australia.
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130
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Liu J, Chen L, Tao X, Tang K. Phosphoinositide 3-kinase/Akt signaling is essential for prostaglandin E2-induced osteogenic differentiation of rat tendon stem cells. Biochem Biophys Res Commun 2012. [PMID: 23206708 DOI: 10.1016/j.bbrc.2012.11.083] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Tissue calcification is a typical histopathological feature of tendinopathy. The osteogenic differentiation of tendon stem cells (TSCs) induced by inflammatory mediators is believed to play a key role in this process. Previous studies showed that the major inflammatory mediator prostaglandin E2 (PGE2) induced osteogenic differentiation of TSCs via bone morphogenetic protein (BMP)-2 production. Using a rat TSC culture model, we showed that PGE2 induced BMP-2 production through up-regulation of BMP-2 mRNA expression. PGE2 activated Akt, but not extracellular-signal-regulated kinase, in TSCs. Increased BMP-2 mRNA expression mediated by PGE2 was prevented by phosphoinositide 3-kinase (PI3K) and Akt inhibitors, but not by a MEK inhibitor. Furthermore, in the presence of exogenous BMP-2, PI3K and Akt inhibitors blocked Runx2 and osteocalcin expression, although BMP-2 did not activate Akt. BMP-2-induced alkaline phosphatase activity and mineralization were also inhibited by PI3K and Akt inhibitors. However, these inhibitors did not block activation of Smad, implying that Akt was involved downstream of Smad. Taken together, these results indicate that the PI3K-Akt signaling cascade is essential for PGE2-induced BMP-2 production and BMP-2-mediated osteogenic differentiation, suggesting that PI3-kinase-Akt signaling contributes to the formation of calcified tissues in tendinopathy.
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Affiliation(s)
- Junpeng Liu
- Department of Orthopaedics, Southwest Hospital, Third Military Medical University, Chongqing, China
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131
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Mistieri MLA, Wigger A, Canola JC, Filho JGP, Kramer M. Ultrasonographic Evaluation of Canine Supraspinatus Calcifying Tendinosis. J Am Anim Hosp Assoc 2012; 48:405-10. [DOI: 10.5326/jaaha-ms-5818] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Supraspinatus calcifying tendinosis is an uncommon finding in dogs. Although its radiographic appearance has been described previously, radiographs alone do not provide detailed information about the tendon parenchyma. Tendon ultrasonography has been widely applied for the diagnosis of human tendinosis, but it remains underused in dogs. This article reviews the ultrasonographic technique and variable appearance of canine supraspinatus calcifying tendinosis observed in 33 tendons. The ultrasonographic findings are described. The most common ultrasonographic finding was a hyperechoic area accompanied by distal acoustic shadowing. No relationship with bicipital tenosynovitis was found. A color Doppler examination was possible in only five of the tendons, revealing no blood flow in those tendons. There was evidence that the presence of a hypoechoic area surrounding the calcification was related to clinical signs of pain, suggesting an active inflammatory process. Ultrasonography was an excellent technique to evaluate lesions of the supraspinatus tendon and it revealed details not apparent on radiographs.
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Affiliation(s)
- Maria Ligia A. Mistieri
- Department of Veterinary Medicine, Pampa Federal University, Uruguaiana, Brazil (M.M.); Department of Veterinary Clinical Science, Clinic for Small Animal Surgery, Justus Liebig University of Giessen, Ludwigstrasse, Germany (A.W., M.K.); and Department of Veterinary Clinics and Surgery, Sao Paulo State University, Jaboticabal, Brazil (J.C., J.F.)
| | - Antje Wigger
- Department of Veterinary Medicine, Pampa Federal University, Uruguaiana, Brazil (M.M.); Department of Veterinary Clinical Science, Clinic for Small Animal Surgery, Justus Liebig University of Giessen, Ludwigstrasse, Germany (A.W., M.K.); and Department of Veterinary Clinics and Surgery, Sao Paulo State University, Jaboticabal, Brazil (J.C., J.F.)
| | - Julio C. Canola
- Department of Veterinary Medicine, Pampa Federal University, Uruguaiana, Brazil (M.M.); Department of Veterinary Clinical Science, Clinic for Small Animal Surgery, Justus Liebig University of Giessen, Ludwigstrasse, Germany (A.W., M.K.); and Department of Veterinary Clinics and Surgery, Sao Paulo State University, Jaboticabal, Brazil (J.C., J.F.)
