Marked sympathetic component in the perivascular innervation of the dorsal paratendinous tissue of the patellar tendon in arthroscopically treated tendinosis patients

Ultrasound- and Doppler-Guided WALANT Arthroscopic Surgery for Patellar Tendinopathy with Partial Rupture in Elite Athletes-A 2-Year Follow-Up of a Prospective Case Series

Background and Objectives: Patellar tendinopathy is difficult to treat, and when combined with partial rupture, there are additional challenges. The aim of this study was to evaluate the subjective outcome and return-to-sport status after ultrasound (US)- and colour doppler (CD)-guided wide awake local anaesthetic no tourniquet (WALANT) arthroscopic shaving in elite athletes. Material and Methods: Thirty Swedish and international elite athletes (27 males) with a long duration (>1 year) of persistent painful patellar tendinopathy in 35 patellar tendons, not responding to non-surgical treatment, were included. All patients were treated with the same protocol of arthroscopic shaving, including bone removal and debridement of partial rupture, followed by at least 3 months of structured rehabilitation. The VISA-P score and a study-specific questionnaire evaluating physical activity level and subjective satisfaction with the treatment were used for evaluation. Results: At the 2-year follow-up (mean 23, range 8-38 months), 25/30 patients (29/35 tendons) were satisfied with the treatment result and had returned to their pre-injury sport. The mean VISA-P score increased from 37 (range 7-69) before surgery to 80 (range 44-100) after surgery (p < 0.05). There was one drop-out (one tendon). There were no complications. Conclusions: US- and CD-guided WALANT arthroscopic shaving for persistent painful patellar tendinopathy, including bone removal and debridement of partial rupture, followed by structured rehabilitation showed good clinical results in the majority of the elite-level athletes.

Patellar ligament desmopathy in the horse – a review and comparison to human patellar tendinopathy (‘Jumper’s knee’)

Patellar ligament desmopathy in horses is regarded as an uncommon condition with unclear aetiology. Of the three patellar ligaments in the horse, the intermediate is the one most often diagnosed with desmopathy in horses presenting with chronic lameness. This structure corresponds to the patellar tendon in humans. As diagnostic imaging modalities continuously improve, changes in echogenicity of the patellar ligaments are identified ultrasonographically with increasing frequency. However, disruption of the normal fibre pattern may be present also in patellar ligaments in horses that show no signs of lameness. Similarly, there is a poor correlation between pain and diagnostic imaging findings in human patellar tendinopathy. Consequently, there appears to be a knowledge gap pertaining to normal ultrasonographic variation and diagnostic criteria for disease of the patellar ligaments in horses. Furthermore, local anaesthetic techniques to verify the diagnosis are poorly described, and due to the low number of treated cases, no specific treatment modality can be recommended on a scientific basis. The aim of this paper is to review the current knowledge regarding the pathogenesis, diagnosis and management of patellar ligament desmopathy in horses, compare this condition with patellar tendinopathy in humans, and identify areas for further research to increase the diagnostic accuracy in horses. We conclude that there is a profound need for better descriptions of ultrasonographic variation and pathological changes of the equine patellar ligaments. Identification of areas of maximal ligament strain and descriptions of early histopathological changes could render more information on the possible aetiology, preventive measurements and treatment options of desmopathy. Description of regional innervation could aid in development of methods for diagnostic anaesthesia to verify pain originating from the ligaments.

Is the Superficial Peritendinous Tissue an Additional Pain Driver in Patellar Tendinopathy?—Studies on Morphology and Innervation in a Case Series

Background and Objectives: Ultrasound (US) and Doppler (DP) guided arthroscopic shaving targeting the area with neovessels and nerves on the dorsal side of the tendon has shown good clinical results. Recently, we observed that in a sub-group of patients there is also local tenderness on the superficial side of the proximal patellar tendon; Material and Methods: The aim was to examine morphology and innervation patterns of the superficial peritendinous tissue from patients (four men and two women; mean age 23 years, range 17–31 years) that on US+DP examination showed a locally thickened paratenon including high blood flow. Tissue sections were stained for morphology (hematoxylin and eosin, H&E) and immunohistochemically for nerve markers (β-tubulin; tyrosine hydroxylase, TH; calcitonin related gene peptide, CRGP); Results: All tissue specimens contained high levels of blood vessels and nerves (fascicles, sprouting nerve fibers, perivascular innervation) as evidenced by evaluation for H&E and β-tubulin reactions. Nerve fascicles mainly contained sensory but also sympathetic axons. Nerves related to blood vessels were sympathetic fibers; Conclusions: There was a marked innervation in the superficial peritendinous tissue in a sub-group of patients with patellar tendinopathy and severe tenderness in the proximal patellar tendon. The results indicate that this tissue might be an additional pain driver in some patients and should be considered in further studies.

Function of peripheral nerves in the development and healing of tendon and bone

Although the functions of the peripheral nervous system in whole body homeostasis and sensation have been understood for many years, recent investigation has uncovered new roles for innervation in the musculoskeletal system. This review centers on advances regarding the function of nerves in the development and repair of two connected tissues: tendon and bone. Innervation in healthy tendons is generally confined to the tendon sheaths, and tendon-bone attachment units are typically aneural. In contrast to tendon, bone is an innervated and vascularized structure. Historically, the function of abundant peripheral nerves in bone has been limited to pain and some non-painful sensory perception in disease and injury. Indeed, much of our understanding of peripheral nerves in tendons, bones, and entheses is limited to the source and type of innervation in healthy and injured tissues. However, more recent studies have made important observations regarding the appearance, type, and innervation patterns of nerves during embryonic and postnatal development and in response to injury, which suggest a more expansive role for peripheral nerves in the formation of musculoskeletal tissues. Indeed, tendons and bones develop in a close spatiotemporal relationship in the embryonic mesoderm. Models of limb denervation have shed light on the importance of sensory innervation in bone and to a lesser extent, tendon development, and more recent work has unraveled key nerve signaling pathways. Furthermore, loss of sensory innervation also impairs healing of bone fractures and may contribute to chronic tendinopathy. However, more study is required to translate our knowledge of peripheral nerves to therapeutic strategies to combat bone and tendon diseases.

