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Cuttica DJ, Neufeld SK, Baird M, Levy JA. Treatment of Insertional Achilles Tendinosis With Polyurethane Urea-Based Matrix Augmentation. Foot Ankle Spec 2023; 16:392-398. [PMID: 36181272 DOI: 10.1177/19386400221125362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Surgical treatment for insertional Achilles tendinosis (IAT) sometimes requires tendon repair augmentation. The purpose of this study is to evaluate the efficacy of polycaprolactone-based polyurethane urea (PUUR) matrix augmentation in the treatment of IAT. METHODS A retrospective review was performed in surgically treated IAT. Repairs were augmented with a PUUR matrix. Factors evaluated included date of full weightbearing, patient satisfaction, Visual Analog Scale (VAS) pain score, strength, and ankle motion. The Wilcoxon signed-rank test was used to compare baseline and final follow-up VAS scores. RESULTS A total of 18 cases were included in the study. The mean patient age was 54.61 ± 8.25 (40-75) years with a mean follow-up of 163.61 ± 57.81 (92-314) days. Patient satisfaction was obtained on 15 of 18 patients, with 14 patients satisfied with their outcome. Mean VAS for pain significantly decreased from 6.19 ± 1.97 (2.5-9) to 0.83 ± 1.54 (0-5) postoperatively, which was statistically significant (P < .01). CONCLUSION Achilles tendon augmentation with the PUUR matrix is a viable option in the treatment of IAT. Its use in this condition has minimal morbidity and can be an alternative to other forms of augmentation. LEVELS OF EVIDENCE Level IV: Retrospective case series.
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Affiliation(s)
| | | | - Michael Baird
- Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Jeffrey A Levy
- The Orthopaedic Foot & Ankle Center, Falls Church, Virginia
- Riverside Orthopedic Specialists Williamsburg, Williamsburg, Virginia
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Wasker SVZ, Challoumas D, Weng W, Murrell GAC, Millar NL. Is neurogenic inflammation involved in tendinopathy? A systematic review. BMJ Open Sport Exerc Med 2023; 9:e001494. [PMID: 36793930 PMCID: PMC9923261 DOI: 10.1136/bmjsem-2022-001494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2023] [Indexed: 02/11/2023] Open
Abstract
Neurogenic pain and inflammation have been hypothesised to play an important role in tendinopathy. This systematic review aimed to present and assess the evidence on neurogenic inflammation in tendinopathy. A systematic search was conducted through multiple databases to identify human case-control studies assessing neurogenic inflammation through the upregulation of relevant cells, receptors, markers and mediators. A newly devised tool was used for the methodological quality assessment of studies. Results were pooled based on the cell/receptor/marker/mediator assessed. A total of 31 case-control studies were eligible for inclusion. The tendinopathic tissue was obtained from Achilles (n=11), patellar (n=8), extensor carpi radialis brevis (n=4), rotator cuff (n=4), distal biceps (n=3) and gluteal (n=1) tendons. Through pooling the results of included studies based on the marker of neurogenic inflammation assessed, we identified possible upregulation of protein gene product 9.5 (PGP 9.5), N-methyl-D-aspartate Receptors, glutamate, glutamate receptors (mGLUT), neuropeptide Y (NPY) and adrenoreceptors in tendinopathic tissue versus control. Calcitonin gene-related peptide (CGRP) was not found to be upregulated, and the evidence was conflicting for several other markers. These findings show the involvement of the glutaminergic and sympathetic nervous systems and the upregulation of nerve ingrowth markers supporting the concept that neurogenic inflammation plays a role in tendinopathy.
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Affiliation(s)
- Shimon Vinay Zedeck Wasker
- Orthopaedic Research Institute, St George Hospital Sydney, University of New South Wales, Sydney, New South Wales, Australia
| | - Dimitris Challoumas
- School of Infection and Immunity, College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Wai Weng
- Orthopaedic Research Institute, St George Hospital Sydney, University of New South Wales, Sydney, New South Wales, Australia
| | - George A C Murrell
- Orthopaedic Research Institute, St George Hospital Sydney, University of New South Wales, Sydney, New South Wales, Australia
| | - Neal L Millar
- School of Infection and Immunity, College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
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Wheeler PC. Nearly half of patients with chronic tendinopathy may have a neuropathic pain component, with significant differences seen between different tendon sites: a prospective cohort of more than 300 patients. BMJ Open Sport Exerc Med 2022; 8:e001297. [PMID: 35965784 PMCID: PMC9301817 DOI: 10.1136/bmjsem-2021-001297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 11/04/2022] Open
Abstract
ObjectivesIdentifying the prevalence of neuropathic pain components in patients with chronic tendinopathy conditions using the Self-Administered Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) questionnaire.MethodsPatients with chronic tendinopathy and ‘tendon-like’ conditions treated within a single hospital outpatient clinic specialising in tendinopathy were identified. Pain scores, plus global function patient-reported outcome measures (5-Level version of EuroQol-5 Dimension and Musculoskeletal Health Questionnaire (MSK-HQ)), were completed and compared with the S-LANSS questionnaireResults341 suitable patients with chronic tendinopathy and potentially similar conditions were identified. Numbers: lateral elbow tendinopathy (39), greater trochanteric pain syndrome (GTPS; 112), patellar tendinopathy (11), non-insertional Achilles tendinopathy (40), insertional Achilles tendinopathy (39), plantar fasciopathy (100). 68% were female, with a mean age of 54.0±11.3 years and a mean symptom duration of 38.1±33.7 months.There was a mean S-LANSS score of 11.4±6.4. Overall, 47% of patients scored 12 or greater points on S-LANSS, indicating the possible presence of neuropathic pain. The highest proportion was in patients with plantar fasciopathy (61%), the lowest in those with GTPS (33%). Weak correlations were found between the S-LANSS score and MSK-HQ score, the numerical rating scale (0–10) values for ‘average pain’ and for ‘worst pain’, but not with the MSK-HQ %health value.ConclusionS-LANSS identified nearly half of patients with chronic tendinopathy as possibly having a neuropathic pain component. This is of unclear clinical significance but worth further study to see if/how this may relate to treatment outcomes. These results are from a single hospital clinic dealing with patients with chronic tendinopathy, without a control group or those with shorter symptom duration. However, this reinforces the probability of neuropathic pain components in at least some patients with chronic tendinopathy.
