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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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Accuracy of infrared thermography in detecting tendinopathy: A systematic review with meta-analysis. Phys Ther Sport 2022; 58:117-125. [DOI: 10.1016/j.ptsp.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 10/05/2022] [Accepted: 10/06/2022] [Indexed: 11/18/2022]
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Jewson J, Lambert E, Sari C, Jona E, Shorakae S, Lambert G, Gaida J. Does moxonidine reduce Achilles tendon or musculoskeletal pain in women with polycystic ovarian syndrome? A secondary analysis of a randomised controlled trial. BMC Endocr Disord 2020; 20:131. [PMID: 32847570 PMCID: PMC7449016 DOI: 10.1186/s12902-020-00610-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/14/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sympathetic activity and insulin resistance have recently been linked with chronic tendon and musculoskeletal pain. Polycystic ovarian syndrome is linked with insulin resistance and increased sympathetic drive and was therefore an appropriate condition to study the effects of modulating sympathetic activity on Achilles tendon and musculoskeletal symptoms. METHODS A secondary analysis of a double-blinded, randomised controlled trial on women with polycystic ovarian syndrome was conducted. Participants received 12 weeks of moxonidine (n = 14) or placebo (n = 18). Musculoskeletal symptom and Victorian Institute of Sport Assessment - Achilles (VISA-A) questionnaires were distributed, and ultrasound tissue characterisation quantified tendon structure at 0 and 12 weeks. 2-way ANOVA was used for multiple comparisons. RESULTS There was no difference in mean change in musculoskeletal symptoms (- 0.6 ± 1.7 vs - 0.4 ± 1.8, p = 0.69) or VISA-A (moxonidine - 0.2 ± 8.8 vs placebo + 4.2 ± 14.6, p = 0.24) attributable to the intervention. There was no difference in any measures of Achilles structure. Moxonidine did not reduce sympathetic drive when compared to placebo. CONCLUSIONS This was the first study to investigate the effects of blocking sympathetic drive on musculoskeletal and Achilles tendon symptoms in a metabolically diverse population. While the study was limited by small sample size and lack of sympathetic modulation, moxonidine did not change tendon pain/structure or musculoskeletal symptoms. TRIAL REGISTRATION ClinicalTrials.gov, NCT01504321 . Registered 5 January 2012.
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Affiliation(s)
- Jacob Jewson
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.
- Present Address: Olympic Park Sports Medicine Centre, Melbourne, Victoria, Australia.
| | - Elisabeth Lambert
- Iverson Health Innovation Research Institute and School of Health Sciences, Swinburne University of Technology, Melbourne, Victoria, Australia
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Carolina Sari
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Eveline Jona
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Soulmaz Shorakae
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Diabetes and Vascular Medicine Unit, Monash Health, Melbourne, Victoria, Australia
| | - Gavin Lambert
- Iverson Health Innovation Research Institute and School of Health Sciences, Swinburne University of Technology, Melbourne, Victoria, Australia
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Jamie Gaida
- University of Canberra Research Institute for Sport and Exercise (UCRISE), Canberra, ACT, Australia
- Discipline of Physiotherapy, University of Canberra, Canberra, ACT, Australia
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Liu L, Gisselman AS, Tumilty S. Thermal profiles over the Patella tendon in a cohort of non-injured collegiate athletes over the course of a cross-country season. Phys Ther Sport 2020; 44:47-52. [PMID: 32416581 DOI: 10.1016/j.ptsp.2020.04.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To determine normal temperatures over the Patella tendon over eleven weeks. DESIGN A prospective cohort study with eleven weeks of observation. SETTING University's Human Biomechanics and Physiology Laboratory. PARTICIPANTS Male or female collegiate runners running at least 25 miles per week who did not report pain in the region of the Patella tendon over 11 weeks of data collection. MAIN OUTCOME MEASURES Thermal images taken at the same time and day of the week, were used to measure the temperature of the skin over the Patella tendon. RESULTS Eighteen athletes were eligible for analysis. The mean temperature of the Patella tendon was 30.13 °C (SD = 1.51 °C). Patella tendon temperature changes over time were insignificant (right p = 0.66, left p = 0.90) with ICC right = 0.92, left = 0.94. Mean temperature difference side to side was 0.14 °C (SD = 0.60 °C). Mixed-model Linear regression for mean temperature differences found the effect of (i) time (t = 0.39, p = 0.70, df = 361) and (ii) side (t = -0.89, p = 0.38, df = 361) to be insignificant. CONCLUSIONS This is the first report of normal thermal profiles of collegiate runners over an extended period. Temperature variation above 1.20 °C may represent an abnormal asymmetry in the running population. Variations in Patella tendon temperatures left to right, and over time were not significant.