Management of Achilles and patellar tendinopathy: what we know, what we can do

Tendinopathies are challenging conditions frequent in athletes and in middle-aged overweight patients with no history of increased physical activity. The term “tendinopathy” refers to a clinical condition characterised by pain, swelling, and functional limitations of tendons and nearby structures, the effect of chronic failure of healing response. Tendinopathies give rise to significant morbidity, and, at present, only limited scientifically proven management modalities exist. Achilles and patellar tendons are among the most vulnerable tendons, and among the most frequent lower extremity overuse injuries. Achilles and patellar tendinopathies can be managed primarily conservatively, obtaining good results and clinical outcomes, but, when this approach fails, surgery should be considered. Several surgical procedures have been described for both conditions, and, if performed well, they lead to a relatively high rate of success with few complications. The purpose of this narrative review is to critically examine the recent available scientific literature to provide evidence-based opinions on these two common and troublesome conditions.

Ultrasound-guided tendon debridement improves pain, function and structure in persistent patellar tendinopathy: short term follow-up of a case series

There is a need for effective therapeutic options for resistant patellar tendinopathy. Ultrasound (US)-guided arthroscopic debridement has demonstrated promising clinical results.

Structural and molecular characteristics of axons in the long head of the biceps tendon

The innervation of the long head of the biceps tendon (LHBT) is not sufficiently documented. This is a drawback since pathologies of the LHBT are a major source of shoulder pain. Thus, the study aimed to characterize structurally and molecularly nervous elements of the LHBT. The proximal part of 11 LHBTs was harvested intraoperatively. There were 8 female and 3 male specimens. Age ranged from 66 to 86 years. For structural analyses, nervous elements were viewed in the transmission electron microscope. For molecular characterization, we used general neuronal markers including antibodies against neurofilament and protein gene product 9.5 (PGP9.5) as well as specific neuronal markers including antibodies against myelin basic protein (MBP), calcitonin gene-related product (CGRP), substance P (SP), tyrosine hydroxylase (TH), and growth-associated protein 43 (GAP43). Anti-neurofilament and anti-PGP9.5 visualized the overall innervation. Anti-MBP visualized myelination, anti-CGRP and anti-SP nociceptive fibers, anti-TH sympathetic nerve fibers, and anti-GAP43 nerve fibers during development and regeneration. Immunolabeled sections were analyzed in the confocal laser scanning microscope. We show that the LHBT contains unmyelinated as well as myelinated nerve fibers which group in nerve fascicles and follow blood vessels. Manny myelinated and unmyelinated axons exhibit molecular features of nociceptive nerve fibers. Another subpopulation of unmyelinated axons exhibits molecular characteristics of sympathetic nerve fibers. Unmyelinated sympathetic fibers and unmyelinated nociceptive fibers express proteins that are found during development and regeneration. Present findings support the hypothesis that ingrowth of nociceptive fibers are the source of chronic tendon pain.

Subacromial Impingement Syndrome of the Shoulder: A Musculoskeletal Disorder or a Medical Myth?

Subacromial impingement syndrome (SAIS) is a commonly diagnosed disorder of the shoulder. Though this disorder has been known for a long time, it remains a poorly understood entity. Over the years several hypotheses have been put forward to describe the pathogenesis of SAIS but no clear explanation has been found. Two mechanisms, the extrinsic and intrinsic mechanism, have been described for the impingement syndrome. The intrinsic mechanism theories which deny the existence of impingement are gaining popularity in recent years. The various shoulder tests used to diagnose SAIS have low specificity with an average of about 50%. Meta-analysis shows that neither the Neer sign nor the Hawkins sign has diagnostic utility for impingement syndrome. Several randomised controlled trials have shown that the outcome of treatment of SAIS by surgery is no better than conservative treatment. Physiotherapy alone can provide good outcome which is comparable to that achieved with surgery without the costs and complications associated with surgery. Since decompression with surgery does not provide any additional benefits as compared to conservative treatment for patients with SAIS, the impingement theory has become antiquated and surgical treatment should have no role in the treatment of such patients. There are calls by some practitioners to abandon the term impingement syndrome and rename it as anterolateral shoulder pain syndrome. It appears that SAIS is a medical myth. There are others who called SAIS as a clinical illusion.

Subacromial impingement syndrome: management challenges

The painful shoulder is the most common condition seen in specialist shoulder clinics. It is often associated with lack of range of motion and reduced shoulder function. Lack of sleep and difficulties in performing basic daily life activities are common findings. Subacromial Impingement Syndrome (SAIS) has been considered as the most common cause of shoulder pain since it was described in 1852. Charles Neer, in 1972, described the presence of a "proliferative spur and ridge" on the undersurface of the acromion, which needs to be removed to improve the symptoms (acromioplasty). Neer's "impingement" hegemony was undisputed for at least 30 years. A more extensive knowledge of the pathogenesis of SAIS, however, has led authors to challenge the role of "impingement" in the shoulder pain and the role of surgical intervention. The aim of this review was to understand if there is still a role for surgical decompression in patients with SAIS. A literature review was performed in PubMed, PEDro, Embase, and the Cochrane Central Register of Controlled Trials using impingement, subacromial space, rotator cuff tears, tendinopathy, and tendinitis as key words. Randomized clinical trials (RCTs) with long-term follow-up comparing surgical intervention and conservative treatments in SAIS were preferred; however, prospective articles studying the outcome of surgical decompression and physiotherapy were also included. The majority of the studies showed no difference in the outcome between patients randomized to surgical decompression or conservative management. However, some studies reported better results after surgery, especially in the long term. Interpretation of the results is very difficult as most of the studies are of poor quality and have short follow-up. In our opinion, the type of subacromial lesion needs to be considered; this may offer an explanation to the difference in severity of symptoms and to the varying degrees of response to certain treatments, including surgery. Further studies are mandatory to better understand the role of surgery in SAIS.