| | - João G. P. Filho
- Department of Veterinary Medicine, Pampa Federal University, Uruguaiana, Brazil (M.M.); Department of Veterinary Clinical Science, Clinic for Small Animal Surgery, Justus Liebig University of Giessen, Ludwigstrasse, Germany (A.W., M.K.); and Department of Veterinary Clinics and Surgery, Sao Paulo State University, Jaboticabal, Brazil (J.C., J.F.)
| | - Martin Kramer
- Department of Veterinary Medicine, Pampa Federal University, Uruguaiana, Brazil (M.M.); Department of Veterinary Clinical Science, Clinic for Small Animal Surgery, Justus Liebig University of Giessen, Ludwigstrasse, Germany (A.W., M.K.); and Department of Veterinary Clinics and Surgery, Sao Paulo State University, Jaboticabal, Brazil (J.C., J.F.)
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132
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De Mey K, Danneels L, Cagnie B, Cools AM. Scapular muscle rehabilitation exercises in overhead athletes with impingement symptoms: effect of a 6-week training program on muscle recruitment and functional outcome. Am J Sports Med 2012; 40:1906-15. [PMID: 22785606 DOI: 10.1177/0363546512453297] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous research has identified some specific exercises to correct scapular muscle balance and onset timing in healthy subjects. However, evidence for their effectiveness in overhead athletes with impingement symptoms has been lacking until now. HYPOTHESIS A 6-week exercise program consisting of previously selected exercises is able to improve muscle activation and onset timing during shoulder elevation. This program may also change pain and functionality levels in overhead athletes with mild impingement symptoms. STUDY DESIGN Case series; Level of evidence, 4. METHODS Forty-seven overhead athletes with mild impingement symptoms (25 men and 22 women) were enrolled in this study. Before and after the 6-week training program, the Shoulder Pain and Disability Index (SPADI) score was individually obtained and maximum voluntary isometric contraction (MVIC) values were determined by surface electromyography. Mean muscle activation levels, muscle ratio data, and muscle onset timing were assessed for the upper (UT), middle (MT), and lower (LT) trapezius and serratus anterior (SA) muscle during arm elevation in the scapular plane. RESULTS Forty participants completed the exercise program. The SPADI scores significantly decreased from 29.86 ± 17.03 during initial assessment to 11.7 ± 13.78 during postmeasurements (P < .001). The 3 trapezius muscle parts showed increased MVIC values and decreased activation levels during arm elevation, whereas this was not the case for the SA muscle. After the training program, UT/SA significantly decreased, whereas UT/MT and UT/LT did not change (P < .05). No differences in muscle timing between pre- and postmeasurements could be identified. The LT showed significant earlier activation compared with UT (-0.47; P < .001) and MT (-0.49; P < .001). The serratus anterior showed significant earlier activation compared with the UT (-0.74; P < .001), MT (-0.76; P < .001), and LT muscles (F = 0.27; P = .046). CONCLUSION This is the first longitudinal study to demonstrate that previously selected exercises (1) improve pain and function based on SPADI scores, (2) reduce relative trapezius muscle activation, and (3) alter UT/SA ratios. However, they were unable to change the timing of the scapular muscles during arm elevation when compared before and after a 6-week training program in overhead athletes with mild impingement symptoms.
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Affiliation(s)
- Kristof De Mey
- Ghent University Hospital, Department of Rehabilitation Sciences and Physiotherapy, De Pintelaan 185, 2B3, B9000 Ghent, Belgium.