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Affiliation(s)
- Patrick C Wheeler
- Department of Sport and Exercise Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
- SSEHS, Loughborough University, Loughborough, UK
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Savva C, Karagiannis C, Korakakis V, Efstathiou M. The analgesic effect of joint mobilization and manipulation in tendinopathy: a narrative review. J Man Manip Ther 2021; 29:276-287. [PMID: 33769226 PMCID: PMC8491707 DOI: 10.1080/10669817.2021.1904348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Objective: To summarize the available literature with regards to the potential analgesic effect and mechanism of joint mobilization and manipulation in tendinopathy. Results: The effect of these techniques in rotator cuff tendinopathy and lateral elbow tendinopathy, applied alone, compared to a placebo intervention or along with other interventions has been reported in some randomized controlled trials which have been scrutinized in systematic reviews. Due to the small randomized controlled trials and other methodological limitations of the evidence base, including short-term follow-ups, small sample size and lack of homogenous samples further studies are needed. Literature in other tendinopathies such as medial elbow tendinopathy, de Quervain's disease and Achilles tendinopathy is limited since the analgesic effect of these techniques has been identified in few case series and reports. Therefore, the low methodological quality renders caution in the generalization of findings in clinical practice. Studies on the analgesic mechanism of these techniques highlight the activation of the descending inhibitory pain mechanism and sympathoexcitation although this area needs further investigation. Conclusion: Study suggests that joint mobilization and manipulation may be a potential contributor in the management of tendinopathy as a pre-conditioning process prior to formal exercise loading rehabilitation or other proven effective treatment approaches.
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Affiliation(s)
- Christos Savva
- Department of Health Science, European University, Nicosia, Cyprus
| | | | | | - Michalis Efstathiou
- Department of Life and Health Sciences, University of Nicosia, Nicosia, Cyprus
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Leonardi EA, Xiao M, Murray IR, Robinson WH, Abrams GD. Tendon-Derived Progenitor Cells With Multilineage Potential Are Present Within Human Patellar Tendon. Orthop J Sports Med 2021; 9:23259671211023452. [PMID: 34435068 PMCID: PMC8381435 DOI: 10.1177/23259671211023452] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 02/24/2021] [Indexed: 01/13/2023] Open
Abstract
Background: Progenitor cells serve as a promising source of regenerative potential in a
variety of tissue types yet remain underutilized in tendinopathy.
Tendon-derived progenitor cells (TDPCs) have previously been isolated from
hamstring tendon but only as part of a concomitant medical procedure.
Determining the presence of TDPCs in patellar tendon may facilitate clinical
utilization of these cells because of the relative accessibility of this
location for tissue harvest. Purpose: To characterize TDPCs in human patellar tendon samples. Study Design: Descriptive laboratory study. Methods: Human patellar tendon samples were obtained during elective knee surgery.
TDPCs were isolated and seeded at an optimal low cell density and
subcultured to confluence for up to 2 passages. Flow cytometry was used to
analyze for the expression of CD90+, CD105+, CD44+, and CD31–, CD34–, and
CD45– markers. The multilineage differentiation potential of TDPCs was
tested in vitro via adipogenic, osteogenic, and chondrogenic culture with
subsequent cytochemical staining for Oil Red O, Alizarin Red, and Alcian
Blue, respectively. Enzyme-linked immunosorbent assay was used to quantify
the amount of adiponectin, alkaline phosphatase, and SRY-box transcription
factor 9 secreted into cell culture supernatant for further confirmation of
lineage differentiation. Results were analyzed statistically using the
2-tailed Student t test. Results: TDPCs demonstrated near-uniform expression of CD90, CD105, and CD44 with
minimal expression of CD34, CD31, and CD45. Adipogenic, osteogenic, and
chondrogenic differentiation of TDPCs was confirmed using qualitative
analysis. The expression of adiponectin, alkaline phosphatase, and SRY-box
transcription factor 9 were significantly increased in differentiated cells
versus undifferentiated TDPCs (P < .05). Conclusion: TDPCs can be successfully isolated from human patellar tendon samples, and
they exhibit characteristics of multipotent progenitor cells. Clinical Relevance: These data demonstrate the promise of patellar tendon tissue as a source of
progenitor cells for use in biologic therapies for the treatment of
tendinopathy.
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Affiliation(s)
- Erika A Leonardi
- Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Michelle Xiao
- Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Iain R Murray
- Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - William H Robinson
- Division of Rheumatology and Immunology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA.,Palo Alto Division, VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Geoffrey D Abrams
- Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, California, USA
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Adverse Impact of Corticosteroids on Rotator Cuff Tendon Health and Repair: A Systematic Review of Basic Science Studies. Arthrosc Sports Med Rehabil 2020; 2:e161-e169. [PMID: 32368753 PMCID: PMC7190543 DOI: 10.1016/j.asmr.2020.01.002] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 01/13/2020] [Indexed: 11/22/2022] Open
Abstract
Purpose To evaluate the in vitro effects of corticosteroid injections (CSIs) on rotator cuff tendon (RCT). Methods A systematic review of the MEDLINE database was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for all studies reporting on adverse biochemical and biomechanical effects of CSIs on RCT. Results Sixteen studies were identified that had been published in the last 15 years on the effects of corticosteroids on RCTs. Eight of these studies were on human RCTs, 6 were on rat tendons, 1 considered both human and rat tendons, and 1 was on dog tendon. Five studies analyzed the effects of corticosteroids on the biomechanical properties of RCT or rotator cuff repair, whereas the remaining observed the cellular and molecular effects of CSIs on RCT. Corticosteroids suppress an inflammatory response, induce apoptosis, and have negative effects on collagen and tendon cell viability in RCTs. The mechanical properties, including load to failure of RCTs and rotator cuff repair anchor pull-out strength, also are decreased by CSIs. These in vitro effects appear to be transient as well as frequency and dose dependent. Conclusions On a molecular level, CSIs decrease cellular proliferation, alter collagen and extracellular matrix composition, impede inflammatory pathways, decrease cellular viability, increase adipocyte differentiation, and increase apoptosis. These changes can be seen as early as 24 hours after corticosteroid exposure, last as long as 2 to 3 weeks, and are exacerbated by increased doses and decreased latency between doses. Biomechanical studies demonstrate that these changes result in decreased maximal load to failure, tendon stiffness, and suture anchor pull-out strength in rat shoulders up to 2 weeks but not at 3 and 4 weeks, post-CSI. Clinical Relevance Shoulder subacromial steroid injection is common, and practitioners should be aware of results both positive and deleterious.