Current trends in tendinopathy: consensus of the ESSKA basic science committee. Part II: treatment options

The treatment of painful chronic tendinopathy is challenging. Multiple non-invasive and tendon-invasive methods are used. When traditional non-invasive treatments fail, the injections of platelet-rich plasma autologous blood or cortisone have become increasingly favored. However, there is little scientific evidence from human studies supporting injection treatment. As the last resort, intra- or peritendinous open or endoscopic surgery are employed even though these also show varying results. This ESSKA basic science committee current concepts review follows the first part on the biology, biomechanics and anatomy of tendinopathies, to provide a comprehensive overview of the latest treatment options for tendinopathy as reported in the literature.

Calcitonin gene-related peptide and pain: a systematic review

BACKGROUND

Calcitonin gene-related peptide (CGRP) is widely distributed in nociceptive pathways in human peripheral and central nervous system and its receptors are also expressed in pain pathways. CGRP is involved in migraine pathophysiology but its role in non-headache pain has not been clarified.

METHODS

We performed a systematic literature search on PubMed, Embase and ClinicalTrials.gov for articles on CGRP and non-headache pain covering human studies including experimental studies and randomized clinical trials.

RESULTS

The literature search identified 375 citations of which 50 contained relevant original data. An association between measured CGRP levels and somatic, visceral, neuropathic and inflammatory pain was found. In 13 out of 20 studies in somatic pain conditions, CGRP levels had a positive correlation with pain. Increased CGRP levels were reported in plasma, synovial and cerebrospinal fluid in subjects with musculoskeletal pain. A randomized clinical trial on monoclonal antibody, which selectively binds to and inhibits the activity of CGRP (galcanezumab) in patients with osteoarthritis knee pain, failed to demonstrate improvement of pain compared with placebo. No studies to date have investigated the efficacy of monoclonal antibodies against CGRP receptor in non-headache pain conditions.

CONCLUSION

The present review revealed the association between measured CGRP levels and somatic, visceral, neuropathic and inflammatory pain. These data suggest that CGRP may act as a neuromodulator in non-headache pain conditions. However, more studies are needed to fully understand the role of CGRP in nociceptive processing and therapy of chronic pain.

Prognostic value of MRI in arthroscopic treatment of chronic patellar tendinopathy: a prospective cohort study

Background

To date, prognostic outcome factors for patients undergoing arthroscopic treatment due to chronic patellar tendinopathy (PT) are lacking. The purpose of this study was to investigate whether preoperatively assessed MRI parameters might be of prognostic value for prediction of functional outcome and return to sports in arthroscopic treatment of chronic PT.

Methods

A prospective cohort study was conducted including 30 cases (4 female and 24 male competitive athletes) undergoing arthroscopic patellar release (APR) due to chronic PT. The mean age was 28.2 years (range, 18–49 years) at the time of surgery, and the mean follow-up period was 4.2 years (range, 2.2–10.4 years). Preoperatively assessed MRI parameters included bone marrow edema (BME) of the inferior patellar pole, patellar tendon thickening, infrapatellar fat pad (IFP) edema, and infrapatellar bursitis. Prevalences of preoperative MRI findings were correlated to functional outcome scores in order to determine statistically significant predictors.

Results

All athletes regained their preinjury sports levels. Athletes featuring preoperative IFP edema showed significantly inferior modified Blazina score (0.6 ± 0.7 vs. 0.2 ± 0.5), single assessment numeric evaluation (SANE; 86.0 ± 8.8 vs. 94.3 ± 7.5), and Visual Analogue Scale (VAS; 1.0 ± 1.2 vs. 0.3 ± 0.8) compared to subjects without IFP edema (p < 0.05). Return to sports required a mean of 4 ± 3.2 months. On average, patients with IFP edema needed significantly more time to return to sports than subjects without IFP edema (6.5 vs 2.8 months; p < 0.05). The simultaneous presence of BME and IFP edema was associated with significantly inferior outcomes by means of the Victorian Institute of Sport Assessment questionnaire for patients with patellar tendinopathy (VISA-P; 88.1 ± 11.9 vs. 98.6 ± 4.2), SANE (84.3 ± 10.2 vs. 93.1 ± 8.3), and VAS (1.3 ± 1.4 vs. 0.3 ± 0.9) compared to an isolated BME or isolated IFP edema.

Conclusions

This is the first study identifying prognostic outcome factors in arthroscopic treatment of chronic PT. Preoperative IFP edema alone or simultaneous BME and IFP edema on preoperative MRI were associated with inferior functional outcome and delayed return to sports. Knowledge of these predictive factors might improve risk stratification, individualize treatment and postoperative rehabilitation, and contribute to improve clinical outcome. Moreover, current findings offer the potential for novel therapeutic approaches.

Refractory patella tendinopathy with failed conservative treatment-shock wave or arthroscopy?

AIM

To identify whether the location of refractory patella tendinopathy (PT) has an effect on treatment modality (radial extracorporeal shock wave therapy (rESWT) or arthroscopic debridement).

METHODS

Between 2012 and 2014, 40 patients with PT underwent a magnetic resonance imaging (MRI) scan. This confirmed the diagnosis as either involving the tendon itself (group A, 20) or with retropatella fat pad extension (group B, 20). All patients underwent rESWT. If there was no improvement patients proceeded with surgery in the form of arthroscopic debridement (by senior authors CW and AG). Outcomes were assessed before and after treatment using the Victorian Institute of Sports Assessment-Patella (VISA-P) score.

RESULTS

There were 18 males and 2 females in group A and 15 males and 5 females in group B. The mean age was 41.4 years in group A (23-59) and 34.7 in group B (19-52). Seventeen of 20 in group A reported good or excellent outcomes and did not require surgical intervention (remaining three improved after second course of ESWT). All patients in group B failed to improve with rESWT, resulting in arthroscopic debridement and reported good or excellent outcomes. After 6 months, group A mean VISA-P score increased from 50.2 to 65.0 ( p = 0.01) and group B from 39.6 to 78.4 ( p = <0.001).