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133
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Andia I, Abate M. Platelet-rich plasma injections for tendinopathy and osteoarthritis. ACTA ACUST UNITED AC 2012. [DOI: 10.2217/ijr.12.36] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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134
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Todd NW, Luzina IG, Atamas SP. Molecular and cellular mechanisms of pulmonary fibrosis. FIBROGENESIS & TISSUE REPAIR 2012; 5:11. [PMID: 22824096 PMCID: PMC3443459 DOI: 10.1186/1755-1536-5-11] [Citation(s) in RCA: 289] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Accepted: 06/28/2012] [Indexed: 12/22/2022]
Abstract
Pulmonary fibrosis is a chronic lung disease characterized by excessive accumulation of extracellular matrix (ECM) and remodeling of the lung architecture. Idiopathic pulmonary fibrosis is considered the most common and severe form of the disease, with a median survival of approximately three years and no proven effective therapy. Despite the fact that effective treatments are absent and the precise mechanisms that drive fibrosis in most patients remain incompletely understood, an extensive body of scientific literature regarding pulmonary fibrosis has accumulated over the past 35 years. In this review, we discuss three broad areas which have been explored that may be responsible for the combination of altered lung fibroblasts, loss of alveolar epithelial cells, and excessive accumulation of ECM: inflammation and immune mechanisms, oxidative stress and oxidative signaling, and procoagulant mechanisms. We discuss each of these processes separately to facilitate clarity, but certainly significant interplay will occur amongst these pathways in patients with this disease.
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Affiliation(s)
- Nevins W Todd
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
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135
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Jensen J, Hölmich P, Bandholm T, Zebis MK, Andersen LL, Thorborg K. Eccentric strengthening effect of hip-adductor training with elastic bands in soccer players: a randomised controlled trial. Br J Sports Med 2012; 48:332-8. [PMID: 22763117 DOI: 10.1136/bjsports-2012-091095] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Soccer players with weak hip-adductor muscles are at increased risk of sustaining groin injuries. Therefore, a simple hip-adductor strengthening programme for prevention of groin injuries is needed. OBJECTIVE We aimed to investigate the effect of an 8-week hip-adductor strengthening programme, including one hip-adduction exercise, on eccentric and isometric hip-adduction strength, using elastic bands as external load. METHODS Thirty-four healthy, sub-elite soccer players, mean (±SD) age of 22.1 (±3.3) years, were randomised to either training or control. During the mid-season break, the training group performed 8 weeks of supervised, progressive hip-adduction strength training using elastic bands. The participants performed two training sessions per week (weeks 1-2) with 3×15 repetition maximum loading (RM), three training sessions per week (weeks 3-6) with 3×10 RM and three training sessions per week (weeks 7-8) with 3×8 RM. Eccentric hip-adduction (EHAD), isometric hip-adduction (IHAD) and isometric hip-abduction (IHAB) strength, and the IHAD/IHAB ratio were measured assessor-blinded preintervention and postintervention, using reliable hand-held dynamometry procedures. RESULTS In the training group, EHAD strength increased by 30% (p<0.001). In the control group, EHAD strength increased by 17% (p<0.001), but the increase was significantly larger in the training group compared with the control group (p=0.044). No other significant between-group strength-differences in IHAD, IHAB or the IHAD/IHAB ratio existed (p>0.05). CONCLUSIONS 8 weeks of hip-adduction strength training, using elastic bands, induce a relevant increase in eccentric hip-adduction strength in soccer players, and thus may have implications as a promising approach towards prevention of groin injuries in soccer.
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Affiliation(s)
- Jesper Jensen
- Arthroscopic Centre Amager, Copenhagen University Hospital, Copenhagen, Denmark
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136
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Fessel G, Wernli J, Li Y, Gerber C, Snedeker JG. Exogenous collagen cross-linking recovers tendon functional integrity in an experimental model of partial tear. J Orthop Res 2012; 30:973-81. [PMID: 22102295 DOI: 10.1002/jor.22014] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Accepted: 10/31/2011] [Indexed: 02/04/2023]
Abstract
We investigated the hypothesis that exogenous collagen cross-linking can augment intact regions of tendon to mitigate mechanical propagation of partial tears. We first screened the low toxicity collagen cross-linkers genipin, methylglyoxal and ultra-violet (UV) light for their ability to augment tendon stiffness and failure load in rat tail tendon fascicles (RTTF). We then investigated cross-linking effects in load bearing equine superficial digital flexor tendons (SDFT). Data indicated that all three cross-linking agents augmented RTTF mechanical properties but reduced native viscoelasticity. In contrast to effects observed in fascicles, methylglyoxal treatment of SDFT detrimentally affected tendon mechanical integrity, and in the case of UV did not alter tendon mechanics. As in the RTTF experiments, genipin cross-linking of SDFT resulted in increased stiffness, higher failure loads and reduced viscoelasticity. Based on this result we assessed the efficacy of genipin in arresting tendon tear propagation in cyclic loading to failure. Genipin cross-linking secondary to a mid-substance biopsy-punch significantly reduced tissue strains, increased elastic modulus and increased resistance to fatigue failure. We conclude that genipin cross-linking of injured tendons holds potential for arresting tendon tear progression, and that implications of the treatment on matrix remodeling in living tendons should now be investigated.