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Steinmann S, Pfeifer CG, Brochhausen C, Docheva D. Spectrum of Tendon Pathologies: Triggers, Trails and End-State. Int J Mol Sci 2020; 21:ijms21030844. [PMID: 32013018 PMCID: PMC7037288 DOI: 10.3390/ijms21030844] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/18/2020] [Accepted: 01/24/2020] [Indexed: 12/31/2022] Open
Abstract
The biggest compartment of the musculoskeletal system is the tendons and ligaments. In particular, tendons are dense tissues connecting muscle to bone that are critical for the integrity, function and locomotion of this system. Due to the increasing age of our society and the overall rise in engagement in extreme and overuse sports, there is a growing prevalence of tendinopathies. Despite the recent advances in tendon research and due to difficult early diagnosis, a multitude of risk factors and vague understanding of the underlying biological mechanisms involved in the progression of tendon injuries, the toolbox of treatment strategies remains limited and non-satisfactory. This review is designed to summarize the current knowledge of triggers, trails and end state of tendinopathies.
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Affiliation(s)
- Sara Steinmann
- Experimental Trauma Surgery, Department of Trauma Surgery, University Medical Center Regensburg, Am Biopark 9, 93053 Regensburg, Germany; (S.S.); (C.G.P.)
| | - Christian G. Pfeifer
- Experimental Trauma Surgery, Department of Trauma Surgery, University Medical Center Regensburg, Am Biopark 9, 93053 Regensburg, Germany; (S.S.); (C.G.P.)
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Christoph Brochhausen
- Institute of Pathology, University Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany;
| | - Denitsa Docheva
- Experimental Trauma Surgery, Department of Trauma Surgery, University Medical Center Regensburg, Am Biopark 9, 93053 Regensburg, Germany; (S.S.); (C.G.P.)
- Department of Medical Biology, Medical University-Plovdiv, 15A Vassil Aprilov Blvd., 4002 Plovdiv, Bulgaria
- Correspondence: ; Tel.: +49 941 943-1605
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Tumilty S, Adhia DB, Smoliga JM, Gisselman AS. Thermal profiles over the Achilles tendon in a cohort of non-injured collegiate athletes over the course of a cross country season. Phys Ther Sport 2019; 36:110-115. [DOI: 10.1016/j.ptsp.2019.01.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 01/24/2019] [Accepted: 01/25/2019] [Indexed: 10/27/2022]
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Dinhane KGI, Godoy-Santos AL, Fabro AT, Moretto MR, Deprá I, Yoshida WB. Short-term Changes After Corticosteroid Injections Into the Normal Tendons of Rabbits: A Controlled Randomized Study. Am J Sports Med 2019; 47:721-728. [PMID: 30640506 DOI: 10.1177/0363546518818819] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Corticosteroid injections in or around tendons for the treatment of athletic injuries are a common practice among orthopaedic surgeons and are apparently efficacious in the short term, although controversies persist related to local complications. PURPOSE This study evaluated short-term (48 hours) biomechanical, biochemical, and histological alterations after a single injection of betamethasone into the normal tendons of rabbits. STUDY DESIGN Controlled laboratory study. METHODS A total of 72 New Zealand White rabbits were randomly divided into 2 groups: the test group-in which 36 animals underwent 1 intratendinous injection of betamethasone (1.4 mg / 0.2 mL) in the right calcaneal tendon; the control group-in which the right calcaneal tendon of 36 animals was injected with saline (placebo control group) and the left calcaneal tendon was left untreated for normal standards (normal control). Forty-eight hours later, animals were euthanized and tendons were harvested. Metalloproteinase (MMP1 and MMP2) and interleukin (IL1 and IL6) expression levels, biomechanical resistance (load × elongation parameters), and histomorphometry (hematoxylin and eosin and picrosirius red stains for collagen fibers, tenocytes, and inflammatory cells) were analyzed in the tendons. RESULTS The test group had a significant reduction in MMP2 expression as compared with the control groups ( P = .027). Regarding the other parameters, there were no additional significant differences between the groups. CONCLUSION A single injection of corticosteroid into normal calcaneal tendons did not trigger acute local morphological, structural, or biomechanical injuries at 48 hours, but it did promote a significant decrease in MMP2 levels. Additional studies are needed with increased duration of follow-up, various doses, and multiple injections and in tendinopathic models. CLINICAL RELEVANCE Some previous studies demonstrated early structural changes in tendons after a single corticosteroid injection, which was not corroborated by the present study. Metalloproteinase decrease is usually associated with a reduction in collagen degradation, which would be protective for the healing process. More studies are necessary to confirm the possible beneficial effect of these results in the long term and for tendinopathies.
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Affiliation(s)
| | | | | | - Maria Regina Moretto
- University Hospital of Botucatu Medical School, Paulista State University, Botucatu, Brazil
| | - Igor Deprá
- University Hospital of Botucatu Medical School, Paulista State University, Botucatu, Brazil
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Aicale R, Tarantino D, Maffulli N. Overuse injuries in sport: a comprehensive overview. J Orthop Surg Res 2018; 13:309. [PMID: 30518382 PMCID: PMC6282309 DOI: 10.1186/s13018-018-1017-5] [Citation(s) in RCA: 110] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 11/21/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The absence of a single, identifiable traumatic cause has been traditionally used as a definition for a causative factor of overuse injury. Excessive loading, insufficient recovery, and underpreparedness can increase injury risk by exposing athletes to relatively large changes in load. The musculoskeletal system, if subjected to excessive stress, can suffer from various types of overuse injuries which may affect the bone, muscles, tendons, and ligaments. METHODS We performed a search (up to March 2018) in the PubMed and Scopus electronic databases to identify the available scientific articles about the pathophysiology and the incidence of overuse sport injuries. For the purposes of our review, we used several combinations of the following keywords: overuse, injury, tendon, tendinopathy, stress fracture, stress reaction, and juvenile osteochondritis dissecans. RESULTS Overuse tendinopathy induces in the tendon pain and swelling with associated decreased tolerance to exercise and various types of tendon degeneration. Poor training technique and a variety of risk factors may predispose athletes to stress reactions that may be interpreted as possible precursors of stress fractures. A frequent cause of pain in adolescents is juvenile osteochondritis dissecans (JOCD), which is characterized by delamination and localized necrosis of the subchondral bone, with or without the involvement of articular cartilage. The purpose of this compressive review is to give an overview of overuse injuries in sport by describing the theoretical foundations of these conditions that may predispose to the development of tendinopathy, stress fractures, stress reactions, and juvenile osteochondritis dissecans and the implication that these pathologies may have in their management. CONCLUSIONS Further research is required to improve our knowledge on tendon and bone healing, enabling specific treatment strategies to be developed for the management of overuse injuries.