CONCLUSION

An MRI should be performed to determine the precise location of tendinosis in patients with refractory PT who fail standard conservative management. If the MRI scan shows intratendon changes only, ESWT should be performed and those with extension into the fat pad should proceed to arthroscopic debridement without rESWT.

Role of VEGF, Nitric Oxide, and Sympathetic Neurotransmitters in the Pathogenesis of Tendinopathy: A Review of the Current Evidences

Chronic tendinopathy is a painful common condition affecting athletes as well as the general population undergoing to tendon overuse. Although its huge prevalence, little is known about tendinopathy pathogenesis, and even cloudier is its treatment. Traditionally, tendinopathy has been defined as a lack of tendon ability to overcome stressing stimuli with appropriate adaptive changes. Histologic studies have demonstrated the absence of inflammatory infiltrates, as a consequence conventional antinflammatory drugs have shown little or no effectiveness in treating tendinopathies. New strategies should be therefore identified to address chronic tendon disorders. Angiofibroblastic changes have been highlighted as the main feature of tendinopathy, and vascular endothelial growth factor (VEGF) has been demonstrated as one of the key molecules involved in vascular hyperplasia. More recently, attention has been focused on new peptides such as Substance P, nitric oxide, and calcitonin gene-related peptide (CGRP). Those new findings support the idea of a nerve-mediated disregulation of tendon metabolism. Each of those molecules could be a target for new treatment options. This study aimed to systematically review the current available clinical and basic science in order to summarize the latest evidences on the pathophysiology and its effect on treatment of chronic tendinopathy, and to spread suggestions for future research on its treatment.

Anatomical study on the innervation of the elbow capsule

OBJECTIVES

To put forward an anatomical description of the innervation of the elbow capsule, illustrated through morphological analysis on dissections.

METHODS

Thirty elbows from fresh fixed adult cadavers aged 32-74 years, of both sexes, were dissected.

RESULTS

Among the dissected arms, we observed that the median nerve did not have any branches in two arms, while it had one branch in five arms, two branches in two arms, three branches in ten arms, four branches in nine arms and five branches in two arms. The radial nerve did not have any branches in two arms, while it had one branch in two arms, two branches in nine arms, three branches in ten arms, four branches in five arms and five branches in two arms. The ulnar nerve did not have any branches in three arms, while it had one branch in six arms, two branches in four arms, three branches in five arms, four branches in seven arms, five branches in four arms and six branches in one arm.

CONCLUSIONS

We observed branches of the radial, ulnar and medial nerves in the elbow joint, and a close relationship between their capsular and motor branches.

The sympathetic nervous system and tendinopathy: a systematic review

BACKGROUND

Tendinopathy is a clinical diagnosis of localised tendon pain often confirmed by imaging findings. The pathophysiological cause of the pain is unknown and the sympathetic nervous system (SNS) may be implicated.

OBJECTIVE

To review what is known regarding the role of the SNS in human tendinopathy.

STUDY SELECTION

Published data describing sympathetic innervation or an index of sympathetic activity in human tendons were eligible for inclusion.

DATA SOURCES

Bibliographical databases (AMED, Biological Abstracts, CINAHL Plus, EMBASE, MEDLINE, Scopus, SPORTDiscus and Web of Science) were searched for relevant articles. Reference lists from included articles were screened for additional articles.

STUDY APPRAISAL

Studies were scored with a quality assessment tool to identify potential sources of bias. Each question had an explicit decision rule to guide assessment.

RESULTS

Nine case-control and four cross-sectional studies examined sympathetic innervation of tendons. There was evidence suggesting a lack of difference in sympathetic innervation of tendon proper between tendinopathy biopsies and healthy controls. In contrast, the paratendinous tissue showed evidence of increased sympathetic innervation in painful tendons. The most notable increase in SNS markers was seen in abnormal tenocytes from painful tendons. Data from two studies were suitable for meta-analysis. These heterogeneous studies revealed no difference in sympathetic innervation between painful and pain-free tendons. No studies recorded SNS activity in vivo.

CONCLUSION

Sympathetic innervation in painful tendons depends on tissue type. Abnormal tenocytes may have increased capacity for self-production of sympathetic neurotransmitters. Future insight may be gained by measuring global in vivo sympathetic drive in tendinopathy.

Endoscopic Resection of Avulsed Fragment of Tibial Tuberosity and Endoscopic-Assisted Repair of Patellar Tendon

An avulsion fracture of part of the tibial tuberosity can occur as a result of a tophaceous tuberosity or Osgood-Schlatter disease. We describe an endoscopic technique of debridement, bone fragment resection, and tendon repair. This technique has the potential advantage of fewer wound complications. It is performed through proximal and distal portals on the sides of the patellar tendon. The working space is deep to the tendon. After debridement of the tendon and resection of the bone fragment, the tendon gap is assessed. Endoscopic-assisted side-by-side repair is performed to close the gap if the gap is less than 30% of the width of the tendon. If the gap is more than 30% of the width of the tendon, the proximal stump of the avulsed tendon can be retrieved through the proximal portal. Krackow suture with stay stitches is applied to the proximal stump. The stump is put back and sutured to the tibial insertion through a bone tunnel or suture anchor. This is augmented by side-by-side suturing of the avulsed tendon with the adjacent normal tendon.

Endoscopic Resection of Gouty Tophus of the Patellar Tendon

Tophaceous deposition of tendon can result in spontaneous patellar tendon rupture. Surgical therapy may be needed to control symptoms and prevent tendon rupture. Open debridement of the lesion requires a lengthy incision over the lesion; this may result in symptomatic scar adhesion of the patellar tendon or an unhealed wound with persistent tophaceous discharge. Moreover, the other part of the patellar tendon cannot be examined through the incision. We describe a technique for endoscopic resection of a gouty tophus of the patellar tendon. It has the advantage of small incisions away from the lesion and tendon and minimizes wound problems. The whole patellar tendon can be examined endoscopically.