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Affiliation(s)
- Gion Fessel
- Department of Orthopedics, University Hospital Zurich, Balgrist, Forchstrasse 340, 8008 Zurich, Switzerland
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137
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Chang KV, Wu CH, Ding YH, Shen HY, Wang TG, Chen WS. Application of contrast-enhanced sonography with time-intensity curve analysis to explore hypervascularity in Achilles tendinopathy by using a rabbit model. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2012; 31:737-746. [PMID: 22535721 DOI: 10.7863/jum.2012.31.5.737] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVES The purpose of this study was to investigate the ability of contrast-enhanced sonography in staging and grading hypervascularity in tendinopathic tissues by using a rabbit model. METHODS Fourteen rabbits were injected with 100 and 50 μL of collagenase in their left and right Achilles tendons, respectively. The vascularity was assessed by non-contrast-enhanced and contrast-enhanced power Doppler sonography on day 0 (baseline) and days 1, 7, and 14 after collagenase injections. Color pixels within targeted areas were plotted according to time and analyzed by a curve-fitting method. RESULTS Non-contrast-enhanced power Doppler sonography failed to differentiate vascularity at various stages or between bilateral tendons, whereas contrast-enhanced sonography showed that the peak color pixel amount reached its maximum on day 1 and declined over time in tendons treated with 100 μL of collagenase. A similar trend was observed in tendons receiving 50 μL of collagenase. For comparisons between bilateral tendons, higher vascularity was detected in those treated with more collagenase on day 1 or 7. Time-intensity curve analysis revealed rapid microbubble replenishment in both tendons during their initial phase after collagenase injections. CONCLUSIONS Contrast-enhanced sonography discriminated the vascularity of various injury grades at different time points after collagenase injections. Time-intensity curve analysis detailed the hemodynamics in tendinopathic tissues, which helped differentiate vascularity in acute inflammatory from later degenerative phases.
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Affiliation(s)
- Ke-Vin Chang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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138
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139
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Grigg NL, Wearing SC, Smeathers JE. Achilles tendinopathy has an aberrant strain response to eccentric exercise. Med Sci Sports Exerc 2012; 44:12-7. [PMID: 21659896 DOI: 10.1249/mss.0b013e318227fa8c] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE Eccentric exercise has become the treatment of choice for Achilles tendinopathy. However, little is known about the acute response of tendons to eccentric exercise or the mechanisms underlying its clinical benefit. This research evaluated the sonographic characteristics and acute anteroposterior (AP) strain response of control (healthy), asymptomatic, and symptomatic Achilles tendons to eccentric exercise. METHODS Eleven male adults with unilateral midportion Achilles tendinopathy and nine control male adults without tendinopathy participated in the research. Sagittal sonograms of the Achilles tendon were acquired immediately before and after completion of a common eccentric rehabilitation exercise protocol and again 24 h later. Tendon thickness, echogenicity, and AP strain were determined 40 mm proximal to the calcaneal insertion. RESULTS Compared with the control tendon, both the asymptomatic and symptomatic tendons were thicker (P < 0.05) and hypoechoic (P < 0.05) at baseline. All tendons decreased in thickness immediately after eccentric exercise (P < 0.05). The symptomatic tendon was characterized by a significantly lower AP strain response to eccentric exercise compared with both the asymptomatic and control tendons (P < 0.05). AP strains did not differ in the control and asymptomatic tendons. For all tendons, preexercise thickness was restored 24 h after exercise completion. CONCLUSIONS These observations support the concept that Achilles tendinopathy is a bilateral or systemic process and structural changes associated with symptomatic tendinopathy alter fluid movement within the tendon matrix. Altered fluid movement may disrupt remodeling and homeostatic processes and represents a plausible mechanism underlying the progression of tendinopathy.