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Affiliation(s)
- R. Aicale
- Department of Musculoskeletal Disorders, School of Medicine and Dentistry, University of Salerno, Salerno, Italy
| | - D. Tarantino
- Department of Musculoskeletal Disorders, School of Medicine and Dentistry, University of Salerno, Salerno, Italy
| | - N. Maffulli
- Department of Musculoskeletal Disorders, School of Medicine and Dentistry, University of Salerno, Salerno, Italy
- Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary University of London, 275 Bancroft Road, London, E1 4DG England
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Abate M, Di Carlo L, Verna S, Di Gregorio P, Schiavone C, Salini V. Synergistic activity of platelet rich plasma and high volume image guided injection for patellar tendinopathy. Knee Surg Sports Traumatol Arthrosc 2018; 26:3645-3651. [PMID: 29605861 DOI: 10.1007/s00167-018-4930-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 03/26/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE Platelet rich plasma and high volume image guided injections of saline have been used in the treatment of patellar tendinopathy with positive results. As the different mechanisms of action do not interfere each other, it can be hypothesized that they can be used in combination. Aim of this study was twofold: first, to evaluate the efficacy of these two treatments in the management of patellar tendinopathy; second, to verify whether the combination of these therapies could provide further advantages. METHODS Fifty-four patients suffering from patellar tendinopathy were enrolled. After clinical (VAS and VISA-P) and sonographic evaluation, two ultrasound guided injections (2 weeks apart) of platelet rich plasma, high-volume image-guided injections of saline, or both in association were performed. The VAS and VISA-P scores obtained from the three treatments groups (18 patients in each group) were compared across the different follow-up times (3 and 6 months). RESULTS In the short term both treatments showed comparable efficacy, whereas in the medium term the positive effects of high-volume image-guided injections gradually diminished and platelet rich plasma showed greater efficacy. Better results (reduced pain, improved function and increased number of subjects who exhibited optimal recovery [> 20 points in VISA-P score]) were observed when both procedures were associated. CONCLUSIONS The contemporaneous administration of platelet rich plasma and high volume image guided injections of saline treatments, which influence tendon repair by means of different mechanisms, grants a greater improvement for patellar tendinopathy. This finding has clinical relevance, given that this condition has a substantial impact on sports and work performance. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Michele Abate
- Department of Medicine and Science of Aging, University G. d'Annunzio, Chieti-Pescara, Via dei Vestini 31, Chieti Scalo, 66013, Chieti, CH, Italy.
| | - Luigi Di Carlo
- Department of Medicine and Science of Aging, University G. d'Annunzio, Chieti-Pescara, Via dei Vestini 31, Chieti Scalo, 66013, Chieti, CH, Italy
| | - Sandra Verna
- Immunohaematology and Transfusional Medicine Service, "SS. Annunziata" Hospital, Chieti Scalo, Chieti, Italy
| | - Patrizia Di Gregorio
- Immunohaematology and Transfusional Medicine Service, "SS. Annunziata" Hospital, Chieti Scalo, Chieti, Italy
| | - Cosima Schiavone
- Department of Medicine and Science of Aging, University G. d'Annunzio, Chieti-Pescara, Via dei Vestini 31, Chieti Scalo, 66013, Chieti, CH, Italy
| | - Vincenzo Salini
- Department of Medicine and Science of Aging, University G. d'Annunzio, Chieti-Pescara, Via dei Vestini 31, Chieti Scalo, 66013, Chieti, CH, Italy
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13
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Klemt C, Prinold JA, Morgans S, Smith SH, Nolte D, Reilly P, Bull AM. Analysis of shoulder compressive and shear forces during functional activities of daily life. Clin Biomech (Bristol, Avon) 2018; 54:34-41. [PMID: 29550641 PMCID: PMC6405441 DOI: 10.1016/j.clinbiomech.2018.03.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 03/02/2018] [Accepted: 03/13/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Knowledge of forces acting through the glenohumeral joint during activities of daily living is a prerequisite for improving implant design and aiding rehabilitation planning. Existing data are limited by the number of activities performed and, in some cases, the lack of representation of the glenohumeral loading direction, although high shear force components may cause joint dislocation or implant loosening. This study aims to analyse shoulder compression and shear force components during essential functional activities of daily living. METHODS This is a combined modelling and experimental study. Motion data and external forces measured from 25 participants for 26 activities of daily living serve as input into an upper limb musculoskeletal model that quantifies glenohumeral loading. FINDINGS The shoulder contact force exceeds 50% of the body weight in 10/26 activities of daily living with a maximum contact force of 164% of the body weight (SD 69%) for a sit to stand task. The ratio of glenohumeral shear force component to compression force component exceeds 0.5 in 8/26 functional activities, with maximum ratios for reaching across the body (1.09; SD 0.41) and pick and place an everyday object (0.88; SD 0.36). INTERPRETATION This study demonstrates substantial loads through the glenohumeral joint during activities of daily living. The ratios of glenohumeral shear force component to compression force component are considerable when high loads act at long lever arms and at high angles of arm elevation. These glenohumeral ratios represent a key component of loading that should be considered when designing implants, surgical procedures, or rehabilitation protocols.
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Affiliation(s)
- Christian Klemt
- Department of Bioengineering, Imperial College London, London, SW7 2AZ, United Kingdom,Corresponding author.
| | - Joe A. Prinold
- Department of Bioengineering, Imperial College London, London, SW7 2AZ, United Kingdom
| | - Sharon Morgans
- Physiotherapy Unit, Imperial College Healthcare NHS Trust, London, NW8 9NH, United Kingdom
| | - Samuel H.L. Smith
- Department of Bioengineering, Imperial College London, London, SW7 2AZ, United Kingdom
| | - Daniel Nolte
- Department of Bioengineering, Imperial College London, London, SW7 2AZ, United Kingdom
| | - Peter Reilly
- Department of Bioengineering, Imperial College London, London, SW7 2AZ, United Kingdom,Department of Trauma and Orthopaedics, Imperial College Healthcare NHS Trust, London, W2 1NY, United Kingdom
| | - Anthony M.J. Bull
- Department of Bioengineering, Imperial College London, London, SW7 2AZ, United Kingdom
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Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2018. J Orthop Sports Phys Ther 2018; 48:A1-A38. [PMID: 29712543 DOI: 10.2519/jospt.2018.0302] [Citation(s) in RCA: 134] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to midportion Achilles tendinopathy. J Orthop Sports Phys Ther 2018;48(5):A1-A38. doi:10.2519/jospt.2018.0302.