Sclerosing injections and ultrasound-guided arthroscopic shaving for patellar tendinopathy: good clinical results and decreased tendon thickness after surgery-a medium-term follow-up study

PURPOSE

Treatment of patellar tendinopathy/jumper's knee with ultrasound-guided sclerosing injections or ultrasound-guided arthroscopic shaving has shown good clinical short-term results. Former studies indicate that the tendon thickness and structure stays unaffected after successful treatment. The aim of this study was to evaluate the sonographic findings and clinical outcome 3-5 years after treatment of patellar tendinopathy with ultrasound-guided sclerosing injections or arthroscopic shaving.

METHODS

Fifty-seven patellar tendons (43 patients) with chronic patellar tendinopathy were evaluated, with ultrasound, colour Doppler (CD) and visual analogue scale (VAS) for pain and satisfaction with treatment, 3-5 years after treatment. Functional status was evaluated with a single question-"Back in full loading activity?" yes or no.

RESULTS

At endpoint (mean 46 months), there was a significant decrease in anteroposterior thickness of the proximal patellar tendon in patients treated with ultrasound-guided arthroscopic shaving but not after sclerosing injections. Tendon structure had improved, and CD local blood flow had diminished significantly in both groups. There were good clinical results with a significant decrease in VAS for pain after sclerosing injections (VAS 64 ± 18 → 17 ± 23) with 74 % satisfied patients and also after arthroscopic shaving (VAS 77 ± 16 → 13 ± 23) with 80 % satisfied patients. There were no significant differences in VAS between groups. A significant correlation between low local blood flow and high patient satisfaction was found.

CONCLUSIONS

Tendon thickness decreased over time after ultrasound-guided arthroscopic shaving, and tendon structure and local blood flow decreased after both treatments. There were good, and similar, clinical results with both methods.

LEVEL OF EVIDENCE

III.

Endoscopic resection of lipoma of the patellar tendon

Synovial lipoma of the patellar tendon is a very rare entity. It can be associated with rupture of the patellar tendon. We present a case of synovial lipoma that was successfully resected endoscopically. The other indications for patellar tendoscopy include chronic patellar tendinitis and tendinosis, recalcitrant bursitis around the tendon, Osgood-Schlatter disease, and jumper's knee. The major potential danger of this endoscopic procedure is iatrogenic damage to the patellar insertion during endoscopic debridement in patients with jumper's knee or the tibial insertion during endoscopic debridement in patients with Osgood-Schlatter disease.

Are multiple platelet-rich plasma injections useful for treatment of chronic patellar tendinopathy in athletes? a prospective study

BACKGROUND

Chronic patellar tendinopathy (PT) is one of the most common overuse knee disorders. Platelet-rich plasma (PRP) appears to be a reliable nonoperative therapy for chronic PT.

PURPOSE

To evaluate clinical and radiological outcomes of 3 consecutive ultrasound (US)-guided PRP injections for the treatment of chronic PT in athletes.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 28 athletes (17 professional, 11 semiprofessional) with chronic PT refractory to nonoperative management were prospectively included for US-guided pure PRP injections into the site of the tendinopathy. The same treating physician at a single institution performed 3 consecutive injections 1 week apart, with the same PRP preparation used. All patients underwent clinical evaluation, including the Victorian Institute of Sport Assessment-Patella (VISA-P) score, visual analog scales (VAS) for pain, and Lysholm knee scale before surgery and after return to practice sports. Tendon healing was assessed with MRI at 1 and 3 months after the procedure.

RESULTS

The VISA-P, VAS, and Lysholm scores all significantly improved at the 2-year follow-up. The average preprocedure VISA-P, VAS, and Lysholm scores improved from 39 to 94 (P < .001), 7 to 0.8 (P < .0001), and 60 to 96 (P < .001), respectively, at the 2-year follow-up. Twenty-one of the 28 athletes returned to their presymptom sporting level at 3 months (range, 2-6 months) after the procedure. Follow-up MRI assessment showed improved structural integrity of the tendon at 3 months after the procedure and complete return to normal structural integrity of the tendon in 16 patients (57%). Seven patients did not recover their presymptom sporting level (among them, 6 were considered treatment failures): 3 patients returned to sport at a lesser level, 1 patient changed his sport activity (for other reasons), and 3 needed surgical intervention.

CONCLUSION

In this study, application of 3 consecutive US-guided PRP injections significantly improved symptoms and function in athletes with chronic PT and allowed fast recovery to their presymptom sporting level. The PRP treatment permitted a return to a normal architecture of the tendon as assessed by MRI.

New objective findings after whiplash injuries: High blood flow in painful cervical soft tissue: An ultrasound pilot study

Background

The presence of high blood flow in the structurally abnormal and painful regions of tendinosis, but not in the normal pain-free tendons, was recently confirmed by colour Doppler (CD) ultrasound (US). Biopsies from the regions with high blood flow demonstrated the presence of sympathetic and sensitive nerve fibres juxtapositioned to neovessels. Grey-scale US and CD are reliable methods used to evaluate structural homogeneity, thickness, and blood flow in the peripheral tendons. The aim of this study was to utilize CD to qualitatively evaluate for the presence of abnormal high blood flow in paravertebral tissues after whiplash injuries in patients with chronic neck pain.

Methods

Twenty patients with chronic neck pain after whiplash-associated disorder (WAD) and 20 pain-free control subjects were included in the study. The same experienced radiologist performed all grey-scale US and CD examinations.

Results

More regions with high blood flow were observed in the patient group than in the control group. At all levels, the high blood flow pattern was detected at the enthesis of the spinous processes and bilaterally juxtapositioned to the facet joints.

Conclusion

All regions identified by the patients as painful and tender corresponded to the positive high blood flow found during the CD examination.

