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Arias-Vázquez PI, Guzzardo MN, Guzzardo DR, Castillo-Avila RG, Tovilla-Zárate CA, Ake Montiel MAN. Efficacy of ozone injections for reducing musculoskeletal pain in comparison with corticosteroid injections: A systematic review and meta-analysis. J Back Musculoskelet Rehabil 2024; 37:821-838. [PMID: 38277280 DOI: 10.3233/bmr-230173] [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: 01/28/2024]
Abstract
BACKGROUND Corticosteroid injections are frequently used in the short-term treatment of musculoskeletal pain, but their use is controversial as repeated exposures to corticosteroids can lead to deleterious effects on musculoskeletal tissue. Ozone injections have been proposed as a possible treatment for musculoskeletal pain; however, their effectiveness has not been compared with corticosteroids. OBJECTIVE To evaluate the effectiveness of ozone injections for reducing pain in individuals with musculoskeletal pain in comparison with corticosteroid injections through a meta-analysis. METHODS An online systematic search was performed using electronic databases up to September 2023. We searched for studies that compared corticosteroid injections with ozone injections in the treatment of musculoskeletal pain of diverse origins. RESULTS Eleven studies were included comprising a total of 534 individuals. In the overall pooled analysis, a pain reduction in favor of corticosteroid injections was found in the short term (d= 0.31, 95% CI 0.01 to 0.60, p (z) 0.04, I2 = 32%). In the medium term, no significant differences were found in reducing pain between groups (d=-0.17, 95% CI -0.42 to 0.07, p (z) 0.15, I2 = 0%). CONCLUSIONS Our results suggest that corticosteroids injections are more effective in reducing musculoskeletal pain in the short term, but equally effective in the medium term when compared with ozone injections. Nonetheless, better-quality clinical trials are necessary to corroborate these results.
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Affiliation(s)
| | - Mauro Nicolás Guzzardo
- Team of Formation and Research in Pain (EFID in Spanish), National University of Rosario, Rosario, Argentina
| | - Duilio Román Guzzardo
- Team of Formation and Research in Pain (EFID in Spanish), National University of Rosario, Rosario, Argentina
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Norman MB, Norman ER, Langer GH, Allen MR, Meller L, Vitale KC. Return to Sport Using Corticosteroid Injections for Knee Pain in Triathletes. Cureus 2023; 15:e39985. [PMID: 37416041 PMCID: PMC10321459 DOI: 10.7759/cureus.39985] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2023] [Indexed: 07/08/2023] Open
Abstract
Introduction Despite the prevalence of corticosteroid injections in athletes, little is known about their efficacy in triathletes. We aim to assess attitudes, use, subjective effectiveness, and time to return to sport with corticosteroid injections compared to alternative methods in triathletes with knee pain. Methods This is an observational study during the COVID-19 pandemic. Triathletes answered a 13-question survey posted to three triathlon-specific websites. Results Sixty-one triathletes responded, 97% of whom experienced knee pain at some point in their triathlete career; 63% with knee pain received a corticosteroid injection as treatment (average age 51 years old). The most popular attitude (44.3%) regarding corticosteroid injections was "tried them, with good improvement". Most found the cortisone injection helpful for two to three months (28.6%), or more than one year (28.6%); of individuals who found the injections useful for more than one year, four-eight (50%) had received multiple injections during that same period. After injection, 80.6% returned to sport within one month. The average age of people using alternative treatment methods was 39 years old; most returned to sport within one month (73.7%). Compared to alternative methods, there was an ~80% higher odds of returning to sport within one month using corticosteroid injections; however, this relationship was not significant (OR=1.786, p=0.480, 95% CI:0.448-7.09). Conclusion This is the first study to examine corticosteroid use in triathletes. Corticosteroid use is more common in older triathletes and results in subjective pain improvement. A strong association does not exist for a quicker return to sport using corticosteroid injections compared to alternative methods. Triathletes should be counseled on the timing of injections, duration of side effects, and be aware of potential risks.
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Affiliation(s)
| | - Emily R Norman
- Physical Medicine and Rehabilitation, Dartmouth Geisel School of Medicine, Hanover, USA
| | | | - Matthew R Allen
- Orthopedic Surgery, University of California San Diego School of Medicine, La Jolla, USA
| | - Leo Meller
- Orthopedic Surgery, University of California San Diego School of Medicine, La Jolla, USA
| | - Kenneth C Vitale
- Orthopedic Surgery, University of California San Diego School of Medicine, La Jolla, USA
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Lee CS, Jeon OH, Han SB, Jang KM. Mesenchymal Stem Cells for Enhanced Healing of the Medial Collateral Ligament of the Knee Joint. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59040725. [PMID: 37109683 PMCID: PMC10146272 DOI: 10.3390/medicina59040725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 03/21/2023] [Accepted: 04/04/2023] [Indexed: 04/29/2023]
Abstract
Background and Objectives: The medial collateral ligament (MCL) is one of the major supporting ligaments of the knee joint, and MCL injuries are common where excessive valgus loading is applied to the knee joint. Although most MCL injuries can be treated conservatively, healing of the MCL can take several weeks to months. Furthermore, once injured, the biomechanical properties of the healed MCL differ from those of the native MCL, resulting in an increased risk of re-injury and chronic remnant symptoms. Mesenchymal stem cells (MSCs), owing to their therapeutic potential, have been investigated in various musculoskeletal injuries, and some preclinical studies regarding MSC-based approaches in MCL injuries have shown promising results. Despite satisfactory results in preclinical studies, there is still a lack of clinical studies in the orthopedic literature. This article describes the basic knowledge of the MCL, standard treatments for MCL injuries, and recent studies regarding the application of MSCs for enhanced healing of the MCL. MSC-based approaches are expected to be a potential therapeutic option for enhanced healing of the MCL in the future.
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Affiliation(s)
- Chul-Soo Lee
- Department of Orthopaedic Surgery, Anam Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea
| | - Ok-Hee Jeon
- Department of Biomedical Sciences, Korea University College of Medicine, Seoul 02841, Republic of Korea
| | - Seung-Beom Han
- Department of Orthopaedic Surgery, Anam Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea
| | - Ki-Mo Jang
- Department of Orthopaedic Surgery, Anam Hospital, Korea University College of Medicine, Seoul 02841, Republic of Korea
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Porter A, Wang L, Han L, Lu XL. Bio-orthogonal Click Chemistry Methods to Evaluate the Metabolism of Inflammatory Challenged Cartilage after Traumatic Overloading. ACS Biomater Sci Eng 2022; 8:2564-2573. [PMID: 35561285 PMCID: PMC10461521 DOI: 10.1021/acsbiomaterials.2c00024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
During traumatic joint injuries, impact overloading can cause mechanical damage to the cartilage. In the following inflammation phase, excessive inflammatory cytokines (e.g., interleukin-1β (IL-1β)) can act on chondrocytes, causing over-proliferation, apoptosis, and extracellular matrix (ECM) degradation that can lead to osteoarthritis. This study investigated the combined effects of traumatic overloading and IL-1β challenge on the metabolic activities of chondrocytes. Bovine cartilage explants underwent impact overloading followed by IL-1β exposure at a physiologically relevant dosage (1 ng/mL). New click chemistry-based methods were developed to visualize and quantify the proliferation of in situ chondrocytes in a nondestructive manner without the involvement of histological sectioning or antibodies. Click chemistry-based methods were also employed to measure the ECM synthesis and degradation in cartilage explants. As the click reactions are copper-free and bio-orthogonal, i.e., with negligible cellular toxicity, cartilage ECM was cultured and studied for 6 weeks. Traumatic overloading induced significant cell death, mainly in the superficial zone. The high number of dead cells reduced the overall proliferation of chondrocytes as well as the synthesis of glycosaminoglycan (GAG) and collagen contents, but overloading alone had no effects on ECM degradation. IL-1β challenge had little effect on cell viability, proliferation, or protein synthesis but induced over 40% GAG loss in 10 days and 61% collagen loss in 6 weeks. For the overloaded samples, IL-1β induced greater degrees of degradation, with 68% GAG loss in 10 days and 80% collagen loss in 6 weeks. The results imply a necessary immediate ease of inflammation after joint injuries when trauma damage on cartilage is present. The new click chemistry methods could benefit many cellular and tissue engineering studies, providing convenient and sensitive assays of metabolic activities of cells in native three-dimensional (3D) environments.