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Song XX, Shi S, Guo Z, Li XF, Yu BW. Estrogen receptors involvement in intervertebral discogenic pain of the elderly women: colocalization and correlation with the expression of Substance P in nucleus pulposus. Oncotarget 2018; 8:38136-38144. [PMID: 28430617 PMCID: PMC5503520 DOI: 10.18632/oncotarget.15421] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 02/08/2017] [Indexed: 11/25/2022] Open
Abstract
Estrogenic modulation of pain is an exceedingly complex phenomenon. However, whether estrogen is involved in discogenic low back pain still remains unclear. Here, immunoreactivity staining technique was used to examine the expression level of the estrogen receptors (ERα and ERβ) and a pain related neuropeptide, Substance P in the lumbar intervertebral discs to analyze the relationship between the ERs and Substance P. Nucleus pulposus tissues of 23 elderly female patients were harvested during spinal surgeries and made to detect the immunoreactivity staining of ERα, ERβ and Substance P. The colocalization and intensities of ERs and Substance P were explored and evaluated respectively. The correlations between changes of ERα, ERβ and Substance P were also assessed.Our results revealed that Substance P colocalized with ERα and ERβ both in cytoplasm and nucleus of the nucleus pulposus cells. HSCORE analysis indicated that Substance P negatively correlated with both ERα and ERβ expression. Collectively, the crosstalk between ERs and Substance P might exist in the disc tissue. Estrogen-dependent pain mechanism might partly be mediated through ERs and Substance P in the nucleus pulposus of the elderly females. Estrogen and its receptors might be drug targets in discogenic low back pain diseases.
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Affiliation(s)
- Xiao-Xing Song
- Department of Anesthesiology, Rui Jin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Department of Orthopaedic Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Sheng Shi
- Department of Orthopaedic Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhen Guo
- Department of Orthopaedic Surgery, Yang Pu Hospital, Tongji University, Shanghai, China
| | - Xin-Feng Li
- Department of Orthopaedic Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Bu-Wei Yu
- Department of Anesthesiology, Rui Jin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Andia I, Martin JI, Maffulli N. Advances with platelet rich plasma therapies for tendon regeneration. Expert Opin Biol Ther 2018; 18:389-398. [DOI: 10.1080/14712598.2018.1424626] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Isabel Andia
- Regenerative Medicine Laboratory, BioCruces Health Research Institute, Cruces University Hospital, Barakaldo, Spain
| | - Jose Ignacio Martin
- Regenerative Medicine Laboratory, BioCruces Health Research Institute, Cruces University Hospital, Barakaldo, Spain
- Interventional Imaging. Department of Radiology, Cruces University Hospital, Barakaldo, Spain
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, University of Salerno School of Medicine and Dentristry, Salerno, Italy
- Barts and the London School of Medicine and Dentistry Centre for Sports and Exercise Medicine, Queen Mary University of London, London, England
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Chimenti RL, Cychosz CC, Hall MM, Phisitkul P. Current Concepts Review Update: Insertional Achilles Tendinopathy. Foot Ankle Int 2017; 38:1160-1169. [PMID: 28789557 PMCID: PMC5956523 DOI: 10.1177/1071100717723127] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Ruth L. Chimenti
- Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA, USA
| | - Chris C. Cychosz
- Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
| | - Mederic M. Hall
- Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, IA, USA,Department of Radiology, University of Iowa, Iowa City, IA, USA
| | - Phinit Phisitkul
- Department of Orthopaedics and Rehabilitation, University of Iowa, Iowa City, IA, USA
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Dean BJF, Dakin SG, Millar NL, Carr AJ. Review: Emerging concepts in the pathogenesis of tendinopathy. Surgeon 2017; 15:349-354. [PMID: 28619548 PMCID: PMC5714045 DOI: 10.1016/j.surge.2017.05.005] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 05/19/2017] [Accepted: 05/22/2017] [Indexed: 02/07/2023]
Abstract
Tendinopathy is a common clinical problem and has a significant disease burden attached, not only in terms of health care costs, but also for patients directly in terms of time off work and impact upon quality of life. Controversy surrounds the pathogenesis of tendinopathy, however the recent systematic analysis of the evidence has demonstrated that many of the claims of an absence of inflammation in tendinopathy were more based around belief than robust scientific data. This review is a summary of the emerging research in this topical area, with a particular focus on the role of neuronal regulation and inflammation in tendinopathy.
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Affiliation(s)
- Benjamin J F Dean
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK.
| | - Stephanie G Dakin
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK.
| | - Neal L Millar
- Institute of Infection, Immunity and Inflammation, College of Medicine, Veterinary and Life Sciences University of Glasgow, Glasgow, Scotland, UK.
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK.
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Abate M, Salini V, Schiavone C, Andia I. Clinical benefits and drawbacks of local corticosteroids injections in tendinopathies. Expert Opin Drug Saf 2016; 16:341-349. [PMID: 28005449 DOI: 10.1080/14740338.2017.1276561] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION local glucocorticoids injections are widely administered for the treatment of tendinopathies. positive results have been observed in some tendinopathies but not in others. moreover, worsening of symptoms, and even spontaneous tendon ruptures has been reported. the characteristics of the tendinopathies, the clinical peculiarities of the patient, and the technique used to administer glucocorticoids, can influence the therapeutic response. Areas covered: After reviewing the pertinent literature on the clinical results, basic information, both on the pathogenesis of tendinopathies and the effects of glucocorticoids on tendons, is reported. The pharmacological properties of glucocorticoids are useful to counteract some pathogenetic mechanisms of tendinopathies. However, several experimental studies suggest that the direct action of glucocorticoids on tendons is detrimental. Loss of collagen organization, impaired viability of fibroblasts, depletion of stem cells pool, and reduced mechanical properties have been observed. Expert opinion: Drawbacks of local glucocorticoids injections could be predicted on an individual basis, after a careful appraisal of patient characteristics and concomitant medications, along with the specific stage of tendon disease.