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Affiliation(s)
- Nicole L Grigg
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Queensland, Australia.
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140
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Godoy-Santos A, Ortiz RT, Junior RM, Fernandes TD, Santos MCLG. MMP-8 polymorphism is genetic marker to tendinopathy primary posterior tibial tendon. Scand J Med Sci Sports 2012; 24:220-3. [DOI: 10.1111/j.1600-0838.2012.01469.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2012] [Indexed: 02/01/2023]
Affiliation(s)
- A. Godoy-Santos
- Department of Orthopedics and Traumatology; University of São Paulo; São Paulo SP Brazil
| | - R. T. Ortiz
- Department of Orthopedics and Traumatology; University of São Paulo; São Paulo SP Brazil
| | - R. Mattar Junior
- Department of Orthopedics and Traumatology; University of São Paulo; São Paulo SP Brazil
| | - T. D. Fernandes
- Department of Orthopedics and Traumatology; University of São Paulo; São Paulo SP Brazil
| | - M. C. L. G. Santos
- Department of Cell Biology; University Federal of Paraná; Curitiba PR Brazil
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141
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Boesen AP, Boesen MI, Torp-Pedersen S, Christensen R, Boesen L, Hölmich P, Nielsen MB, Koenig MJ, Hartkopp A, Ellegaard K, Bliddal H, Langberg H. Associations between abnormal ultrasound color Doppler measures and tendon pain symptoms in badminton players during a season: a prospective cohort study. Am J Sports Med 2012; 40:548-55. [PMID: 22328709 DOI: 10.1177/0363546511435478] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Color Doppler ultrasound is widely used to examine intratendinous flow in individuals with overuse tendon problems, but the association between color Doppler and pain is still unclear. HYPOTHESIS Intratendinous flow is present and associated with pain in badminton players, and intratendinous flow and pain increase during a badminton season. STUDY DESIGN Cohort study (prognosis); Level of evidence, 2. METHODS Ninety-five semiprofessional badminton players were included in the study at a tournament at the start of the badminton season. All players were interviewed regarding pain. The anterior knee tendons and Achilles tendons were studied. Each tendon was scored using a quantitative grading system (grades 0-5) and a qualitative scoring system (color fraction) using color Doppler ultrasound. Eight months later, 86 of the players (91%) were retested by the same investigators during an equivalent badminton tournament (including 1032 tendon regions; 86 players with 4 tendons each with 3 regions), thus forming the study group. RESULTS At the start of the season, 24 players (28%) experienced pain in 37 tendons (11%), and at the end of the season, 31 players (36%) experienced pain in 51 tendons (15%), which was a statistically significant increase (P = .0002). Abnormal flow was found in 230 tendon regions in 71 players (83%) at the start of the season compared with 78 tendon regions in 41 players (48%) at the follow-up. The decrease in abnormal flow was statistically significant (P < .0001). Of the 37 painful tendons at the start of the season, 25 had abnormal flow (68%). In contrast, 131 tendons (85%) with abnormal flow at the start of the season were pain free. At the end of the season, 18 of the 51 painful tendons (35%) had abnormal flow. Ninety-six of the 131 pain-free tendons (73%) with abnormal flow at the start of the season were normalized (no pain and normal flow) at the end of the season. CONCLUSION It was not possible to verify any association between intratendinous flow and pain at the start of the season or at the follow-up (end of the season). Intratendinous flow at the start of the season could not predict symptomatic outcome at the end of the season. The decrease in Doppler flow during the season might suggest that intratendinous flow could be part of a physiological adaptive response to loading and that intratendinous flow as previously believed is not always a sign of pathological changes.
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Affiliation(s)
- Anders Ploug Boesen
- Institute of Sports Medicine, Bispebjerg Hospital and Center for Healthy Aging, Faculty of Health Sciences, University of Copenhagen, Bispebjerg Bakke 23, 2400 Copenhagen NV, Denmark.