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Affiliation(s)
- Annie Porter
- Department of Mechanical Engineering, University of Delaware, Newark, Delaware 19716, United States
| | - Liyun Wang
- Department of Mechanical Engineering, University of Delaware, Newark, Delaware 19716, United States
| | - Lin Han
- School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, Pennsylvania 19104, United States
| | - X Lucas Lu
- Department of Mechanical Engineering, University of Delaware, Newark, Delaware 19716, United States
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Kallianos SA, Singh V, Henry DS, Berkoff DJ, Arendale CR, Weinhold PS. Interleukin-1 receptor antagonist inhibits arthrofibrosis in a post-traumatic knee immobilization model. Knee 2021; 33:210-215. [PMID: 34715560 DOI: 10.1016/j.knee.2021.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 10/05/2021] [Accepted: 10/07/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Therapies for arthrofibrosis after knee surgery are needed to prevent loss of joint function. Interleukin-1 receptor antagonists (IL-1RA) have shown promise in treating established arthrofibrosis in pilot clinical studies. The objective of this study was to evaluate the ability of intra-articular injection of IL-1RA to prevent knee joint contracture in a post-traumatic knee immobilization model. METHODS 20 male Sprague Dawley rats were block randomized into two groups: control and IL-1RA. Rats underwent intra-articular surgical trauma of the right knee with placement of an immobilization suture, securing the knees in 150° flexion. On post-operative days 1 and 8, each group received a 0.1 ml intra-articular injection of either saline (control) or anakinra (IL-1RA:single dosage; 2.63 mg/kg). Rats were euthanized fourteen days after surgery and the immobilization femorotibial angles were measured on the operative limbs with the suture and musculature intact. Subsequently, musculature was removed and femorotibial angles were measured in the operative and non-operative limbs with a defined extension moment applied with the posterior capsule intact or cut. A contracture angle was calculated as the angular difference between the operative and non-operative limb. RESULTS The immobilization knee flexion angle did not differ (P = 0.761) between groups (control: 152 ± 9; IL-1RA: 150 ± 11). The joint contracture angles (smaller angle = improved outcome) were reduced by 12 degrees on average in the IL-1RA group compared to the control for both the capsule intact (P = 0.024) and cut (P = 0.019) states. CONCLUSIONS Intra-articular IL-1RA injection was found to diminish knee extension deficits associated with arthrofibrosis in a post-traumatic joint immobilization model.
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Affiliation(s)
- Stephen A Kallianos
- Dept. of Orthopaedics, University of North Carolina, Chapel Hill, NC, United States
| | - Vishavpreet Singh
- Dept. of Orthopaedics, University of North Carolina, Chapel Hill, NC, United States
| | - David S Henry
- School of Osteopathic Medicine, Campbell University, Lillington, NC, United States
| | - David J Berkoff
- Dept. of Orthopaedics, University of North Carolina, Chapel Hill, NC, United States
| | - C Richard Arendale
- Dept. of Orthopaedics, University of North Carolina, Chapel Hill, NC, United States
| | - Paul S Weinhold
- Dept. of Orthopaedics, University of North Carolina, Chapel Hill, NC, United States.
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Magnetic resonance imaging of deltoid muscle/tendon tears: a descriptive study. Skeletal Radiol 2021; 50:1995-2003. [PMID: 33661326 DOI: 10.1007/s00256-021-03727-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/26/2021] [Accepted: 01/27/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To describe the MRI features of deltoid tears and to evaluate tear characteristics in patient groups based on history of trauma and rotator cuff tear (RCT). MATERIALS AND METHODS The records of patients who underwent shoulder MRI at our institution between July 2007 and June 2018 were retrospectively reviewed to identify deltoid tears, and patients were divided into groups based on history of recent trauma and presence of RCT. Images were reviewed to identify the location and size of the deltoid tear; the presence or absence of RCT, muscle atrophy, tendon retraction, humeral head subluxation, soft tissue edema, and additional pathologies were also noted. Medical records were reviewed for information about history of steroid injection, previous rotator cuff surgery, and treatments used. RESULTS Among 69 patients with deltoid tears (45 men; mean age, 65.2 years; range, 19-89 years), patients with RCTs and no trauma had the highest frequency of deltoid tears in the middle portion (p = 0.005). Only patients with RCTs had undergone steroid injection or rotator cuff surgery. Two patients had deltoid tear without RCT and without recent trauma; these patients demonstrated evidence of calcific tendinopathy and chronic subacromial-subdeltoid bursitis. CONCLUSION The middle (acromial) portion of the deltoid is more frequently affected in patients with RCTs than in those with trauma. Although deltoid tears are commonly associated with RCT, calcific tendinopathy and chronic bursitis may also be seen in patients with deltoid tears.
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Abstract
The Gaelic sports of hurling and football, native to Ireland, are increasing in popularity worldwide. The injury profile of these sports requires multidisciplinary management by sports physicians, orthopaedic surgeons, and musculoskeletal (MSK) radiologists, among others. Advances in imaging modalities and interventional techniques have aided the diagnosis and treatment of sport injuries. In this article, we review the literature and our own institutional experience to describe common injury patterns identified in Gaelic games athletes, their main imaging features and relevant therapeutic interventions. We discuss the increasing prevalence of imaging services at sporting events and the central role of MSK radiologists in sports injury management.
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Affiliation(s)
- Charles J Sullivan
- Department of Radiology, National Orthopaedic Hospital Cappagh, Finglas, Dublin, Ireland
| | - Eoin C Kavanagh
- Department of Radiology, National Orthopaedic Hospital Cappagh, Finglas, Dublin, Ireland.,Department of Radiology, Mater Misericordiae University Hospital, Eccles Street, Dublin, Ireland
| | - Stephen J Eustace
- Department of Radiology, National Orthopaedic Hospital Cappagh, Finglas, Dublin, Ireland.,Department of Radiology, Mater Misericordiae University Hospital, Eccles Street, Dublin, Ireland
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Effect of dose of the corticosteroid injected locally on inflammatory diseases. CURRENT ORTHOPAEDIC PRACTICE 2019. [DOI: 10.1097/bco.0000000000000734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Kim YH, Gu JH. Hand infections after steroid injections. Int J Dermatol 2018; 58:e12-e14. [PMID: 30368778 DOI: 10.1111/ijd.14284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 10/08/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Young H Kim
- Department of Plastic Surgery, Dankook University Hospital, Cheonan, Korea
| | - Ja H Gu
- Department of Plastic Surgery, Dankook University Hospital, Cheonan, Korea
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Abstract
Noninsertional Achilles tendinosis is differentiated from insertional Achilles tendinosis based on anatomic location. Tendinosis, as opposed to tendonitis, is primarily a degenerative process and the role of inflammation is believed limited. The etiology of Achilles tendinopathy may include overuse leading to repetitive microtrauma, poor vascularity of the tissue, mechanical imbalances of the extremity, or combination of these elements. There is evidence to support eccentric exercise nonoperative management for patients with noninsertional Achilles tendinopathy. Operative treatment options include percutaneous longitudinal tenotomies, minimally invasive tendon scraping, open débridement and tubularization, and tendon augmentation with flexor hallucis longus.
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Affiliation(s)
- Avreeta Singh
- University of California, Davis, 4860 Y Street, Suite 1700, Sacramento, CA 95817, USA
| | - Arash Calafi
- University of California, Davis, 4860 Y Street, Suite 1700, Sacramento, CA 95817, USA
| | - Chris Diefenbach
- University of California, Davis, 4860 Y Street, Suite 1700, Sacramento, CA 95817, USA
| | - Chris Kreulen
- University of California, Davis, 4860 Y Street, Suite 1700, Sacramento, CA 95817, USA
| | - Eric Giza
- University of California, Davis, 4860 Y Street, Suite 1700, Sacramento, CA 95817, USA.
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11
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Rozmaryn LM. The Collateral Ligament of the Digits of the Hand: Anatomy, Physiology, Biomechanics, Injury, and Treatment. J Hand Surg Am 2017; 42:904-915. [PMID: 29101974 DOI: 10.1016/j.jhsa.2017.08.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 08/23/2017] [Indexed: 02/02/2023]
Abstract
Ligament injuries are among the most common musculoskeletal injuries seen in clinical practice and ligaments are the most frequently injured structures in a joint. Ligaments play an important role in balancing joint mobility and joint stability. Disruption of joint ligaments severely impairs joint function. Over the past 10 years, a new appreciation of a neuroanatomy and neurophysiology of joint ligaments and its biofeedback loops to surrounding muscles and tendons has emerged to explain the relationship between primary and secondary restraints that allow normal joint motion yet prevent pathological motion. This review focuses on this recent information with a view to new clinical approaches to these common problems.
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Affiliation(s)
- Leo M Rozmaryn
- The Orthopedic Center, The Centers for Advanced Orthopedics, Rockville, MD.
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12
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Everhart JS, Cole D, Sojka JH, Higgins JD, Magnussen RA, Schmitt LC, Flanigan DC. Treatment Options for Patellar Tendinopathy: A Systematic Review. Arthroscopy 2017; 33:861-872. [PMID: 28110807 DOI: 10.1016/j.arthro.2016.11.007] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 10/24/2016] [Accepted: 11/03/2016] [Indexed: 02/07/2023]
Abstract
PURPOSE To compare the efficacy of common invasive and noninvasive patellar tendinopathy (PT) treatment strategies. METHODS A systematic search was performed in PubMed, Google Scholar, CINAHL, UptoDate, Cochrane Reviews, and SPORTDiscus. Fifteen studies met the following inclusion criteria: (1) therapeutic outcome trial for PT, and (2) Victorian Institute of Sports Assessment was used to assess symptom severity at follow-up. Methodological quality and reporting bias were evaluated with a modified Coleman score and Begg's and Egger's tests of bias, respectively. RESULTS A total of 15 studies were included. Reporting quality was high (mean Coleman score 86.0, standard deviation 9.7), and there was no systematic evidence of reporting bias. Increased duration of symptoms resulted in poorer outcomes regardless of treatment (0.9% decrease in improvement per additional month of symptoms; P = .004). Eccentric training with or without core stabilization or stretching improved symptoms (61% improvement in the Victorian Institute of Sports Assessment score, 95% confidence interval [CI] 53% to 69%). Surgery in patients refractory to nonoperative treatment also improved symptoms (57%, 95% CI 52% to 62%) with similar outcomes among arthroscopic and open approaches. Results from shockwave (54%, 95% CI 22% to 87%) and platelet-rich plasma (PRP) studies (55%, 95% CI 5% to 105%) varied widely though PRP may accelerate early recovery. Finally, steroid injection provided no benefit (20%, 95% CI -20% to 60%). CONCLUSIONS Initial treatment of PT can consist of eccentric squat-based therapy, shockwave, or PRP as monotherapy or an adjunct to accelerate recovery. Surgery or shockwave can be considered for patients who fail to improve after 6 months of conservative treatment. Corticosteroid therapy should not be used in the treatment of PT. LEVEL OF EVIDENCE Level IV, systematic review of Level II-IV studies.