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Affiliation(s)
- Michele Abate
- a Department of Medicine and Science of Aging , University G. d'Annunzio, Chieti-Pescara , Chieti Scalo , Italy
| | - Vincenzo Salini
- a Department of Medicine and Science of Aging , University G. d'Annunzio, Chieti-Pescara , Chieti Scalo , Italy
| | - Cosima Schiavone
- a Department of Medicine and Science of Aging , University G. d'Annunzio, Chieti-Pescara , Chieti Scalo , Italy
| | - Isabel Andia
- b BioCruces Health Research Institute , Cruces University Hospital , Barakaldo , Spain
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Gadau M, Zhang SP, Yip HY, Yeung WF, Bian ZX, Lu AP, Zaslawski C. Pattern Differentiation of Lateral Elbow Pain in Traditional Chinese Medicine: A Systematic Review. J Altern Complement Med 2016; 22:921-935. [DOI: 10.1089/acm.2016.0098] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Marcus Gadau
- School of Chinese Medicine, Hong Kong Baptist University, Hong Kong SAR, China
| | - Shi-Ping Zhang
- School of Chinese Medicine, Hong Kong Baptist University, Hong Kong SAR, China
| | - Ho-Yin Yip
- School of Chinese Medicine, Hong Kong Baptist University, Hong Kong SAR, China
| | - Wing-Fai Yeung
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong SAR, China
| | - Zhao-Xiang Bian
- School of Chinese Medicine, Hong Kong Baptist University, Hong Kong SAR, China
| | - Ai-Ping Lu
- School of Chinese Medicine, Hong Kong Baptist University, Hong Kong SAR, China
| | - Chris Zaslawski
- College of TCM, University of Technology Sydney, Sydney, Australia
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Jewson JL, Lambert GW, Storr M, Gaida JE. The sympathetic nervous system and tendinopathy: a systematic review. Sports Med 2016; 45:727-43. [PMID: 25655371 DOI: 10.1007/s40279-014-0300-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Jacob L Jewson
- Central Medical School, Monash University, Melbourne, VIC, Australia,
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Musculoskeletal overuse injuries and heart rate variability: Is there a link? Med Hypotheses 2015; 87:1-7. [PMID: 26826630 DOI: 10.1016/j.mehy.2015.12.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 11/05/2015] [Accepted: 12/06/2015] [Indexed: 01/06/2023]
Abstract
Accurate detection and prevention of overuse musculoskeletal injuries is limited by the nature of somatic tissue injury. In the pathogenesis of overuse injuries, it is well recognized that an abnormal inflammatory response occurs within somatic tissue before pain is perceived which can disrupt the normal remodeling process and lead to subsequent degeneration. Current overuse injury prevention methods focused on biomechanical faults or performance standards lack the sensitivity needed to identify the status of tissue injury or repair. Recent evidence has revealed an apparent increase in the prevalence and impact of overuse musculoskeletal injuries in athletics. When compared to acute injuries, overuse injuries have a potentially greater negative impact on athletes' overall health burden. Further, return to sport rehabilitation following overuse injury is complicated by the fact that the absence of pain does not equate to complete physiological healing of the injured tissue. Together, this highlights the need for exercise monitoring and injury prevention methods which incorporate assessment of somatic tissue response to loading. One system primarily involved in the activation of pathways and neuromediators responsible for somatic tissue repair is the autonomic nervous system (ANS). Although not completely understood, emerging research supports the critical importance of peripheral ANS activity in the health and repair of somatic tissue injury. Due to its significant contributions to cardiac function, ANS activity can be measured indirectly with heart rate monitoring. Heart rate variability (HRV) is one index of ANS activity that has been used to investigate the relationship between athletes' physiological response to accumulating training load. Research findings indicated that HRV may provide a reflection of ANS homeostasis, or the body's stress-recovery status. This noninvasive marker of the body's primary driver of recovery has the potential to incorporate important and as yet unmonitored physiological mechanisms involved in overuse injury development. We hypothesize that abnormal somatic tissue response to accumulating microtrauma may modulate ANS activity at the level of HRV. Exploring the link between HRV modulation and somatic tissue injury has the potential to reveal the putative role of ANS homeostasis on overuse musculoskeletal injury development.
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de Jonge S, Tol JL, Weir A, Waarsing JH, Verhaar JAN, de Vos RJ. The Tendon Structure Returns to Asymptomatic Values in Nonoperatively Treated Achilles Tendinopathy but Is Not Associated With Symptoms: A Prospective Study. Am J Sports Med 2015; 43:2950-8. [PMID: 26464495 DOI: 10.1177/0363546515605077] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Tendinopathy is characterized by alterations in the tendon structure, but there are conflicting results on the potential of tendon structure normalization and no large studies on the quantified, ultrasonographic tendon structure and its association with symptoms. PURPOSE To determine whether the tendon structure returns to values of asymptomatic individuals after treatment with 2 substances injected within the tendon, to assess the association between the tendon structure and symptoms, and to assess the prognostic value of the baseline tendon structure on treatment response. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS This study was part of a randomized trial on chronic midportion Achilles tendinopathy using eccentric exercises with either a platelet-rich plasma or saline injection. Symptoms were recorded using the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire. The tendon structure was quantified with ultrasound tissue characterization (UTC); echo types I + II (as a percentage of total tendon types I-IV) are structure related. Follow-up was at 6, 12, 24, and 52 weeks. A control group of asymptomatic subjects (similar age) was selected to compare the tendon structure. Patient symptoms were correlated with the tendon structure using a linear model. RESULTS Fifty-four patients were included in the symptomatic group. The mean (± SD) echo types I + II in the symptomatic group increased significantly from 74.6% ± 10.8% at baseline to 85.6% ± 6.0% at 24-week follow-up. The result for echo types I + II at 24 weeks was not significantly different (P = .198) from that of the asymptomatic control group (87.5% ± 6.0%). In 54 repeated measurements at 5 time points, the adjusted percentage of echo types I + II was not associated with the VISA-A score (main effect: β = .12; 95% CI, -0.12 to 0.35; P = .338). The adjusted baseline echo types I + II were not associated with a change in the VISA-A score from baseline to 52 weeks (β = -.15; 95% CI, -0.67 to 0.36; P = .555). CONCLUSION In symptomatic, tendinopathic Achilles tendons, the ultrasonographic tendon structure improved during nonoperative treatment and normalized after 24 weeks to values of matched asymptomatic controls. There was no association between the tendon structure and symptoms. The percentage of echo types I + II before treatment was not associated with change in symptoms over time. This study demonstrates that restoration of the tendon structure is not required for an improvement of symptoms.
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Affiliation(s)
- Suzan de Jonge
- Department of Orthopaedics, Erasmus Medical Centre, Rotterdam, the Netherlands Department of Sports Medicine, The Hague Medical Center Antoniushove, Leidschendam, the Netherlands
| | - Johannes L Tol
- The Sports Physician Group, Department of Sports Medicine, St Lucan Andreas Hospital, Amsterdam, the Netherlands Department of Sports Medicine, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar Academic Center for Evidence Based Sports Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Adam Weir
- Department of Sports Medicine, Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
| | - Jan H Waarsing
- Department of Orthopaedics, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Jan A N Verhaar
- Department of Orthopaedics, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Robert-Jan de Vos
- Department of Orthopaedics, Erasmus Medical Centre, Rotterdam, the Netherlands
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Hall MM, Rajasekaran S. Ultrasound-Guided Scraping for Chronic Patellar Tendinopathy: A Case Presentation. PM R 2015; 8:593-6. [PMID: 26548965 DOI: 10.1016/j.pmrj.2015.10.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 10/19/2015] [Accepted: 10/28/2015] [Indexed: 11/24/2022]
Abstract
Chronic patellar tendinopathy is a common complaint among athletes who repetitively stress the extensor mechanism of the knee. Multiple treatment options have been described, but evidence is lacking, specifically when eccentric loading has failed. Debate continues regarding the patho-etiology of chronic patellar tendon pain. There has been recent interest regarding the neurogenic influences involved in chronic tendinopathy, and interventions targeting neovessels and accompanying neonerves have shown promise. This is the first description of an ultrasound-guided technique in which the neovessels and accompanying neonerves in patellar tendinopathy were targeted using a needle scraping technique of the posterior surface of the patellar tendon.