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142
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Skorupska E, Lisinski P, Samborski W. The Effectiveness of the Conservative Versus Myofascial Pain Physiotherapy in Tennis Elbow Patients: Double-Blind Randomized Trial of 80 Patients. ACTA ACUST UNITED AC 2011. [DOI: 10.3109/10582452.2011.635846] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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143
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Del Buono A, Papalia R, Denaro V, Maccauro G, Maffulli N. Platelet rich plasma and tendinopathy: state of the art. Int J Immunopathol Pharmacol 2011; 24:79-83. [PMID: 21669143 DOI: 10.1177/03946320110241s215] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Platelet-rich plasma (PRP) is increasingly used in the management of tendon injury in sports, supposedly accelerating the process of healing, tissue regeneration, and return to play. However, the scientific clinical evidence to support its use is scanty, and more level I studies need to be performed to justify its widespread use.
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Affiliation(s)
- A Del Buono
- Department of Orthopaedic and Trauma Surgery, Campus Biomedico University of Rome, Italy
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144
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Evoked spinal reflexes and force development in elite athletes with middle-portion Achilles tendinopathy. J Orthop Sports Phys Ther 2011; 41:785-94. [PMID: 21891876 DOI: 10.2519/jospt.2011.3564] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Controlled laboratory study. OBJECTIVES To compare the neuromuscular function of the triceps surae muscle bilaterally in elite athletes with unilateral chronic Achilles tendinopathy. BACKGROUND Previous studies suggest that tendinopathies or chronic pain may lead to a spinal/supraspinal level modulation of the excitability or voluntary activation of ipsilateral motor units. However, this has not been studied in Achilles tendinopathy. METHODS Fourteen college athletes (mean ± SD age, 24.2 ± 1.7 years) who had unilateral chronic middle-portion tendinopathy in their Achilles tendons were recruited. Bilateral measurements of soleus reflex tests, including H-reflex and V wave, and rate of force development (RFD), as well as corresponding electromyography of the tibialis anterior and triceps surae muscles, were performed. Statistical within-subject and between-leg comparisons were made. RESULTS In the leg with tendinopathy, the V wave of the soleus muscle was significantly increased (P<.001). The side with tendinopathy also had a reduced normalized RFD (0-30, 0-50, and 0-100 ms) in plantar flexion, and concomitant higher electromyography ratios between the tibialis anterior and soleus (0-30 and 0-50 milliseconds) during the early stage of explosive contractions (P<.05). No significant differences were found for H-reflex, maximal plantar flexion and dorsiflexion torque, and absolute RFD. CONCLUSIONS Higher volitional supraspinal reflexes and lower maximal-strength independent force development occur in the triceps surae of elite athletes with unilateral middle-portion Achilles tendinopathy. These changes potentially indicate an acquired compensatory mechanism for maximal force production and deficits in explosive strength. The RFD is also suggested as a sensitive parameter to depict neuromuscular changes during treatment of chronic tendinopathies.
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145
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Reinking M. Tendinopathy in athletes. Phys Ther Sport 2011; 13:3-10. [PMID: 22261424 DOI: 10.1016/j.ptsp.2011.06.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Revised: 06/11/2011] [Accepted: 06/17/2011] [Indexed: 02/07/2023]
Abstract
Overuse related tendon pain is a significant problem in sport and can interfere with and, in some instances, end an athletic career. This article includes a consideration of the biology of tendon pain including a review of tendon anatomy and histopathology, risk factors for tendon pain, semantics of tendon pathology, and the pathogenesis of tendon pain. Evidence is presented to guide the physical therapist in clinical decision-making regarding the examination of and intervention strategies for athletes with tendon pain.
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Affiliation(s)
- Mark Reinking
- Saint Louis University, Department of Physical Therapy and Athletic Training, Doisy College of Health Sciences, 3437 Caroline Mall, Saint Louis, MO 63104, USA.