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Affiliation(s)
- Joshua S Everhart
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio, U.S.A.; College of Medicine, The Ohio State University, Columbus, Ohio, U.S.A
| | - Devon Cole
- College of Medicine, The Ohio State University, Columbus, Ohio, U.S.A
| | - John H Sojka
- College of Medicine, The Ohio State University, Columbus, Ohio, U.S.A
| | - John D Higgins
- College of Medicine, The Ohio State University, Columbus, Ohio, U.S.A
| | - Robert A Magnussen
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio, U.S.A.; College of Medicine, The Ohio State University, Columbus, Ohio, U.S.A
| | - Laura C Schmitt
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio, U.S.A.; College of Medicine, The Ohio State University, Columbus, Ohio, U.S.A.; Division of Physical Therapy, School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio, U.S.A
| | - David C Flanigan
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio, U.S.A.; College of Medicine, The Ohio State University, Columbus, Ohio, U.S.A.; Division of Physical Therapy, School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio, U.S.A.; Cartilage Restoration Center, The Ohio State University, Columbus, Ohio, U.S.A..
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Brook EM, Hu CH, Kingston KA, Matzkin EG. Corticosteroid Injections: A Review of Sex-Related Side Effects. Orthopedics 2017; 40:e211-e215. [PMID: 27874912 DOI: 10.3928/01477447-20161116-07] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 03/28/2016] [Indexed: 02/03/2023]
Abstract
Corticosteroid injections are used as a nonoperative modality to combat acute inflammation when conservative treatments fail. As female patients are regularly seen by orthopedic physicians, it is essential to identify and understand potential sex-related side effects. The aim of this article is to examine available literature for sex-related side effects of orthopedic-related corticosteroid injections. Although the incidence is low, sex-related side effects, such as abnormal menstruation, lactation disturbances, facial flushing, and hirsutism, are associated with corticosteroid injections. Physicians should be aware of these female-specific side effects and relay this information as part of the informed consent process. [Orthopedics. 2017; 40(2):e211-e215.].
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Pak J, Lee JH, Park KS, Park M, Kang LW, Lee SH. Current use of autologous adipose tissue-derived stromal vascular fraction cells for orthopedic applications. J Biomed Sci 2017; 24:9. [PMID: 28143470 PMCID: PMC5282826 DOI: 10.1186/s12929-017-0318-z] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 01/25/2017] [Indexed: 12/20/2022] Open
Abstract
Autologous adipose stromal vascular fractions (SVFs) containing adipose tissue-derived stem cells (ASCs) are currently being used in clinical settings for various orthopedic applications for human patients. Due to its potential capability of regenerating cartilage, bone, and tendons, autologous adipose SVFs are being tried in treating patients with osteoarthritis (OA), chondromalacia, meniscus tear, osteonecrosis of the femoral head, and tendon injuries. Here, we have reviewed available human clinical studies with regard to patient applications of autologous adipose SVF containing ASCs, specifically assessing effectiveness and safety in the field of orthopedic disorders. All studies reviewed in this article presents potential benefits of autologous adipose SVF in various orthopedic applications without any serious side effects.
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Affiliation(s)
- Jaewoo Pak
- Stems Medical Clinic, 32-3 Chungdamdong, Gangnamgu, Seoul, 06068 Republic of Korea
- TEDA-Puhua International Hospital, Tianjin, 300457 People’s Republic of China
- Life Science Institute, Komplek Permata Senayan, Jalan Tentara Pelajar, Jakarta Selatan, 12210 Indonesia
| | - Jung Hun Lee
- Stems Medical Clinic, 32-3 Chungdamdong, Gangnamgu, Seoul, 06068 Republic of Korea
- National Leading Research Laboratory, Department of Biological Sciences, Myongji University, 116 Myongjiro, Yongin, Gyeonggido 17058 Republic of Korea
| | - Kwang Seung Park
- National Leading Research Laboratory, Department of Biological Sciences, Myongji University, 116 Myongjiro, Yongin, Gyeonggido 17058 Republic of Korea
| | - Moonhee Park
- National Leading Research Laboratory, Department of Biological Sciences, Myongji University, 116 Myongjiro, Yongin, Gyeonggido 17058 Republic of Korea
- DNA Analysis Division, Seoul institute, National Forensic Service, 139 Jiyangro, Yangcheongu, Seoul, 08036 Republic of Korea
| | - Lin-Woo Kang
- Department of Biological Sciences, Konkuk University, 1 Hwayangdong, Gwangjingu, Seoul, 05029 Republic of Korea
| | - Sang Hee Lee
- National Leading Research Laboratory, Department of Biological Sciences, Myongji University, 116 Myongjiro, Yongin, Gyeonggido 17058 Republic of Korea
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Lu H, Yang H, Shen H, Ye G, Lin XJ. The clinical effect of tendon repair for tendon spontaneous rupture after corticosteroid injection in hands: A retrospective observational study. Medicine (Baltimore) 2016; 95:e5145. [PMID: 27741145 PMCID: PMC5072972 DOI: 10.1097/md.0000000000005145] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Corticosteroid injections for hand tendinitis can lead to a rare significant complication of tendon spontaneous rupture. However, only sporadic cases were reported in the literature before. This study was designed to gauge the clinical effect of tendon repair in patients of tendon spontaneous rupture after corticosteroid injection and analyze our experience.This was a retrospective observational study of 13 patients (8 women and 5 men) operated between July 2011 and December 2015 for tendon spontaneous rupture after corticosteroid injection. Demographic data, clinical features, imaging data, and surgical treatments were carefully reviewed.The average age was 52.308 ± 15.381 years (range 29-71). The average injection times were 2.538 ± 1.664 times (range 1-6). The average rupture time (after last injection) was 10.923 ± 9.500 weeks (range 3-32). Nine patients were treated by tendon suture (69% of cases), and 4 patients were treated by tendon grafting (31% of cases). All patients received follow-up in our outpatient clinic. The sites of the tendon rupture (15 tendons of 13 patients had involved) include extensor pollicis longus (6 tendons, 40% of cases), extensor digiti quinti and extensor digiti minimi (4 tendons, 27% of cases), ring finger of extensor digitorum communis (3 tendons, 20% of cases), and middle finger of extensor digitorum communis (2 tendons, 13% of cases). Two patients who had tendon adhesion (15% of cases) were treated by tendon release. One patient who had tendon rerupture (8% of cases) was treated by tendon grafting. No patient had complications of infections, vascular, or nerve injury.Tendon spontaneous rupture is a serious complication after corticosteroid injection for tendinitis. Rigid standard of corticosteroid injection is very important. Magnetic resonance imaging was contributory to preoperative assess tendon defect and can be used to monitor healing quality of tendons during the follow-up.
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Affiliation(s)
- Hui Lu
- Department of Hand Surgery
- Correspondence: Hui Lu, Department of Hand Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, 79# Qingchun Road, Hangzhou 310003, Zhejiang Province, PR China (e-mail: )
| | | | | | - Ganmin Ye
- Departments of Orthopedics, Sanmen People's Hospital, Taizhou, Zhejiang Province, PR China
| | - Xiang-Jin Lin
- Department of Orthopedics, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou
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Sanli I, Morgan B, van Tilborg F, Funk L, Gosens T. Single injection of platelet-rich plasma (PRP) for the treatment of refractory distal biceps tendonitis: long-term results of a prospective multicenter cohort study. Knee Surg Sports Traumatol Arthrosc 2016; 24:2308-12. [PMID: 25502475 DOI: 10.1007/s00167-014-3465-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 11/10/2014] [Indexed: 11/21/2022]
Abstract
PURPOSE There is a lack of evidence regarding the use of PRP in the treatment of distal biceps tendonitis. The purpose of this study was to assess the effectiveness of ultrasound (US)-guided injection of PRP in relieving pain and functional impairment in the treatment of refractory distal biceps tendonitis. METHODS Twelve patients from two large tertiary referral hospitals were recruited over a period of 20 months. Clinical diagnosis of distal biceps tendonitis was confirmed using magnetic resonance imaging. All patients had a single US-guided injection of PRP carried out by the two senior authors. Patients were objectively assessed for clinical and functional improvement using visual analogue (VAS) rest and activity pain scores, subjective satisfaction scale, elbow functional assessment (EFA) and isometric muscular (biceps) strength. Symptom severity and subsequent functional outcome were measured pre-injection and at final follow-up. RESULTS At a median follow-up of 47 months (36-52 months), all patients showed significant improvement in pain (p < 0.002) and functional outcome (p < 0.004). Median resting VAS score improved from 6 (3-8) to 0.5 (0-2) and the activity VAS score improved from 8 (6-9) to 2.5 (0-4). EFA improved from 63 to 90. In the English cases, isometric muscular strength also showed significant improvement. All patients were satisfied with the clinical and functional outcomes at final follow-up. CONCLUSION US-guided PRP injection seems to be an effective treatment modality for symptomatic refractory distal biceps tendonitis. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Ilknur Sanli
- Department of Orthopaedic Surgery and Traumatology, St. Elisabeth Hospital Tilburg, Hilvarenbeekseweg 60, P.O. Box 90151, 5000 LC, Tilburg, The Netherlands
| | - Barnes Morgan
- Department of Orthopaedic Surgery and Traumatology, Wrightington Hospital, Wigan, UK
| | - Fiek van Tilborg
- Department of Radiology, St. Elisabeth Hospital Tilburg, Hilvarenbeekseweg 60, P.O. Box 90151, 5000 LC, Tilburg, The Netherlands
| | - Lennard Funk
- Department of Orthopaedic Surgery and Traumatology, Wrightington Hospital, Wigan, UK
| | - Taco Gosens
- Department of Orthopaedic Surgery and Traumatology, St. Elisabeth Hospital Tilburg, Hilvarenbeekseweg 60, P.O. Box 90151, 5000 LC, Tilburg, The Netherlands.