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Affiliation(s)
- Lizhou Liu
- Centre for Health, Activity, and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | | | - Steve Tumilty
- Centre for Health, Activity, and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand.
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Zunke P, Auffarth A, Hitzl W, Moursy M. The effect of manual therapy to the thoracic spine on pain-free grip and sympathetic activity in patients with lateral epicondylalgia humeri. A randomized, sample sized planned, placebo-controlled, patient-blinded monocentric trial. BMC Musculoskelet Disord 2020; 21:186. [PMID: 32209068 PMCID: PMC7093973 DOI: 10.1186/s12891-020-3175-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 02/27/2020] [Indexed: 12/17/2022] Open
Abstract
Background The treatment of first choice for lateral epicondylalgia humeri is conservative therapy. Recent findings indicate that spinal manual therapy is effective in the treatment of lateral epicondylalgia. We hypothesized that thoracic spinal mobilization in patients with epicondylalgia would have a positive short–term effect on pain and sympathetic activity. Methods Thirty patients (all analyzed) with clinically diagnosed (physical examination) lateral epicondylalgia were enrolled in this randomized, sample size planned, placebo-controlled, patient-blinded, monocentric trial. Pain-free grip, skin conductance and peripheral skin temperature were measured before and after the intervention. The treatment group (15 patients) received a one-time 2-min T5 costovertebral mobilization (2 Hz), and the placebo group (15 patients) received a 2-min one-time sham ultrasound therapy. Results Mobilization at the thoracic spine resulted in significantly increased strength of pain-free grip + 4.6 kg ± 6.10 (p = 0.008) and skin conductance + 0.76 μS ± 0.73 (p = 0.000004) as well as a decrease in peripheral skin temperature by − 0.80 °C ± 0.35 (p < 0.0000001) within the treatment group. Conclusion A thoracic costovertebral T5 mobilization at a frequency of 2 Hz shows an immediate positive effect on pain-free grip and sympathetic activity in patients with lateral epicondylalgia. Clinical trial registration German clinical trial register DRKS00013964, retrospectively registered on 2.2.2018.
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Affiliation(s)
- Philipp Zunke
- Physiozentrum Salzburg, Innsbrucker Bundesstraße 35, 5020, Salzburg, Austria. .,Department of Orthopedics and Traumatology, Paracelsus Medical University Salzburg, Muellner Hauptstr. 48, 5020, Salzburg, Austria.
| | - Alexander Auffarth
- Department of Orthopedics and Traumatology, Paracelsus Medical University Salzburg, Muellner Hauptstr. 48, 5020, Salzburg, Austria
| | - Wolfgang Hitzl
- Paracelsus Medical University Salzburg, Research Office (biostatistics), Strubergasse 20, 5020, Salzburg, Austria.,Department of Ophthalmology and Optometry, Paracelsus Medical University Salzburg, Muellner Hauptstr. 48, 5020, Salzburg, Austria.,Research Program Experimental Ophthalmology and Glaucoma Research, Paracelsus Medical University, Muellner Hauptstrasse 48, 5020, Salzburg, Austria
| | - Mohamed Moursy
- Department of Orthopedics and Traumatology, Paracelsus Medical University Salzburg, Muellner Hauptstr. 48, 5020, Salzburg, Austria
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Lewis T, Zeisig E, Gaida JE. Does glucocorticoid exposure explain the association between metabolic dysfunction and tendinopathy? Endocr Connect 2020; 9:EC-19-0555.R1. [PMID: 31967969 PMCID: PMC7040857 DOI: 10.1530/ec-19-0555] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 01/21/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND While metabolic health is acknowledged to affect connective tissue structure and function, the mechanisms are unclear. Glucocorticoids are present in almost every cell type throughout the body and control key physiological processes such as energy homeostasis, stress response, inflammatory and immune processes, and cardiovascular function. Glucocorticoid excess manifests as visceral adiposity, dyslipidaemia, insulin resistance, and type 2 diabetes. As these metabolic states are also associated with tendinopathy and tendon rupture, it may be that glucocorticoids excess is the link between metabolic health and tendinopathy. OBJECTIVE To synthesise current knowledge linking glucocorticoids exposure to tendon structure and function. METHODS Narrative literature review. RESULTS We provide an overview of endogenous glucocorticoid production, regulation, and signalling. Next we review the impact that oral glucocorticoid has on risk of tendon rupture and the effect that injected glucocorticoid has on resolution of symptoms. Then we highlight the clinical and mechanistic overlap between tendinopathy and glucocorticoid excess in the areas of visceral adiposity, dyslipidaemia, insulin resistance and type 2 diabetes. In these areas, we highlight the role of glucocorticoids and how these hormones might underpin the connection between metabolic health and tendon dysfunction. CONCLUSIONS There are several plausible pathways through which glucocorticoids might mediate the connection between metabolic health and tendinopathy.