Implications

These findings document increased blood-flow/neovascularisation at insertions of neck muscles which may indicate that there are pathological neovascularisation with accomanying pain-and sympathetic nerves, similar to what has been found in Achilles-tendinosis. These findings promise that similar treatments that now is successful with Achilles tendinosis, may be effective in the WAD-painful muscle insertions of the neck.

Comparative analysis of inter- and intraligamentous distribution of sensory nerve endings in ankle ligaments: a cadaver study

BACKGROUND

The aim of this study was to analyze the inter-, intraligamentous, and side-related patterns of sensory nerve endings in ankle ligaments.

METHODS

A total of 140 ligaments from 10 cadaver feet were harvested. Lateral: calcaneofibular, anterior-, posterior talofibular; sinus tarsi: lateral- (IERL), intermediate-, medial-roots inferior extensor retinaculum, talocalcaneal oblique and canalis tarsi (CTL); medial: tibionavicular (TNL), tibiocalcaneal (TCL), superficial tibiotalar, anterior/posterior tibiotalar portions; syndesmosis: anterior tibiofibular. Following immunohistochemical staining, the innervation and vascularity was analyzed between ligaments of each anatomical complex, left/right feet, and within the 5 levels of each ligament.

RESULTS

Significantly more free nerve endings were seen in all ligaments as compared to Ruffini, Pacini, Golgi-like, and unclassifiable corpuscles (P ≤ .005). The IERL had significantly more free nerve endings and blood vessels than the CTL (P ≤ .001). No significant differences were seen in the side-related distribution, except for Ruffini endings in right TCL (P = .016) and unclassifiable corpuscles in left TNL (P = .008). The intraligamentous analysis in general revealed no significant differences in mechanoreceptor distribution.

CONCLUSIONS

The IERL at the entrance of the sinus tarsi contained more free nerve endings and blood vessels, as compared to the deeper situated CTL. Despite different biomechanical functions in the medial and lateral ligaments, the interligamentous distribution of sensory nerve endings was equal.

CLINICAL RELEVANCE

The intrinsic innervation patterns of the ankle ligaments provides an understanding of their innate healing capacities following injury as well as the proprioception properties in postoperative rehabilitation.

Innervation pattern at the undersurface of the extensor carpi radialis brevis tendon in recalcitrant tennis elbow

PURPOSE

We investigated the general, sensory, and sympathetic innervation patterns at the undersurface of the extensor carpi radialis brevis (ECRB) origin in patients with recalcitrant tennis elbow.

METHODS

Eight elbows in eight consecutive patients (6 females and 2 males) with tennis elbow who underwent arthroscopic surgery were included in this study. The mean age was 45 years (38-66 years), and the mean duration of symptoms before surgery was 23 months (13-52 months). Operative treatment consisted of an arthroscopic inspection and debridement of the ECRB origin. Control tissues were obtained from biopsy of the ECRB capsule in two patients with osteochondritis dissecance of the capitellum who underwent arthroscopic resection of loose bodies. The tissue specimens were investigated immunohistochemically with antibodies delineating general (PGP9.5), sensory (SP/CGRP), and sympathetic (NPY) nerve patterns.

RESULTS

In the non-tendinosis control tissue, SP/CGRP and NPY immunoreactions were heterogeneously distributed in association with blood vessels. Pathologic evaluation of the biopsy tissue showed atypical fibrous granulation containing numerous vessels and nerve structures in all eight patients. Marked reactions to PGP 9.5 took the form of nerve fibers associated with arteries and arterioles in the atypical granulation. Most of the perivascular innervation was found to express NPY. The immunoreactions for SP and CGRP were invariably weak.

CONCLUSION

Increased perivascular sympathetic innervation accompanied with loss of sensory innervation at the undersurface of the ECRB tendon may play a role in chronic pain generation in recalcitrant tennis elbow.

LEVEL OF EVIDENCE

Diagnostic, Level IV.

Precise nail tip positioning after tibial intramedullary nailing prevents anterior knee pain

PURPOSE

Anterior knee pain (AKP) is a common complication following intramedullary nailing of tibial shaft fractures. Our aim was, by analysing the postoperative lateral knee X-rays and clinical status (VAS score), to find the best intramedullary tip position of a non protruded nail that will provide the best postoperative outcome avoiding AKP.

METHODS

We evaluated the postoperative outcome of 221 patients, from the last four years, with healed fractures initially treated with intramedullary reamed nails with two or three interlocking screws proximally and distally through a medial paratendinous incision for nail entry portal. Our aim was to analyse a possible relationship between AKP according to the VAS scale, and nail position marked as a distance from tip of nail to tibial plateau (NP) and to tibial tuberosity (NT), measured postoperatively on lateral knee X-rays.

RESULTS

Two groups of patients were formed on the basis of presence of pain related to AKP (the level of pain was neglected): group A were patients with pain and group B without pain. The difference between the two groups concerning NP and NT measurements appeared to be statistically significant concerning NT measurement (p < 0.05), with high accuracy according to the classification tree.

CONCLUSIONS

We presume that the position of the proximal tip of the nail and its negative influence on the innervation pattern of the area dorsal to patellar tendon could be the key factor of AKP. We conclude that the symptoms of AKP will not appear if the tip of the nail position is more than 5.5 mm from the tibial plateau (NP) and more than 2.5 mm from the tibial tuberosity (NT).

Evidence of sympathetic innervation and α1-adrenergic receptors of the long head of the biceps brachii tendon

BACKGROUND

The primary purpose of this study was to investigate the sympathetic innervation of the long head of the biceps brachii tendon LHB via immunohistochemical staining for protein S-100 and neuropeptide Y (NPY) in patients with complex proximal humerus fractures, in individuals with chronic biceps tendinosis in the setting of large rotator cuff tears (RC), and in cadaveric samples with no previously reported shoulder pathology.