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Lin YC, Shieh SJ. Extensor-pollicis-longus or -brevis tendon rupture after corticosteroid injection. FORMOSAN JOURNAL OF SURGERY 2016. [DOI: 10.1016/j.fjs.2015.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Lee SY, Kim W, Lim C, Chung SG. Treatment of Lateral Epicondylosis by Using Allogeneic Adipose-Derived Mesenchymal Stem Cells: A Pilot Study. Stem Cells 2015. [PMID: 26202898 DOI: 10.1002/stem.2110] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Mesenchymal stem cell therapy is a novel regenerative approach for treating tendinopathy. Here, we evaluated the safety and efficacy of allogeneic adipose-derived mesenchymal stem cells (allo-ASC) in treating lateral epicondylosis (LE). Under ultrasound guidance, allo-ASCs mixed with fibrin glue were injected into the hypoechoic common extensor tendon lesions of 12 participants with chronic LE; 6 subjects each were administered 10(6) or 10(7) cells in 1 ml. Safety was evaluated at day 3 and weeks 2, 6, 12, 26, and 52 post-injection. Efficacy was assessed by measuring patients' visual analog scale (VAS) score for elbow pain, modified Mayo clinic performance index for the elbow, and by evaluating longitudinal and transverse ultrasound images of tendon defect areas after 6, 12, 26, and 52 weeks. No significant adverse effects of allo-ASC injection were observed through 52 weeks of follow-up. From baseline through 52 weeks of periodic follow-up, VAS scores progressively decreased from 66.8 ± 14.5 mm to 14.8 ± 13.1 mm and elbow performance scores improved from 64.0 ± 13.5 to 90.6 ± 5.8. Tendon defects also significantly decreased through this period. Allo-ASC therapy was thus safe and effective in improving elbow pain, performance, and structural defects for 52 weeks. This clinical study is the first to reveal therapeutic value of mesenchymal stem cell injection for treating chronic tendinopathy.
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Affiliation(s)
- Sang Yoon Lee
- Department of Physical Medicine & Rehabilitation, Chung-Ang University College of Medicine, Seoul, South Korea
| | - Won Kim
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Chaiyoung Lim
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Sun G Chung
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul, South Korea.,Institute of Aging, Medical Research Center, Seoul National University, Seoul, South Korea.,Rheumatism Research Institute, Medical Research Center, Seoul National University, Seoul, South Korea
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Baugé C, Leclercq S, Conrozier T, Boumediene K. TOL19-001 reduces inflammation and MMP expression in monolayer cultures of tendon cells. BMC COMPLEMENTARY AND ALTERNATIVE MEDICINE 2015; 15:217. [PMID: 26156631 PMCID: PMC4495633 DOI: 10.1186/s12906-015-0748-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 06/25/2015] [Indexed: 12/16/2022]
Abstract
Background Tendinopathies are tendon conditions associated with degeneration and disorganization of the matrix collagen fibers, tendon cells apoptosis and inflammation through up-regulation of proinflammatory cytokines, matrix metalloproteinase (MMP) expression, and prostaglandin E2 (PGE2) production. Currently, the pharmacological treatment is mainly based on non-steroidal anti-inflammatory drugs (NSAIDs) use and corticosteroid injections, which both can lead to numerous side effects for patients. TOL19-001 is a diet supplementary composed mostly of spirulina and glucosamine sulfate whose antioxidant properties could be helpful to treat tendinopathies while avoiding taking NSAIDs. In this study we developed an in vitro model of tendinopathy in order to evaluate the therapeutic potential of TOL19-001. Methods Tendon cells were cultured on monolayer and treated with interleukin-1β (IL-1β) or ciprofloxacin (CIP), and then, MMPs, PGE2 and collagen expression was evaluated by RT-PCR or Elisa. In addition, a cotreatment with increased doses of TOL19-001 was done. Toxicity of TOL19-001 was evaluated using a metabolic activity assay. Results This study demonstrates that IL-1β mimics some aspects of tendinopathies with PGE2 induction, MMP expression (mostly MMP1 and MMP3), and increases of type III/I collagen ratio. CIP, meanwhile, leads to an increase of MMP2 and p65 mRNA, whereas it reduces TIMP1 expression. Scleraxis expression was also increased by CIP whereas it was decreased by IL-1β treatment. Besides, TOL19-001 cotreatment suppresses tendon cell inflammation in vitro, marked by the downregulation of PGE2, MMPs and type III collagen in IL-1β stimulated-cells. TOL19-001 also represses CIP induced-changes. Conclusions These findings indicate that TOL19-001 exerts anti-inflammatory effects on tendon cells, which might explain why TOL19-001 diet may improve tendon function in patients with tendon injury. Future research is required to determine TOL19-001 effect on injured or overused tendons in vivo.
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Abstract
Context: Patellar tendinopathy is a common condition. There are a wide variety of treatment options available, the majority of which are nonoperative. No consensus exists on the optimal method of treatment. Evidence Acquisition: PubMed spanning 1962-2014. Study Design: Clinical review. Level of Evidence: Level 4. Results: The majority of cases resolve with nonoperative therapy: rest, physical therapy with eccentric exercises, cryotherapy, anti-inflammatories, corticosteroid injections, extracorporeal shockwave therapy, glyceryl trinitrate, platelet-rich plasma injections, and ultrasound-guided sclerosis. Refractory cases may require either open or arthroscopic debridement of the patellar tendon. Corticosteroid injections provide short-term pain relief but increase risk of tendon rupture. Anti-inflammatories and injectable agents have shown mixed results. Surgical treatment is effective in many refractory cases unresponsive to nonoperative modalities. Conclusion: Physical therapy with an eccentric exercise program is the mainstay of treatment for patellar tendinopathy. Platelet-rich plasma has demonstrated mixed results; evidence-based recommendations on its efficacy cannot be made. In the event that nonoperative treatment fails, surgical intervention has produced good to excellent outcomes in the majority of patients.
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Affiliation(s)
- Aaron Schwartz
- Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Jonathan N Watson
- Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Mark R Hutchinson
- Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois
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Sung CM, Hah YS, Kim JS, Nam JB, Kim RJ, Lee SJ, Park HB. Cytotoxic effects of ropivacaine, bupivacaine, and lidocaine on rotator cuff tenofibroblasts. Am J Sports Med 2014; 42:2888-96. [PMID: 25296645 DOI: 10.1177/0363546514550991] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Concern has recently arisen over the safety of local anesthetics used on human tissues. HYPOTHESIS Aminoamide local anesthetics have cytotoxic effects on human rotator cuff tenofibroblasts. STUDY DESIGN Controlled laboratory study. METHODS Cultured human rotator cuff tenofibroblasts were divided into control, phosphate buffered saline (PBS), and local anesthetic study groups; the PBS study group was further subdivided by pH level (pH 7.4, 6.0, and 4.4). The 6 local anesthetic subgroups (0.2% and 0.75% ropivacaine, 0.25% and 0.5% bupivacaine, and 1% and 2% lidocaine) were also studied at 10% dilutions of their original concentrations. Exposure times were 5, 10, 20, 40, or 60 minutes for the higher concentrations and 2, 6, 12, 24, 48, or 72 hours for the lower concentrations. Cell viability was evaluated through live, apoptotic, and necrotic cell rates using the annexin V-propidium iodide double-staining method. Intracellular reactive oxygen species (ROS) and the activity of mitogen-activated protein kinases (MAPKs) and caspase-3/7 were investigated. RESULTS The control and PBS groups showed no significant differences in cell viability (P > .999). In the local anesthetic study groups, cell viability decreased significantly with increases in anesthetic concentrations (P < .001) and exposure times (P < .001), with the exception of the lidocaine subgroups, where this effect was masked by the very high cytotoxicity of even low concentrations. Among the studied local anesthetic subgroups, 0.2% ropivacaine was the least toxic. The levels of intracellular ROS of each local anesthetic subgroup also increased significantly (P < .05). The studied local anesthetics showed increases in the phosphorylation of extracellular signal-regulated kinase 1/2 (ERK1/2), c-Jun N-terminal kinase (JNK), and p38 as well as in levels of caspase-3/7 activity (P < .001). CONCLUSION The cytotoxicity of the anesthetics studied to tenofibroblasts is dependent on exposure time and concentration. Of the evaluated anesthetics, ropivacaine is the least toxic in the clinically used concentration. The studied anesthetics induce tenofibroblast cell death, mediated by the increased production of ROS, by the increased activation of ERK1/2, JNK, and p38 and by the activation of caspase-3/7. CLINICAL RELEVANCE This study identified the cytotoxic mechanisms of aminoamide local anesthetics acting on rotator cuff tenofibroblasts. The greatest margin of safety was found in lower anesthetic concentrations in general and more specifically in the use of ropivacaine.