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Affiliation(s)
- Trevor Lewis
- Physiotherapy Department, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Eva Zeisig
- Department of Surgical and Perioperative Sciences, Umeå Univerisity, Umeå, Sweden
| | - Jamie E Gaida
- University of Canberra Research Institute for Sport and Exercise (UCRISE), Canberra, Australian Capital Territory, Australia
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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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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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Jewson JL, Lambert EA, Docking S, Storr M, Lambert GW, Gaida JE. Pain duration is associated with increased muscle sympathetic nerve activity in patients with Achilles tendinopathy. Scand J Med Sci Sports 2016; 27:1942-1949. [DOI: 10.1111/sms.12820] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2016] [Indexed: 12/19/2022]
Affiliation(s)
- J. L. Jewson
- Faculty of Medicine, Nursing and Health Sciences; Monash University; Melbourne Vic. Australia
| | - E. A. Lambert
- Human Neurotransmitters Laboratory; Baker IDI Heart and Diabetes Institute; Melbourne Vic. Australia
- Department of Physiology; Monash University; Melbourne Vic. Australia
| | - S. Docking
- Department of Physiotherapy; Monash University; Melbourne Vic. Australia
- Australian Centre for Research into Injury in Sport and its Prevention; Federation University; Ballarat Vic. Australia
| | - M. Storr
- Department of Physiotherapy; Monash University; Melbourne Vic. Australia
| | - G. W. Lambert
- Faculty of Medicine, Nursing and Health Sciences; Monash University; Melbourne Vic. Australia
- Human Neurotransmitters Laboratory; Baker IDI Heart and Diabetes Institute; Melbourne Vic. Australia
| | - J. E. Gaida
- Department of Physiotherapy; Monash University; Melbourne Vic. Australia
- University of Canberra Research Institute for Sport and Exercise (UC-RISE); Canberra ACT Australia
- Discipline of Physiotherapy; University of Canberra; Canberra ACT Australia
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Nemery E, Gabriel A, Piret J, Antoine N. Nociceptive and sympathetic innervations in the abaxial part of the cranial horn of the equine medial meniscus: an immunohistochemical approach. J Anat 2016; 229:791-799. [PMID: 27345299 DOI: 10.1111/joa.12517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2016] [Indexed: 11/28/2022] Open
Abstract
In athletic horses, diseases leading to lameness are of great importance due to the loss of performance and the resultant economic concerns. Although stifle lesions are frequent in the hindlimb, due to the large size and complexity of the joint, and although meniscal tears have been identified as the most common soft tissue injuries in this joint, little is known about the mechanism that causes the painful sensation and thus the lameness. The aim of our study was to highlight any peripheral fibres involved in meniscal nociception in five macroscopically sound cranial horns of the equine medial meniscus, which has been one of the most common sites reported for equine meniscal injuries. Immunohistochemical stainings were performed using antibodies against Substance P in order to identify nociceptive fibres; against tyrosine hydroxylase for detecting postganglionic sympathetic fibres; and against glial fibrillary acidic proteins in order to identify Schwann cells. Our work highlights for the first time the presence of nociceptive and sympathetic fibres in equine menisci. They were found in the abaxial part of the cranial horn of the equine medial meniscus. This study suggests that when the abaxial part is injured, the meniscus itself could be the source of pain. These findings could provide a better understanding of the clinical presentation of horses with meniscal injury and contribute towards improving therapeutic strategies to alleviate pain in cases of equine meniscal injury.