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146
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Hensley CP, Kavchak AJE. Novel use of a manual therapy technique and management of a patient with peroneal tendinopathy: a case report. ACTA ACUST UNITED AC 2011; 17:84-8. [PMID: 21570893 DOI: 10.1016/j.math.2011.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2011] [Revised: 04/11/2011] [Accepted: 04/16/2011] [Indexed: 10/18/2022]
Abstract
Peroneal tendinopathy is an uncommon but underappreciated source of lateral hindfoot pain and dysfunction. There is a paucity of literature describing optimal intervention for those suffering with pain secondary to peroneal tendinopathy. The purpose of this case report is to describe the evaluation and treatment incorporating manual therapy and therapeutic exercise for a patient diagnosed with peroneal tendinopathy. The patient was a 50 year-old female with a history of chronic lateral ankle pain and whose presentation was consistent with peroneal tendinopathy. Despite attempts to improve pain and function with over-the-counter orthotics, manual therapy to a hypomobile talocrural joint, and strengthening of the peroneal tendons, successful response was not reported until a lateral calcaneal glide was added. Improvement in impairments (pain, talocrural dorsiflexion, unilateral heel raises, and Star Excursion Balance Test) and function (Lower Extremity Functional Scale and Global Rating of Change), were observed over a course of eight visits. The patient was able to return to work and her recreational work out routine without limitations. In conclusion a successful physical therapy intervention for a patient with peroneal tendinopathy included a unique manual therapy technique, the lateral calcaneal glide, in conjunction with other manual therapy techniques and a structured home exercise program.
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Affiliation(s)
- Craig P Hensley
- University of Illinois Medical Center, University of Illinois, 1801 W. Taylor Street, Chicago, IL, USA.
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147
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Seitz AL, McClure PW, Finucane S, Boardman ND, Michener LA. Mechanisms of rotator cuff tendinopathy: intrinsic, extrinsic, or both? Clin Biomech (Bristol, Avon) 2011; 26:1-12. [PMID: 20846766 DOI: 10.1016/j.clinbiomech.2010.08.001] [Citation(s) in RCA: 257] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2010] [Revised: 07/30/2010] [Accepted: 08/02/2010] [Indexed: 02/07/2023]
Abstract
The etiology of rotator cuff tendinopathy is multi-factorial, and has been attributed to both extrinsic and intrinsic mechanisms. Extrinsic factors that encroach upon the subacromial space and contribute to bursal side compression of the rotator cuff tendons include anatomical variants of the acromion, alterations in scapular or humeral kinematics, postural abnormalities, rotator cuff and scapular muscle performance deficits, and decreased extensibility of pectoralis minor or posterior shoulder. A unique extrinsic mechanism, internal impingement, is attributed to compression of the posterior articular surface of the tendons between the humeral head and glenoid and is not related to subacromial space narrowing. Intrinsic factors that contribute to rotator cuff tendon degradation with tensile/shear overload include alterations in biology, mechanical properties, morphology, and vascularity. The varied nature of these mechanisms indicates that rotator cuff tendinopathy is not a homogenous entity, and thus may require different treatment interventions. Treatment aimed at addressing mechanistic factors appears to be beneficial for patients with rotator cuff tendinopathy, however, not for all patients. Classification of rotator cuff tendinopathy into subgroups based on underlying mechanism may improve treatment outcomes.
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Affiliation(s)
- Amee L Seitz
- Department of Physical Therapy, Virginia Commonwealth University-Medical College of Virginia Campus, Richmond, VA 23298-0224, USA.
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148
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van Sterkenburg MN, van Dijk CN. Mid-portion Achilles tendinopathy: why painful? An evidence-based philosophy. Knee Surg Sports Traumatol Arthrosc 2011; 19:1367-75. [PMID: 21567177 PMCID: PMC3136709 DOI: 10.1007/s00167-011-1535-8] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Accepted: 04/28/2011] [Indexed: 02/06/2023]
Abstract
Chronic mid-portion Achilles tendinopathy is generally difficult to treat as the background to the pain mechanisms has not yet been clarified. A wide range of conservative and surgical treatment options are available. Most address intratendinous degenerative changes when present, as it is believed that these changes are responsible for the symptoms. Since up to 34% of asymptomatic tendons show histopathological changes, we believe that the tendon proper is not the cause of pain in the majority of patients. Chronic painful tendons show the ingrowth of sensory and sympathetic nerves from the paratenon with release of nociceptive substances. Denervating the Achilles tendon by release of the paratenon is sufficient to cause pain relief in the majority of patients. This type of treatment has the additional advantage that it is associated with a shorter recovery time when compared with treatment options that address the tendon itself. An evidence-based philosophy on the cause of pain in chronic mid-portion Achilles tendinopathy is presented. Level of evidence V.