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Affiliation(s)
- Chang-Meen Sung
- Department of Orthopaedic Surgery, School of Medicine, Gyeongsang National University, Jinju, Korea
| | - Young-Sool Hah
- Biomedical Research Institute, Gyeongsang National University Hospital, Jinju, Korea
| | - Jin-Su Kim
- Surgery of Foot & Ankle, Eulji Medical Center, Eulji College of Medicine, Eulji University, Seoul, Korea
| | - Jeoung-Bin Nam
- Musculoskeletal Research Center, Gyeongsang National University Hospital, Jinju, Korea
| | - Ra Jeong Kim
- Department of Convergence Medical Science, Gyeongsang National University, Jinju, Korea
| | - Sang-Jin Lee
- Department of Orthopaedic Surgery, Barun Hospital, Jinju, Korea
| | - Hyung Bin Park
- Department of Orthopaedic Surgery, School of Medicine, Gyeongsang National University, Jinju, Korea
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Ultrasound-Guided Musculoskeletal Interventions in American Football: 18 Years of Experience. AJR Am J Roentgenol 2014; 203:W674-83. [DOI: 10.2214/ajr.14.12678] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Subcutaneous Rupture of the Extensor Pollicis Longus Tendon after Corticosteroid Injections for DeQuervain's Stenosing Tenovaginitis. Case Rep Orthop 2014; 2014:934384. [PMID: 25371839 PMCID: PMC4209778 DOI: 10.1155/2014/934384] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Accepted: 08/26/2014] [Indexed: 11/17/2022] Open
Abstract
DeQuervain's stenosing tenovaginitis is a common condition. Nonsurgical treatment by corticosteroid injection has significantly improved the management of this disease. The authors describe a case of subcutaneous rupture of the extensor pollicis longus tendon at the wrist, three months after two corticosteroid injections for DeQuervain's stenosing tenovaginitis. The etiological history has not found any trauma history of the wrist. The aim of our work is to draw attention to this rare complication and discuss its therapeutic management. Our functional results were excellent.
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Webborn N, Morrissey D, Sarvananthan K, Chan O. Acute tear of the fascia cruris at the attachment to the Achilles tendon: a new diagnosis. Br J Sports Med 2014; 49:1398-403. [PMID: 25202137 PMCID: PMC4680126 DOI: 10.1136/bjsports-2013-093273] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2014] [Indexed: 12/28/2022]
Abstract
BACKGROUND The fascia cruris encloses the posterior structures of the calf and connects to the paratenon and the Achilles tendon. We describe the clinical presentation, ultrasound imaging characteristics and the time to the recovery of tears of the fascia cruris at the attachment to the Achilles tendon. METHODS Retrospective review of 11 tears of the fascia cruris in the different legs as separate events in 9 patients (6 male and 3 female, mean age 35.52 years, range 11-48) identified using diagnostic ultrasound, after presenting with Achillodynia. RESULTS 11 participants presented at a mean of 4.5 weeks (range 0.5-12) after onset of symptoms. The left Achilles was more commonly injured than the right (7 : 4) and the lateral side more than the medial (6 : 4) with one case with medial and lateral presentation. Clinically, there was swelling and tenderness over the medial or lateral border in the mid to upper portion of the Achilles. 7 of the 11 (63.6%) had functional overpronation. Ultrasound appearances of a tear were identified as hypoechoic area extending from the medial or lateral border of the Achilles extending along the anatomical plane of the fascia cruris. Average return to activity was 5.2 weeks (range 1-22). Participants presenting later had longer recovery but all participants returned to full activity (r=0.4). CONCLUSIONS This is the first description of the clinical details and sonographic findings of a tear to the fascia cruris at its attachment to the Achilles tendon. This needs to be considered as a cause of Achillodynia in athletes as recognition will affect the management.
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Affiliation(s)
- Nick Webborn
- Centre for Sport and Exercise Science and Medicine (SESAME), University of Brighton, Eastbourne, UK
| | - Dylan Morrissey
- Centre for Sports and Exercise Medicine, Bart's and the London School of Medicine and Dentistry, Queen Mary University of London, Mile End Hospital, London, UK
| | - Kasthuri Sarvananthan
- Centre for Sports and Exercise Medicine, Bart's and the London School of Medicine and Dentistry, Queen Mary University of London, Mile End Hospital, London, UK
| | - Otto Chan
- BMI London Independent Hospital, London, UK
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26
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Magnan B, Bondi M, Pierantoni S, Samaila E. The pathogenesis of Achilles tendinopathy: a systematic review. Foot Ankle Surg 2014; 20:154-9. [PMID: 25103700 DOI: 10.1016/j.fas.2014.02.010] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 02/07/2014] [Accepted: 02/23/2014] [Indexed: 02/04/2023]
Abstract
Achilles tendinopathy is a degenerative, not an inflammatory, condition. It is prevalent in athletes involved in running sports. A systematic literature review on Achilles tendon tendinopathy has been performed according to the intrinsic (age, sex, body weight, tendon temperature, systemic diseases, muscle strength, flexibility, previous injuries and anatomical variants, genetic predisposition and blood supply) and extrinsic risk factors (drugs and overuse), which can cause tendon suffering and degeneration. Different theories have been found: Neurogenic, Angiogenic, Impingement and "Iceberg" Hypotheses. Multiple databases were utilized for articles published between 1964 and 2013. The different hypothesis were analyzed, differently considering those concerning the pathogenesis of tendinopathy and those concerning the etiology of complaints in patients. This review of the literature demonstrates the heterogeneity of Achilles tendinopathy pathogenesis. Various risk factors have been identified and have shown an interaction between them such as genes, age, circulating and local cytokine production, sex, biomechanics and body composition.
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Affiliation(s)
- Bruno Magnan
- Orthopaedic Department, University of Verona (Italy), Surgical Center "P. Confortini", Piazzale A. Stefani 1, 37126 Verona, Italy.
| | - Manuel Bondi
- Orthopaedic Department, University of Verona (Italy), Surgical Center "P. Confortini", Piazzale A. Stefani 1, 37126 Verona, Italy
| | - Silvia Pierantoni
- Orthopaedic Department, University of Verona (Italy), Surgical Center "P. Confortini", Piazzale A. Stefani 1, 37126 Verona, Italy
| | - Elena Samaila
- Orthopaedic Department, University of Verona (Italy), Surgical Center "P. Confortini", Piazzale A. Stefani 1, 37126 Verona, Italy
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Clinical applications of platelet-rich plasma in patellar tendinopathy. BIOMED RESEARCH INTERNATIONAL 2014; 2014:249498. [PMID: 25136568 PMCID: PMC4127290 DOI: 10.1155/2014/249498] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 06/26/2014] [Accepted: 07/09/2014] [Indexed: 12/16/2022]
Abstract
Platelet-rich plasma (PRP), a blood derivative with high concentrations of platelets, has been found to have high levels of autologous growth factors (GFs), such as transforming growth factor-β (TGF-β), platelet-derived growth factor (PDGF), fibroblastic growth factor (FGF), vascular endothelial growth factor (VEGF), and epidermal growth factor (EGF). These GFs and other biological active proteins of PRP can promote tissue healing through the regulation of fibrosis and angiogenesis. Moreover, PRP is considered to be safe due to its autologous nature and long-term usage without any reported major complications. Therefore, PRP therapy could be an option in treating overused tendon damage such as chronic tendinopathy. Here, we present a systematic review highlighting the clinical effectiveness of PRP injection therapy in patellar tendinopathy, which is a major cause of athletes to retire from their respective careers.
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Abstract
Peripheral nerve blocks are currently performed relatively blind even in the most complex anatomical structures and physicians mostly rely on palpable anatomical landmarks on the surface. Ultrasound has become an indispensable part of the modern medical world and has long since found its way into almost all medical professions. More and more this trend also reaches interventional pain physicians as it is possible to accurately target structures, to track the needle course during the intervention and to visualize the spread of the local anesthetic. Another advantage compared to other radiological techniques is the profound radiation safety for patients as well as for personnel performing the intervention. A deep understanding of anatomy and its correlate in ultrasound images is one of the most important requirements for the successful use of these interventional techniques. Moreover, the safe performance of the procedure depends on the simultaneous hand-eye coordination. Nevertheless, despite the euphoria ultrasound technology should only be used in pain management with sufficient indications.