METHODS

We investigated the presence of sympathetic innervation and α1-adrenergic receptors of the long head of the biceps brachii tendon (LHB) in patients with complex proximal humerus fractures and individuals with chronic biceps tendinosis in the setting of large rotator cuff tears (RC). The correlation of morphological features with immunohistochemical evidence of neural element presence was also investigated. Forty-one LHB tendon specimens were examined. Seventeen were harvested from patients who underwent hemiarthroplasty for proximal humerus fractures, 14 were from individuals with biceps tendinosis in the context of a large RC tear, and ten were from cadaveric controls with no previous shoulder pathology. Histologic examination was performed using hematoxylin and eosin. Immunohistochemistry was used to detect the expression of the protein S-100, neuropeptide Y, and α1-adrenergic receptors, as well as to characterize the potential neural differentiation of tendon cells.

RESULTS

A strong correlation between the expression of NPY/S-100, α1-adrenergic/S-100, and α1-adrenergic/NPY was found. The LHB tendon has sympathetic innervation and α1-adrenergic receptors in acute and chronic pathological conditions.

CONCLUSION

Our results provide useful guidance on the management of tendinosis and the handling of the LHB in hemiarthroplasties for fractures.

The treatment of patellar tendinopathy

BACKGROUND

Patellar tendinopathy (PT) presents a challenge to orthopaedic surgeons. The purpose of this review is to revise strategies for treatment of PT MATERIALS AND METHODS: A PubMed (MEDLINE) search of the years 2002-2012 was performed using "patellar tendinopathy" and "treatment" as keywords. The twenty-two articles addressing the treatment of PT with a higher level of evidence were selected.

RESULTS

Conservative treatment includes therapeutic exercises (eccentric training), extracorporeal shock wave therapy (ESWT), and different injection treatments (platelet-rich plasma, sclerosing polidocanol, steroids, aprotinin, autologous skin-derived tendon-like cells, and bone marrow mononuclear cells). Surgical treatment may be indicated in motivated patients if carefully followed conservative treatment is unsuccessful after more than 3-6 months. Open surgical treatment includes longitudinal splitting of the tendon, excision of abnormal tissue (tendonectomy), resection and drilling of the inferior pole of the patella, closure of the paratenon. Postoperative inmobilisation and aggressive postoperative rehabilitation are also paramount. Arthroscopic techniques include shaving of the dorsal side of the proximal tendon, removal of the hypertrophic synovitis around the inferior patellar pole with a bipolar cautery system, and arthroscopic tendon debridement with excision of the distal pole of the patella.

CONCLUSION

Physical training, and particularly eccentric training, appears to be the treatment of choice. The literature does not clarify which surgical technique is more effective in recalcitrant cases. Therefore, both open surgical techniques and arthroscopic techniques can be used.

Tendinosis: pathophysiology and nonoperative treatment

Tendinosis is a troublesome clinical entity affecting many active people. Its treatment remains a challenge to sports medicine clinicians. The etiopathophysiology of tendinosis has not been well delineated. The known pathophysiology and the recent advances in the understanding of the etiologic process of tendinosis are discussed here, including new concepts in mechanotransduction and the biochemical alterations that occur during tendon overload. The optimal, nonoperative treatment of tendinosis is not clear. This article reviews recent evidence of the clinical efficacy of the following interventions: eccentric exercise, extracorporal shock wave treatment, corticosteroid and nonsteroidal anti-inflammatory medications, sclerosing injections, nitric oxide, platelet-rich plasma injections, and matrix metalloproteinase inhibitors. Eccentric exercise has strongest evidence of efficacy. Extracorporal shock wave treatment has mixed evidence and needs further study of energy and application protocols. Sclerosing agents show promising early results but require long-term studies. Corticosteroid and nonsteroidal anti-inflammatory medications have not been shown to be effective, and many basic science studies raise possible concerns with their use. Nitric oxide has been shown in several basic science studies to be promising, but clinical efficacy has not been well established. More clinical trials are needed to assess dosing, indications, and clinical efficacy of nitric oxide. Platelet-rich plasma injections have offered encouraging short-term results. Larger and longer-term clinical trials are needed to assess this promising modality. Matrix metalloproteinase inhibitors have had few clinical studies, and their role in the treatment of tendinosis is still in the early phase of investigation.

Transient Appearance of Tyrosine Hydroxylase Immunoreactive Cells in the Midline Epithelial Seam of the Human Fetal Secondary Palate

Objective

Transient immunoreactivity for tyrosine hydroxylase, which mediates the conversion of the amino acid L-tyrosine to dihydroxyphenylalanine, in the midline epithelial seam between the bilateral palatal shelves was investigated in human fetuses.

Materials and Methods

Horizontal or frontal paraffin sections of two human fetuses at 9 and 15 weeks of gestation were used to examine the distribution of tyrosine hydroxylase–immunoreactive cells in regions of the entire head other than the brain. Immunohistochemical staining for S100 protein, calretinin, cytokeratin 14, and vimentin was examined using adjacent or near sections.

Results

Tyrosine hydroxylase–immunoreactive cells were large and densely distributed in the midline epithelial seam at the site of palatal fusion in fetuses at 9 weeks but not in fetuses at 15 weeks, in which the midline epithelial seam had already disappeared. No expression of S100 protein, calretinin, or vimentin was detected, but the midline epithelial seam was positive for cytokeratin 14. Tyrosine hydroxylase immunoreactivity was not detected in epithelia during the process of palatal fusion in mice from E 14.0 to 15.0.

Conclusions

These findings indicate that tyrosine hydroxylase–immunoreactive cells in the midline epithelial seams are nonneural epithelial cells and suggest that the tyrosine hydroxylase is a novel factor involved in normal palatal formation, especially the fate of the midline epithelial seam in humans.