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Affiliation(s)
- Elodie Nemery
- Anatomy Unit, Department of Morphology and Pathology, FARAH Research Center, Faculty of Veterinary Medicine, University of Liège, Liège, Belgium
| | - Annick Gabriel
- Anatomy Unit, Department of Morphology and Pathology, FARAH Research Center, Faculty of Veterinary Medicine, University of Liège, Liège, Belgium
| | - Joëlle Piret
- Histology Unit, Department of Morphology and Pathology, FARAH Research Center, Faculty of Veterinary Medicine, University of Liège, Liège, Belgium
| | - Nadine Antoine
- Histology Unit, Department of Morphology and Pathology, FARAH Research Center, Faculty of Veterinary Medicine, University of Liège, Liège, Belgium
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Rio E, Kidgell D, Moseley GL, Gaida J, Docking S, Purdam C, Cook J. Tendon neuroplastic training: changing the way we think about tendon rehabilitation: a narrative review. Br J Sports Med 2015; 50:209-15. [PMID: 26407586 PMCID: PMC4752665 DOI: 10.1136/bjsports-2015-095215] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2015] [Indexed: 01/16/2023]
Abstract
Tendinopathy can be resistant to treatment and often recurs, implying that current treatment approaches are suboptimal. Rehabilitation programmes that have been successful in terms of pain reduction and return to sport outcomes usually include strength training. Muscle activation can induce analgesia, improving self-efficacy associated with reducing one's own pain. Furthermore, strength training is beneficial for tendon matrix structure, muscle properties and limb biomechanics. However, current tendon rehabilitation may not adequately address the corticospinal control of the muscle, which may result in altered control of muscle recruitment and the consequent tendon load, and this may contribute to recalcitrance or symptom recurrence. Outcomes of interest include the effect of strength training on tendon pain, corticospinal excitability and short interval cortical inhibition. The aims of this concept paper are to: (1) review what is known about changes to the primary motor cortex and motor control in tendinopathy, (2) identify the parameters shown to induce neuroplasticity in strength training and (3) align these principles with tendon rehabilitation loading protocols to introduce a combination approach termed as tendon neuroplastic training. Strength training is a powerful modulator of the central nervous system. In particular, corticospinal inputs are essential for motor unit recruitment and activation; however, specific strength training parameters are important for neuroplasticity. Strength training that is externally paced and akin to a skilled movement task has been shown to not only reduce tendon pain, but modulate excitatory and inhibitory control of the muscle and therefore, potentially tendon load. An improved understanding of the methods that maximise the opportunity for neuroplasticity may be an important progression in how we prescribe exercise-based rehabilitation in tendinopathy for pain modulation and potentially restoration of the corticospinal control of the muscle-tendon complex.
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Affiliation(s)
- Ebonie Rio
- Department of Physiotherapy, School of Primary Health Care, Monash University, Melbourne, Victoria, Australia The Australian Centre for Research into Injury in Sport and its Prevention, Ballarat Federation University, Victoria, Australia
| | - Dawson Kidgell
- Department of Rehabilitation, Nutrition and Sport, School of Allied Health, La Trobe University, Melbourne, Victoria, Australia
| | - G Lorimer Moseley
- Sansom Institute for Health Research, University of South Australia & Pain, Adelaide, South Australia, Australia
| | - Jamie Gaida
- Department of Physiotherapy, School of Primary Health Care, Monash University, Melbourne, Victoria, Australia Department of Physiotherapy, University of Canberra, Bruce, Australian Capital Territory, Australia University of Canberra Research Institute for Sport and Exercise, Australia
| | - Sean Docking
- Department of Physiotherapy, School of Primary Health Care, Monash University, Melbourne, Victoria, Australia The Australian Centre for Research into Injury in Sport and its Prevention, Ballarat Federation University, Victoria, Australia
| | - Craig Purdam
- Department of Physical Therapies, Australian Institute of Sport, Bruce, Australian Capital Territory, Australia
| | - Jill Cook
- Department of Physiotherapy, School of Primary Health Care, Monash University, Melbourne, Victoria, Australia The Australian Centre for Research into Injury in Sport and its Prevention, Ballarat Federation University, Victoria, Australia
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