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Affiliation(s)
- J A Blunk
- Klinik für Anästhesiologie und Operative Intensivmedizin, Uniklinikum Köln, 50937, Köln, Deutschland,
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29
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Turmo-Garuz A, Rodas G, Balius R, Til L, Miguel-Perez M, Pedret C, Del Buono A, Maffulli N. Can local corticosteroid injection in the retrocalcaneal bursa lead to rupture of the Achilles tendon and the medial head of the gastrocnemius muscle? Musculoskelet Surg 2013; 98:121-6. [PMID: 24222527 DOI: 10.1007/s12306-013-0305-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Accepted: 11/04/2013] [Indexed: 01/19/2023]
Abstract
PURPOSE The purpose of the study is to explain the cause-effect relationship in three patients who reported combined ruptures of the Achilles tendon and the gastrosoleus complex 6 months after they had received corticosteroids injections for the management of retrocalcaneal bursitis. METHODS Three cryopreserved cadavers (three men, three left legs) were examined to assess the anatomic connection between the retrocalcaneal bursa and the Achilles tendon (distal and anterior fibers). Blue triptan medium contrast was injected. RESULTS An unexpected connection between the retrocalcaneal bursa and the anterior fibers of the Achilles tendon was found in all instances. CONCLUSIONS Local corticosteroid injection of the retrocalcaneal bursa may help the symptoms of retrocalcanear bursitis, but pose a risk of Achilles tendon rupture. This risk-benefit has to be taken into account when corticosteroid injections are prescribed to professional and high-level athletes.
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Affiliation(s)
- A Turmo-Garuz
- High Performance Center (CAR de Sant Cugat Consorci Sanitari de Terrassa), Barcelona, Spain
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Kjaer M, Bayer ML, Eliasson P, Heinemeier KM. What is the impact of inflammation on the critical interplay between mechanical signaling and biochemical changes in tendon matrix? J Appl Physiol (1985) 2013; 115:879-83. [DOI: 10.1152/japplphysiol.00120.2013] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Mechanical loading can influence tendon collagen homeostasis in animal models, while the dynamics of the human adult tendon core tissue are more debatable. Currently available data indicate that human tendon adaptation to loading may happen primarily in the outer tendon region. A role of inflammation in this peritendinous adaptation is supported by a rise in inflammatory mediators in the peritendinous area after physiological mechanical loading in humans. This plays a role in the exercise-induced rise in tendon blood flow and peritendinous collagen synthesis. Although inflammatory activity can activate proteolytic pathways in tendon, mechanical loading can protect against matrix degradation. Acute tendon injury displays an early inflammatory response that seems to be lowered when mechanical loading is applied during regeneration of tendon. Chronically overloaded tendons (tendinopathy) do neither at rest nor after acute exercise display any enhanced inflammatory activity, and thus the basis for using anti-inflammatory medication to treat tendon overuse seems limited.
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Affiliation(s)
- Michael Kjaer
- Institute of Sports Medicine, Bispebjerg Hospital and Centre of Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Monika L. Bayer
- Institute of Sports Medicine, Bispebjerg Hospital and Centre of Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Pernilla Eliasson
- Institute of Sports Medicine, Bispebjerg Hospital and Centre of Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Katja M. Heinemeier
- Institute of Sports Medicine, Bispebjerg Hospital and Centre of Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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31
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[Ultrasound in interventional pain therapy]. Schmerz 2013; 27:325-37; quiz 337-9. [PMID: 23612787 DOI: 10.1007/s00482-012-1286-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Peripheral nerve blocks are currently performed relatively blind even in the most complex anatomical structures and physicians mostly rely on palpable anatomical landmarks on the surface. Ultrasound has become an indispensable part of the modern medical world and has long since found its way into almost all medical professions. More and more this trend also reaches interventional pain physicians as it is possible to accurately target structures, to track the needle course during the intervention and to visualize the spread of the local anesthetic. Another advantage compared to other radiological techniques is the profound radiation safety for patients as well as for personnel performing the intervention. A deep understanding of anatomy and its correlate in ultrasound images is one of the most important requirements for the successful use of these interventional techniques. Moreover, the safe performance of the procedure depends on the simultaneous hand-eye coordination. Nevertheless, despite the euphoria ultrasound technology should only be used in pain management with sufficient indications.
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32
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Pingel J, Fredberg U, Mikkelsen LR, Schjerling P, Heinemeier KM, Kjaer M, Harisson A, Langberg H. No inflammatory gene-expression response to acute exercise in human Achilles tendinopathy. Eur J Appl Physiol 2013; 113:2101-9. [PMID: 23588255 DOI: 10.1007/s00421-013-2638-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Accepted: 03/30/2013] [Indexed: 11/30/2022]
Abstract
Although histology data favour the view of a degenerative nature of tendinopathy, indirect support for inflammatory reactions to loading in affected tendons exists. The purpose of the present study was to elucidate whether inflammatory signalling responses after acute mechanical loading were more pronounced in tendinopathic versus healthy regions of human tendon and if treatment with non-steroidal anti-inflammatory medications (NSAID's) reduces this response. Twenty-seven tendinopathy patients (>6 months) were randomly assigned to a placebo (n = 14) or NSAID (Ibumetin NYCOMED GmbH Plant Oranienburg Germany (600 mg) × 3/day/1 week) group (n = 13) in a double-blinded-fashion. Tendon biopsies were taken from the painful and a healthy region of the same tendon 2 h after 1 h running. Gene-expression of several targets was analysed in the sampled Achilles tendon biopsies. The mRNA for TGF-β, collagen-I and collagen-III were significantly higher expressed, and decorin, CTGF, IL-6 and IL-10 were significantly lower expressed in the tendinopathic versus healthy tendon area. Only IL-10 was lower in expression in experiments with NSAID administration, while all other determined parameters were unaffected by NSAID. All ultrasonographic outcomes were unchanged in response to acute exercise and not influenced by NSAID. The signalling for collagen and TGF-beta was upregulated after acute loading in tendinopathic tendon. In contrast to the hypothesis, inflammatory signalling was not exaggerated in tendinopathic tendon 2 h after acute mechanical loading.
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Affiliation(s)
- Jessica Pingel
- Department of Orthopaedic Surgery M. Bispebjerg Hospital and Center for Healthy Aging, Faculty of Health Sciences, Institute of Sports Medicine Copenhagen, University of Copenhagen, Bispebjerg Bakke 23, Copenhagen NV, Denmark.
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Prior M, Guerin M, Grimmer K. An evidence-based approach to hamstring strain injury: a systematic review of the literature. Sports Health 2012; 1:154-64. [PMID: 23015867 PMCID: PMC3445075 DOI: 10.1177/1941738108324962] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Hamstring strain injury is a common problem within sport. Despite research interest, knowledge of risks for and management of hamstring strain is limited, as evidenced by high injury rates. Objective: To present the current best evidence for hamstring strain injury risk factors and the management of hamstring strain injury. Methods: MEDLINE, AMED, SportDiscus, and AUSPORT databases were searched (key terms “hamstring” and “strain,” “injury,” “pull,” or “tear”) to identify relevant literature published between 1982 and 2007 in the English language. Studies of adult athlete populations (older than 18 years) pertaining to hamstring strain incidence, prevalence, and/or intervening management of hamstring strain injury were included. Articles were limited to full-text randomized, controlled studies or cohort studies. Twenty-four articles were included. Articles were critically appraised using the McMaster Quantitative Review Guidelines instrument. Data pertaining to injury rates and return to sport outcomes were extracted. Each author undertook independent appraisal of a random selection of articles after establishing inter-rater agreement of appraisal. Results: Previous strain, older age, and ethnicity were consistently reported as significant risks for injury, as was competing in higher levels of competition. Associations with strength and flexibility were conflicting. Functional rehabilitation interventions had preventive effects and resulted in significantly earlier return to sport. Additionally, weak evidence existed for other interventions. Conclusion: Current evidence is inconclusive regarding most interventions for hamstring strain injury, while the effect of potentially modifiable risks is unclear. Further high-quality prospective studies into potential risks and management are required to provide a better framework within which to target interventions.
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Affiliation(s)
- Mathew Prior
- Centre for Allied Health Evidence, University of South Australia ; The Queen Elizabeth Hospital, Adelaide, Australia
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Royall NA, Farrin E, Bahner DP, Stawicki SP. Ultrasound-assisted musculoskeletal procedures: A practical overview of current literature. World J Orthop 2012. [PMID: 22474637 DOI: 10.5312/wjo.v2.i7.] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Traditionally performed by a small group of highly trained specialists, bedside sonographic procedures involving the musculoskeletal system are often delayed despite the critical need for timely diagnosis and treatment. Due to this limitation, a need evolved for more portability and accessibility to allow performance of emergent musculoskeletal procedures by adequately trained non-radiology personnel. The emergence of ultrasound-assisted bedside techniques and increased availability of portable sonography provided such an opportunity in select clinical scenarios. This review summarizes the current literature describing common ultrasound-based musculoskeletal procedures. In-depth discussion of each ultrasound procedure including pertinent technical details, indications and contraindications is provided. Despite the limited amount of prospective, randomized data in this area, a substantial body of observational and retrospective evidence suggests potential benefits from the use of musculoskeletal bedside sonography.