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Affiliation(s)
- Mederic M Hall
- Department of Orthopaedics and Rehabilitation, University of Iowa Sports Medicine, 2701 Prairie Meadow Dr, Iowa City, IA 52242(∗).
| | - Sathish Rajasekaran
- Department of Orthopaedics and Rehabilitation, University of Iowa Sports Medicine, Iowa City, IA(†)
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Abstract
Synopsis The hallmark characteristics of rotator cuff (RC) tendinopathy are pain and weakness, experienced most commonly during shoulder external rotation and elevation. Assessment is complicated by nonspecific clinical tests and the poor correlation between structural failure and symptoms. As such, diagnosis is best reached by exclusion of other potential sources of symptoms. Symptomatic incidence and prevalence data currently cannot be determined with confidence, primarily as a consequence of a lack of diagnostic accuracy, as well as the uncertainty as to the location of symptoms. People with symptoms of RC tendinopathy should derive considerable comfort from research that consistently demonstrates improvement in symptoms with a well-structured and graduated exercise program. This improvement is equivalent to outcomes reported in surgical trials, with the additional generalized benefits of exercise, less sick leave, a faster return to work, and reduced costs to the health care system. This evidence covers the spectrum of conditions that include symptomatic RC tendinopathy and atraumatic partial- and full-thickness RC tears. The principles guiding exercise treatment for RC tendinopathy include relative rest, modification of painful activities, an exercise strategy that initially does not exacerbate pain, controlled reloading, and gradual progression from simple to complex shoulder movements. Evidence also exists for a specific exercise program being beneficial for people with massive inoperable tears of the RC. Education is an essential component of rehabilitation, and attention to lifestyle factors (smoking cessation, nutrition, stress, and sleep management) may enhance outcomes. Outcomes may also be enhanced by subgrouping RC tendinopathy presentations and directing treatment strategies according to the clinical presentation and the patient's response to shoulder symptom modification procedures outlined herein. There are substantial deficits in our knowledge regarding RC tendinopathy that need to be addressed to further improve clinical outcomes. J Orthop Sports Phys Ther 2015;45(11):923-937. Epub 21 Sep 2015. doi:10.2519/jospt.2015.5941.
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Abstract
Synopsis Tendinopathy has become the accepted term to describe a spectrum of changes that occur in damaged and/or diseased tendons. Over the past 2 decades, there have been new insights into tendon pathophysiology of relevance to clinicians, including (1) better characterization of the overuse injury process and the resultant structural and functional disruption in chronically painful tendons, (2) improved understanding of the pathomechanics associated with chronic tendon injury, and (3) greater knowledge about the influence of lifestyle factors and drugs on tendon pathology. The implications of these new insights are discussed. J Orthop Sports Phys Ther 2015;45(11):833-841. Epub 21 Sep 2015. doi:10.2519/jospt.2015.5884.
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Dean BJF, Gettings P, Dakin SG, Carr AJ. Are inflammatory cells increased in painful human tendinopathy? A systematic review. Br J Sports Med 2015; 50:216-20. [DOI: 10.1136/bjsports-2015-094754] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2015] [Indexed: 01/08/2023]
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Bachasson D, Singh A, Shah S, Lane JG, Ward SR. The role of the peripheral and central nervous systems in rotator cuff disease. J Shoulder Elbow Surg 2015; 24:1322-35. [PMID: 26189809 PMCID: PMC4508670 DOI: 10.1016/j.jse.2015.04.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 03/19/2015] [Accepted: 04/04/2015] [Indexed: 02/01/2023]
Abstract
Rotator cuff (RC) disease is an extremely common condition associated with shoulder pain, reduced functional capacities, and impaired quality of life. It primarily involves alterations in tendon health and mechanical properties that can ultimately lead to tendon failure. RC tendon tears induce progressive muscle changes that have a negative impact on surgical reparability of the RC tendons and clinical outcomes. At the same time, a significant base of clinical data suggests a relatively weak relationship between RC integrity and clinical presentation, emphasizing the multifactorial aspects of RC disease. This review aims to summarize the potential contribution of peripheral, spinal, and supraspinal neural factors that may (1) exacerbate structural and functional muscle changes induced by tendon tear, (2) compromise the reversal of these changes during surgery and rehabilitation, (3) contribute to pain generation and persistence of pain, (4) impair shoulder function through reduced proprioception, kinematics, and muscle recruitment, and (5) help explain interindividual differences and response to treatment. Given the current clinical and scientific interest in peripheral nerve injury in the context of RC disease and surgery, we carefully reviewed this body of literature with a particular emphasis on suprascapular neuropathy that has generated a large number of studies in the past decade. Within this process, we highlight the gaps in current knowledge and suggest research avenues for scientists and clinicians.