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Affiliation(s)
- Maayke N. van Sterkenburg
- Department of Orthopaedic Surgery, Academic Medical Center, P.O. Box 22700, 1100 DE Amsterdam, The Netherlands
| | - C. Niek van Dijk
- Department of Orthopaedic Surgery, Academic Medical Center, P.O. Box 22700, 1100 DE Amsterdam, The Netherlands
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149
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Evidence of accumulated stress in Achilles and anterior knee tendons in elite badminton players. Knee Surg Sports Traumatol Arthrosc 2011; 19:30-7. [PMID: 20652535 DOI: 10.1007/s00167-010-1208-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2009] [Accepted: 06/23/2010] [Indexed: 10/19/2022]
Abstract
Tendon-related injuries are a major problem, but the aetiology of tendinopathies is unknown. In tendinopathies as well as during unaccustomed loading, intra-tendinous flow can be detected indicating that extensive loading can provoke intra-tendinous flow. The aim of present study is to evaluate the vascular response as indicated by colour Doppler (CD) activity in both the Achilles and patella tendon after loading during high-level badminton matches. The Achilles tendon was subdivided into a mid-tendon, pre-insertional, and insertional region and the anterior knee tendons into a quadriceps-, patella- and tuberositas region. Intra-tendinous flow was measured using both a semi-quantitative grading system (CD grading) and a quantitative scoring system (CF) on colour Doppler. Intra-tendinous flow in the Achilles and anterior knee tendons was examined in fourteen single players before tournament and after 1st and 2nd match, respectively on both the dominant and non-dominant side. All players had abnormal intra-tendinous flow (Colour Doppler ≥ grade 2) in at least one tendon in at least one scan during the tournament. At baseline, only two of the 14 players had normal flow in all the tendons examined. After 1st match, tendencies to higher intra-tendinous flow were observed in both the dominant patella tendon and non-dominant quadriceps tendon (P-values n.s.). After 2nd match, intra-tendinous flow was significant increased in the dominant patella tendon (P = 0.009). In all other locations, there was a trend towards a stepwise increase in intra-tendinous flow. The preliminary results indicate that high amount of intra-tendinous flow was found in elite badminton players at baseline and was increased after repetitive loading, especially in the patella tendon (dominant leg). The colour Doppler measurement can be used to determine changes in intra-tendinous flow after repetitive loading.
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150
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Fu SC, Rolf C, Cheuk YC, Lui PP, Chan KM. Deciphering the pathogenesis of tendinopathy: a three-stages process. BMC Sports Sci Med Rehabil 2010; 2:30. [PMID: 21144004 PMCID: PMC3006368 DOI: 10.1186/1758-2555-2-30] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Accepted: 12/13/2010] [Indexed: 01/08/2023]
Abstract
Our understanding of the pathogenesis of "tendinopathy" is based on fragmented evidences like pieces of a jigsaw puzzle. We propose a "failed healing theory" to knit these fragments together, which can explain previous observations. We also propose that albeit "overuse injury" and other insidious "micro trauma" may well be primary triggers of the process, "tendinopathy" is not an "overuse injury" per se. The typical clinical, histological and biochemical presentation relates to a localized chronic pain condition which may lead to tendon rupture, the latter attributed to mechanical weakness. Characterization of pathological "tendinotic" tissues revealed coexistence of collagenolytic injuries and an active healing process, focal hypervascularity and tissue metaplasia. These observations suggest a failed healing process as response to a triggering injury. The pathogenesis of tendinopathy can be described as a three stage process: injury, failed healing and clinical presentation. It is likely that some of these "initial injuries" heal well and we speculate that predisposing intrinsic or extrinsic factors may be involved. The injury stage involves a progressive collagenolytic tendon injury. The failed healing stage mainly refers to prolonged activation and failed resolution of the normal healing process. Finally, the matrix disturbances, increased focal vascularity and abnormal cytokine profiles contribute to the clinical presentations of chronic tendon pain or rupture. With this integrative pathogenesis theory, we can relate the known manifestations of tendinopathy and point to the "missing links". This model may guide future research on tendinopathy, until we could ultimately decipher the complete pathogenesis process and provide better treatments.
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Affiliation(s)
- Sai-Chuen Fu
- Department of Orthopaedics & Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, PR China.
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