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Affiliation(s)
- Nelson A Royall
- Nelson A Royall, David P Bahner, Department of Emergency Medicine, The Ohio State University Medical Center, Columbus, OH 43210, United States
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Pigozzi F, Di Gianfrancesco A, Zorzoli M, Bachl N, Mc Donagh D, Cummiskey J, Di Luigi L, Pitsiladis Y, Borrione P. Why glucocorticosteroids should remain in the list of prohibited substances: a sports medicine viewpoint. Int J Immunopathol Pharmacol 2012; 25:19-24. [PMID: 22507313 DOI: 10.1177/039463201202500103] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
In addition to their therapeutic applications, glucocorticosteroids have been widely used and abused in the belief that these substances may enhance athletic performance. Analysis of athlete urine samples by antidoping laboratories around the world support this conclusion. It is commonly accepted in medical practice to use local glucocorticosteroid injections in the treatment of non-infectious local musculotendinous inflammatory conditions conveying symptom relief and often a speedier return to sporting activity. This practice is not to be considered illicit, but sports physicians must accept that such an intervention is not in itself an immediate cure and that an athlete will still require a period of recuperation before continuing sporting activity. How long such a period of recuperation should last is a matter of conjecture and there is little concrete data to support what is, or what is not, an acceptable period of inactivity. In the interest of athlete safety, we would propose to maintain systemic glucocorticosteroids on the World Anti-Doping Agency's (WADA) list of prohibited substances, both in and out-of-competition as well as a mandatory period of 48 hours of rest from play after receiving a local glucocorticosteroid injection.
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Abstract
BACKGROUND Posterior heel pain due to retrocalcaneal bursitis, is a disabling condition that responds well to the conventional methods of treatment. Patients who do not respond to conservative treatment may require surgical intervention. This study evaluates the outcome of endoscopic decompression of retrocalcaneal bursitis, with resection of posterosuperior eminence of the calcaneum. MATERIALS AND METHODS This present study included 25 heels from 23 consecutive patients with posterior heel pain, who did not respond to conservative treatment and underwent endoscopic decompression of the retrocalcaneal bursae and excision of bony spurs. The functional outcome was evaluated by comparing the pre and postoperative American Orthopedic Foot and Ankle Society (AOFAS) scores. The Maryland ankle and foot score was used postoperatively to assess the patient's satisfaction at the one-year followup. RESULTS The University of Maryland scores of 25 heels were categorized as the nonparametric categories, and it was observed that 16 patients had an excellent outcome, six good, three fair and there were no poor results. The AOFAS scores averaged 57.92 ± 6.224 points preoperatively and 89.08 ± 5.267 points postoperatively (P < 0.001), at an average followup of 16.4 months. The 12 heels having noninsertional tendinosis on ultrasound had low AOFAS scores compared to 13 heels having retrocalcaneal bursitis alone. At one year followup, correlation for preoperative ultrasound assessment of tendoachilles degeneration versus postoperative Maryland score (Spearman correlation) had shown a strong negative correlation. CONCLUSION Endoscopic calcaneal resection is highly effective in patients with mild or no degeneration and yields cosmetically better results with fewer complications. Patients with degenerative changes in Achilles tendon had poorer outcomes in terms of subjective satisfaction.
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Affiliation(s)
- Vamsi Kondreddi
- Department of Orthopedics, Mamata Medical College, Giriprasad Nagar, Khammam, A.P., India,Address for correspondence: Dr. Vamsi Kondreddi, Assistant Professor, Department of Orthopedics, Mamata General Hospital, Giriprasad Nagar, Khammam 507002, A.P., India. E-mail:
| | - R Krishna Gopal
- Department of Orthopaedics, Mahatma Gandhi Medical College and Research Institute, Pondicherry, India
| | - Ranjith K Yalamanchili
- Department of Orthopedics, Mamata Medical College, Giriprasad Nagar, Khammam, A.P., India
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Royall NA, Farrin E, Bahner DP, Stawicki SPA. Ultrasound-assisted musculoskeletal procedures: A practical overview of current literature. World J Orthop 2011; 2:57-66. [DOI: 10.5312/wjo.v2.i7.57] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Traditionally performed by a small group of highly trained specialists, bedside sonographic procedures involving the musculoskeletal system are often delayed despite the critical need for timely diagnosis and treatment. Due to this limitation, a need evolved for more portability and accessibility to allow performance of emergent musculoskeletal procedures by adequately trained non-radiology personnel. The emergence of ultrasound-assisted bedside techniques and increased availability of portable sonography provided such an opportunity in select clinical scenarios. This review summarizes the current literature describing common ultrasound-based musculoskeletal procedures. In-depth discussion of each ultrasound procedure including pertinent technical details, indications and contraindications is provided. Despite the limited amount of prospective, randomized data in this area, a substantial body of observational and retrospective evidence suggests potential benefits from the use of musculoskeletal bedside sonography.
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Royall NA, Farrin E, Bahner DP, Stawicki SP. Ultrasound-assisted musculoskeletal procedures: A practical overview of current literature. World J Orthop 2011; 2:57-66. [PMID: 22474637 PMCID: PMC3302042 DOI: 10.5312/wjo.v2.i7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2011] [Revised: 06/28/2011] [Accepted: 07/05/2011] [Indexed: 02/06/2023] Open
Abstract
Traditionally performed by a small group of highly trained specialists, bedside sonographic procedures involving the musculoskeletal system are often delayed despite the critical need for timely diagnosis and treatment. Due to this limitation, a need evolved for more portability and accessibility to allow performance of emergent musculoskeletal procedures by adequately trained non-radiology personnel. The emergence of ultrasound-assisted bedside techniques and increased availability of portable sonography provided such an opportunity in select clinical scenarios. This review summarizes the current literature describing common ultrasound-based musculoskeletal procedures. In-depth discussion of each ultrasound procedure including pertinent technical details, indications and contraindications is provided. Despite the limited amount of prospective, randomized data in this area, a substantial body of observational and retrospective evidence suggests potential benefits from the use of musculoskeletal bedside sonography.
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Affiliation(s)
- Nelson A Royall
- Nelson A Royall, David P Bahner, Department of Emergency Medicine, The Ohio State University Medical Center, Columbus, OH 43210, United States
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High hamstring tendinopathy: MRI and ultrasound imaging and therapeutic efficacy of percutaneous corticosteroid injection. AJR Am J Roentgenol 2010; 195:993-8. [PMID: 20858830 DOI: 10.2214/ajr.09.3674] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The goals of this study were to review the MRI and sonographic findings in patients diagnosed clinically with high hamstring tendinopathy and to evaluate the efficacy of ultrasound-guided corticosteroid injections in providing symptomatic relief. CONCLUSION MRI is more sensitive than ultrasound in detecting peritendinous edema and tendinopathy at the proximal hamstring origin. Fifty percent of patients had symptomatic improvement lasting longer than 1 month after percutaneous corticosteroid injection, and 24% of patients had symptom relief for more than 6 months.
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Fredberg U, Bolvig L, Pfeiffer-Jensen M, Clemmensen D, Jakobsen BW, Stengaard-Pedersen K. Ultrasonography as a tool for diagnosis, guidance of local steroid injection and, together with pressure algometry, monitoring of the treatment of athletes with chronic jumper's knee and Achilles tendinitis: a randomized, double‐blind, placebo‐controlled study. Scand J Rheumatol 2009; 33:94-101. [PMID: 15163110 DOI: 10.1080/03009740310004126] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND The diagnosis of Achilles and patella tendinitis has until recently been based on clinical examination, and treatment with local steroid injection has been given blindly. This is the first randomized, double blind, placebo-controlled study of local steroid injection in athletes with chronic tendinitis, which used ultrasonography to increase diagnostic accuracy, to guide the correct placement of local steroid and, conjunctively with pressure algometry, to objectify and monitor the results of treatment. METHOD Forty-eight athletes each with severe symptomatic tendinitis of a patellar (24) or Achilles tendon (24) for more than 6 months, whose conditions were confirmed ultrasonographically, and who all failed conservative treatment (rehabilitation) were included in this double-blind, placebo-controlled study and treated with three ultrasonographically guided peritendinous injections of steroid or placebo. RESULTS The conditions of only one-third of the referred athletes with clinically suspected tendinitis were confirmed by ultrasonographic examination. The ultrasonographically guided peritendinous injection of steroid had a significant effect in reducing pain and thickening of tendons. CONCLUSION Ultrasonography should be used in the future to assure precise diagnosis and to guide the peritendinous injection of steroid in chronic Achilles and patella tendinitis. Ultrasonography and pressure algometry are recommended as objective methods for monitoring the effect of treatment. Ultrasonographically guided injection of long-acting steroid can normalize the ultrasonographic pathological lesions in the Achilles and patellar tendons, and has a dramatic clinical effect but when combined with aggressive rehabilitation with running after a few days, many will have relapse of symptoms within 6 months.
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Affiliation(s)
- U Fredberg
- Department of Internal Medicine, Silkeborg Central Hospital, Denmark.