Alpha-2 adrenergic stimulation triggers Achilles tenocyte hypercellularity: Comparison between two model systems

The histopathology of tendons with painful tendinopathy is often tendinosis, a fibrosis-like condition of unclear pathogenesis characterized by tissue changes including hypercellularity. The primary tendon cells (tenocytes) have been shown to express adrenoreceptors (mainly alpha-2A) as well as markers of catecholamine production, particularly in tendinosis. It is known that adrenergic stimulation can induce proliferation in other cells. The present study investigated the effects of an exogenously administered alpha-2 adrenergic agonist in an established in vivo Achilles tendinosis model (rabbit) and also in an in vitro human tendon cell culture model. The catecholamine producing enzyme tyrosine hydroxylase and the alpha-2A-adrenoreceptor (α_2A AR) were expressed by tenocytes, and alpha-2 adrenergic stimulation had a proliferative effect on these cells, in both models. The proliferation was inhibited by administration of an α_2A AR antagonist, and the in vitro model further showed that the proliferative alpha-2A effect was mediated via a mitogenic cell signaling pathway involving phosphorylation of extracellular-signal-regulated kinases 1 and 2. The results indicate that catecholamines produced by tenocytes in tendinosis might contribute to the proliferative nature of the pathology through stimulation of the α_2A AR, pointing to a novel target for future therapies. The study furthermore shows that animal models are not necessarily required for all aspects of this research.

Arthroscopic management of chronic patellar tendinopathy

BACKGROUND

In patients with patellar tendinopathy in whom nonoperative management is unsuccessful, surgery is an option to return to high levels of physical activity. Although open surgery is traditionally advocated, an arthroscopic approach may be safe and effective.

PURPOSE

This study was undertaken to analyze medium- and long-term outcome of 64 patients undergoing arthroscopic surgery for the management of patellar tendinopathy after failing nonoperative treatment.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 64 patients (73 knees), 27 of whom were professional athletes, with patellar tendinopathy refractory to nonoperative management underwent arthroscopic debridement of the adipose tissue of the Hoffa's body posterior to the patellar tendon, debridement of abnormal patellar tendon, and excision of the lower pole of the patella. Preoperative and postoperative evaluation was undertaken using the International Knee Documentation Committee (IKDC), Lysholm knee scale, and Victorian Institute of Sport Assessment-Patella (VISA-P) scores for all patients at 1 and 3 years. No patients were lost to follow-up. Forty-three and 29 patients were similarly assessed at 5 and 10 years, respectively, after surgery. Return to sports and rehabilitation was also assessed.

RESULTS

The IKDC, Lysholm, and VISA-P scores all significantly improved at 1 and 3 years' follow-up. The average preoperative IKDC score of 51.6 improved to 86.4 at both the 1- and 3-year stage. The average preoperative Lysholm score of 52.3 improved to 94.7 at 1-year follow-up and was 95.5 at 3-year follow-up. The average preoperative VISA-P score of 35.3 improved to 69.8 at the 1-year stage and was 70.7 at the 3-year follow-up. These scores remained significantly better for the patients assessed at 5 and 10 years' follow-up. There were no postoperative complications. Nineteen of the 27 professional athletes returned to sports at the same level. Seven patients developed pain after sports within 3 years after the operation, a failure rate of 7 of 73 knees (9.6%). All patients were able to return to sports by 3 months.

CONCLUSION

Arthroscopic surgery for patients with patellar tendinopathy, refractory to nonoperative management, appears to provide significant improvements in symptoms and function, with improvements maintained for at least 3 years. These results suggest that some patients may not be able to achieve their presymptom sporting level; or if they do, they may participate in sports with some degree of residual symptoms. Limited data show that these improvements are maintained for up to 10 years. Early return to sports may also be achieved.

Jumper's knee in volleyball athletes: advancements in diagnosis and treatment

Jumper's knee, or patellar tendinopathy, affects nearly one half of elite volleyball athletes and causes significant morbidity. The diagnosis and treatment of jumper's knee is evolving with heavier reliance on the use of diagnostic ultrasound with and without color or power Doppler. Research suggests that conservative treatment is very effective using an eccentric exercise regimen and decline squats. Interventional treatments are expanding as well, with positive results seen using extracorporeal shock wave therapy and polidocanol sclerosing injections. Arthroscopic surgical approaches are being developed, some using intra-operative ultrasound guidance. The findings of several recent basic science studies imply that the future may lie in developing a greater understanding of, and then possibly modulating the balance of, the local neuronal, vascular, or biochemical factors associated with symptomatic patellar tendinopathy.

The role of tendon microcirculation in Achilles and patellar tendinopathy

Tendinopathy is of distinct interest as it describes a painful tendon disease with local tenderness, swelling and pain associated with sonographic features such as hypoechogenic texture and diameter enlargement. Recent research elucidated microcirculatory changes in tendinopathy using laser Doppler flowmetry and spectrophotometry such as at the Achilles tendon, the patellar tendon as well as at the elbow and the wrist level. Tendon capillary blood flow is increased at the point of pain. Tendon oxygen saturation as well as tendon postcapillary venous filling pressures, determined non-invasively using combined Laser Doppler flowmetry and spectrophotometry, can quantify, in real-time, how tendon microcirculation changes over with pathology or in response to a given therapy. Tendon oxygen saturation can be increased by repetitive, intermittent short-term ice applications in Achilles tendons; this corresponds to 'ischemic preconditioning', a method used to train tissue to sustain ischemic damage. On the other hand, decreasing tendon oxygenation may reflect local acidosis and deteriorating tendon metabolism. Painful eccentric training, a common therapy for Achilles, patellar, supraspinatus and wrist tendinopathy decreases abnormal capillary tendon flow without compromising local tendon oxygenation. Combining an Achilles pneumatic wrap with eccentric training changes tendon microcirculation in a different way than does eccentric training alone; both approaches reduce pain in Achilles tendinopathy. The microcirculatory effects of measures such as extracorporeal shock wave therapy as well as topical nitroglycerine application are to be studied in tendinopathy as well as the critical question of dosage and maintenance. Interestingly it seems that injection therapy using color Doppler for targeting the area of neovascularisation yields to good clinical results with polidocanol sclerosing therapy, but also with a combination of epinephrine and lidocaine.