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Affiliation(s)
- Damien Bachasson
- Department of Radiology, University of California San Diego, La Jolla, CA, USA
| | - Anshuman Singh
- Department of Orthopaedics, Kaiser Permanente Southern California, San Diego, CA, USA
| | - Sameer Shah
- Department of Orthopaedic Surgery, University of California San Diego, La Jolla, CA, USA,Department of Bioengineering, University of California San Diego, La Jolla, CA, USA
| | | | - Samuel R. Ward
- Department of Radiology, University of California San Diego, La Jolla, CA, USA,Department of Orthopaedic Surgery, University of California San Diego, La Jolla, CA, USA,Department of Bioengineering, University of California San Diego, La Jolla, CA, USA
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Dean BJF, Snelling SJB, Dakin SG, Murphy RJ, Javaid MK, Carr AJ. Differences in glutamate receptors and inflammatory cell numbers are associated with the resolution of pain in human rotator cuff tendinopathy. Arthritis Res Ther 2015; 17:176. [PMID: 26160609 PMCID: PMC4498529 DOI: 10.1186/s13075-015-0691-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Accepted: 06/18/2015] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION The relationship between peripheral tissue characteristics and pain symptoms in soft tissue inflammation is poorly understood. The primary aim of this study was to determine immunohistochemical differences in tissue obtained from patients with persistent pain and patients who had become pain-free after surgical treatment for rotator cuff tendinopathy. The secondary aim was to investigate whether there would be differences in glutaminergic and inflammatory gene expression between disease-derived and healthy control cells in vitro. METHODS Supraspinatus tendon biopsies were obtained from nine patients with tendon pain before shoulder surgery and from nine further patients whose pain had resolved completely following shoulder surgery. Histological markers relating to the basic tendon characteristics, inflammation and glutaminergic signalling were quantified by immunohistochemical analysis. Gene expression of glutaminergic and inflammatory markers was determined in tenocyte explants derived from painful rotator cuff tendon tears in a separate cohort of patients and compared to that of explants from healthy control tendons. Dual labelling was performed to identify cell types expressing nociceptive neuromodulators. RESULTS Tendon samples from patients with persistent pain demonstrated increased levels of metabotropic glutamate receptor 2 (mGluR2), kainate receptor 1 (KA1), protein gene product 9.5 (PGP9.5), CD206 (macrophage marker) and CD45 (pan-leucocyte marker) versus pain-free controls (p <0.05). NMDAR1 co-localised with CD206-positive cells, whereas PGP9.5 and glutamate were predominantly expressed by resident tendon cells. These results were validated by in vitro increases in the expression of mGluR2, N-methyl-D-aspartate receptor (NMDAR1), KA1, CD45, CD206 and tumour necrosis factor alpha (TNF-α) genes (p <0.05) in disease-derived versus control cells. CONCLUSIONS We conclude that differences in glutamate receptors and inflammatory cell numbers are associated with the resolution of shoulder pain in rotator cuff tendinopathy, and that disease-derived cells exhibit a distinctly different neuro-inflammatory gene expression profile to healthy control cells.
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Affiliation(s)
- Benjamin John Floyd Dean
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK.
| | - Sarah J B Snelling
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK.
| | - Stephanie G Dakin
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK.
| | - Richard J Murphy
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK.
| | - Muhammad Kassim Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK.
| | - Andrew Jonathan Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK.
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Increased CCN2, substance P and tissue fibrosis are associated with sensorimotor declines in a rat model of repetitive overuse injury. J Cell Commun Signal 2015; 9:37-54. [PMID: 25617052 DOI: 10.1007/s12079-015-0263-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 01/14/2015] [Indexed: 01/24/2023] Open
Abstract
Key clinical features of cumulative trauma disorders include pain, muscle weakness, and tissue fibrosis, although the etiology is still under investigation. Here, we characterized the temporal pattern of altered sensorimotor behaviors and inflammatory and fibrogenic processes occurring in forearm muscles and serum of young adult, female rats performing an operant, high repetition high force (HRHF) reaching and grasping task for 6, 12, or 18 weeks. Palmar mechanical sensitivity, cold temperature avoidance and spontaneous behavioral changes increased, while grip strength declined, in 18-week HRHF rats, compared to controls. Flexor digitorum muscles had increased MCP-1 levels after training and increased TNFalpha in 6-week HRHF rats. Serum had increased IL-1beta, IL-10 and IP-10 after training. Yet both muscle and serum inflammation resolved by week 18. In contrast, IFNγ increased at week 18 in both muscle and serum. Given the anti-fibrotic role of IFNγ, and to identify a mechanism for the continued grip strength losses and behavioral sensitivities, we evaluated the fibrogenic proteins CCN2, collagen type I and TGFB1, as well as the nociceptive/fibrogenic peptide substance P. Each increased in and around flexor digitorum muscles and extracellular matrix in the mid-forearm, and in nerves of the forepaw at 18 weeks. CCN2 was also increased in serum at week 18. At a time when inflammation had subsided, increases in fibrogenic proteins correlated with sensorimotor declines. Thus, muscle and nerve fibrosis may be critical components of chronic work-related musculoskeletal disorders. CCN2 and substance P may serve as potential targets for therapeutic intervention, and CCN2 as a serum biomarker of fibrosis progression.
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Dean BJF, Franklin SL, Murphy RJ, Javaid MK, Carr AJ. Glucocorticoids induce specific ion-channel-mediated toxicity in human rotator cuff tendon: a mechanism underpinning the ultimately deleterious effect of steroid injection in tendinopathy? Br J Sports Med 2014; 48:1620-6. [PMID: 24677026 DOI: 10.1136/bjsports-2013-093178] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Glucocorticoid injection (GCI) and surgical rotator cuff repair are two widely used treatments for rotator cuff tendinopathy. Little is known about the way in which medical and surgical treatments affect the human rotator cuff tendon in vivo. We assessed the histological and immunohistochemical effects of these common treatments on the rotator cuff tendon. STUDY DESIGN Controlled laboratory study. METHODS Supraspinatus tendon biopsies were taken before and after treatment from 12 patients undergoing GCI and 8 patients undergoing surgical rotator cuff repair. All patients were symptomatic and none of the patients undergoing local GCI had full thickness tears of the rotator cuff. The tendon tissue was then analysed using histological techniques and immunohistochemistry. RESULTS There was a significant increase in nuclei count and vascularity after rotator cuff repair and not after GCI (both p=0.008). Hypoxia inducible factor 1α (HIF-1α) and cell proliferation were only increased after rotator cuff repair (both p=0.03) and not GCI. The ionotropic N-methyl-d-aspartate receptor 1 (NMDAR1) glutamate receptor was only increased after GCI and not rotator cuff repair (p=0.016). An increase in glutamate was seen in both groups following treatment (both p=0.04), while an increase in the receptor metabotropic glutamate receptor 7 (mGluR7) was only seen after rotator cuff repair (p=0.016). CONCLUSIONS The increases in cell proliferation, vascularity and HIF-1α after surgical rotator cuff repair appear consistent with a proliferative healing response, and these features are not seen after GCI. The increase in the glutamate receptor NMDAR1 after GCI raises concerns about the potential excitotoxic tendon damage that may result from this common treatment.
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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, Oxford, UK
| | - Sarah Louise Franklin
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Botnar Research Centre, Institute of Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Oxford, UK
| | - Richard J Murphy
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Botnar Research Centre, Institute of Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Oxford, UK
| | - Muhammad K Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Botnar Research Centre, Institute of Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Oxford, UK
| | - Andrew Jonathan Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Botnar Research Centre, Institute of Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Oxford, UK
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