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Abate M, Silbernagel KG, Siljeholm C, Di Iorio A, De Amicis D, Salini V, Werner S, Paganelli R. Pathogenesis of tendinopathies: inflammation or degeneration? Arthritis Res Ther 2009; 11:235. [PMID: 19591655 PMCID: PMC2714139 DOI: 10.1186/ar2723] [Citation(s) in RCA: 334] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
The intrinsic pathogenetic mechanisms of tendinopathies are largely unknown and whether inflammation or degeneration has the prominent role is still a matter of debate. Assuming that there is a continuum from physiology to pathology, overuse may be considered as the initial disease factor; in this context, microruptures of tendon fibers occur and several molecules are expressed, some of which promote the healing process, while others, including inflammatory cytokines, act as disease mediators. Neural in-growth that accompanies the neovessels explains the occurrence of pain and triggers neurogenic-mediated inflammation. It is conceivable that inflammation and degeneration are not mutually exclusive, but work together in the pathogenesis of tendinopathies.
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Affiliation(s)
- Michele Abate
- Postgraduate School of Physical Medicine and Rehabilitation, University G d'Annunzio, Chieti-Pescara, 66013 Chieti Scalo, CH, Italy.
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Kongsgaard M, Kovanen V, Aagaard P, Doessing S, Hansen P, Laursen AH, Kaldau NC, Kjaer M, Magnusson SP. Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scand J Med Sci Sports 2009; 19:790-802. [PMID: 19793213 DOI: 10.1111/j.1600-0838.2009.00949.x] [Citation(s) in RCA: 274] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
A randomized-controlled single-blind trial was conducted to investigate the clinical, structural and functional effects of peritendinous corticosteroid injections (CORT), eccentric decline squat training (ECC) and heavy slow resistance training (HSR) in patellar tendinopathy. Thirty-nine male patients were randomized to CORT, ECC or HSR for 12 weeks. We assessed function and symptoms (VISA-p questionnaire), tendon pain during activity (VAS), treatment satisfaction, tendon swelling, tendon vascularization, tendon mechanical properties and collagen crosslink properties. Assessments were made at 0 weeks, 12 weeks and at follow-up (half-year). All groups improved in VISA-p and VAS from 0 to 12 weeks (P<0.05). VISA-p and VAS improvements were maintained at follow-up in ECC and HSR but deteriorated in CORT (P<0.05). In CORT and HSR, tendon swelling decreased (-13+/-9% and -12+/-13%, P<0.05) and so did vascularization (-52+/-49% and -45+/-23%, P<0.01) at 12 weeks. Tendon mechanical properties were similar in healthy and injured tendons and were unaffected by treatment. HSR yielded an elevated collagen network turnover. At the half-year follow-up, treatment satisfaction differed between groups, with HSR being most satisfied. Conclusively, CORT has good short-term but poor long-term clinical effects, in patellar tendinopathy. HSR has good short- and long-term clinical effects accompanied by pathology improvement and increased collagen turnover.
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Affiliation(s)
- M Kongsgaard
- Institute of Sports Medicine, Department 8, Bispebjerg Hospital and Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.
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Patellar tendon ruptures in weight lifters after local steroid injections. Arch Orthop Trauma Surg 2009; 129:369-72. [PMID: 18575877 DOI: 10.1007/s00402-008-0655-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2008] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Weight lifting is commonly associated with an increase in knee injury risk. Local steroid injection is thought to be associated with increased risk of spontaneous tendon rupture. The purpose of this report is to describe incidence of rupture of the patellar tendon after receiving multiple local steroid injections in weight lifters. MATERIALS AND METHODS Seven weight lifters presented at the hospital with ruptured patellar tendon. All the patients had a history of multiple local steroid injections into the patellar tendon. Each patient received surgical treatment within 72 h after injury. RESULTS After an average follow-up time of 26 months, the mean postoperative Lysholm knee score was 94 and the mean Insall-Salvati measurement was 0.96. All seven athletes returned to weight lifting training at 1 year after the operation. They returned to full competition at 18 months after the surgery. CONCLUSION For physicians who treat patellar tendonitis, especially in weight lifters, it is important to recognize the contributing factors for tendon rupture especially in those who have had multiple steroid injections. The functional prognosis of the knee improves if the normal length and strength of the injured tendon have been properly restored.
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Jelinsky SA, Lake SP, Archambault JM, Soslowsky LJ. Gene expression in rat supraspinatus tendon recovers from overuse with rest. Clin Orthop Relat Res 2008; 466:1612-7. [PMID: 18459028 PMCID: PMC2505258 DOI: 10.1007/s11999-008-0270-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2007] [Accepted: 04/11/2008] [Indexed: 01/31/2023]
Abstract
Rest is a common treatment for overuse injuries, but its effectiveness on gene expression has not been systematically evaluated under controlled experimental conditions. We asked whether genes regulated in the supraspinatus tendon as a result of overuse would return to normal levels after 2 or 4 weeks of rest. We used a rat model of tendon overuse that generates reproducible changes in the histology, geometry, gene expression, and mechanical properties consistent with an overuse injury. Animals were subjected to the overuse protocol for 2 or 4 weeks followed by either 2 or 4 weeks of rest. Microarray analysis was used to measure global changes in gene expression after the overuse plus rest protocol. Genes upregulated as a result of the overuse returned to near normal levels after rest in most animals. The biochemical composition of the tendon was similar to normal after the imposed rest period, except for slightly lower collagen content. These results suggest as little as 2 weeks of rest is often sufficient to recover from the molecular and biochemical effects of 2 and 4 weeks of overuse in this rat model.
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Affiliation(s)
- Scott A. Jelinsky
- Wyeth Discovery Research, 87 Cambridge Park Drive, Cambridge, MA 02140 USA
| | - Spencer P. Lake
- McKay Orthopedic Research Laboratory, University of Pennsylvania, Philadelphia, PA USA
| | | | - Louis J. Soslowsky
- McKay Orthopedic Research Laboratory, University of Pennsylvania, Philadelphia, PA USA
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Fredberg U, Bolvig L, Andersen NT. Prophylactic training in asymptomatic soccer players with ultrasonographic abnormalities in Achilles and patellar tendons: the Danish Super League Study. Am J Sports Med 2008; 36:451-60. [PMID: 18079558 DOI: 10.1177/0363546507310073] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND A recent study published in The American Journal of Sports Medicine showed that asymptomatic soccer players with an increased risk of developing Achilles and patellar tendon injuries within the next 12 months can be identified with use of ultrasonography. HYPOTHESIS Prophylactic eccentric training and stretching can reduce both the frequency of asymptomatic ultrasonographic changes in Achilles and patellar tendons in soccer players and the risk of these asymptomatic intratendinous changes becoming symptomatic. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS Two hundred and nine Danish professional soccer players from the best national league (Super League) were followed over 12 months with use of ultrasonography and injury registration. Half the teams were randomized to an intervention group with prophylactic eccentric training and stretching of the Achilles and patellar tendons during the soccer season. RESULTS The eccentric training and stretching did not reduce the injury risk, and, contrary to all expectations, the injury risk during the season was increased in players with abnormal patellar tendons at the beginning of the study in January. Eccentric training and stretching in players with normal patellar tendons significantly reduced the proportion of players with ultrasonographic changes in the patellar tendons at the end of the season (risk difference [RD] = 12%; 95% confidence interval [CI], 2%-22%; P = .02), but the training had no effect on the Achilles tendons (RD = 1%; 95% CI, -7% to 9%; P = .75). The presence of preseason ultrasonographic abnormalities in the tendons significantly increased the risk of developing tendon symptoms during the season (relative risk = 1.9; 95% CI, 1.2-3.1; P = .009). CONCLUSIONS This study demonstrates that with the use of ultrasonography, tendon changes in soccer players can be diagnosed before they become symptomatic. The prophylactic eccentric training and stretching program reduces the risk of developing ultrasonographic abnormalities in the patellar tendons but has no positive effects on the risk of injury. On the contrary, in asymptomatic players with ultrasonographically abnormal patellar tendons, prophylactic eccentric training and stretching increased the injury risk.
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Affiliation(s)
- Ulrich Fredberg
- Stadium Clinic, Atletion, House of Sport West, Aarhus, Denmark.
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Haraldsson BT, Langberg H, Aagaard P, Zuurmond AM, van El B, Degroot J, Kjaer M, Magnusson SP. Corticosteroids reduce the tensile strength of isolated collagen fascicles. Am J Sports Med 2006; 34:1992-7. [PMID: 16902230 DOI: 10.1177/0363546506290402] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Overuse tendon injuries are frequent. Corticosteroid injections are commonly used as treatment, although their direct effects on the material properties of the tendon are poorly understood. PURPOSE To examine the influence of corticosteroids on the tensile strength of isolated collagen fascicles. STUDY DESIGN Controlled laboratory study. METHODS Single strands (300-500 mum) of rat-tail collagen fascicles were incubated in either high (1 mL of 40 mgmL(-1) mixed with 0.5 mL saline 9%) or low (1 mL of 40 mgmL(-1) mixed with 2 mL saline 9%) concentration of methylprednisolone acetate (Depomedrol) for 3 or 7 days, while the control segment from the same fascicle was kept in saline (N = 64). After the incubation period, the fascicles underwent displacement to failure in a mechanical test rig at 0.13 mm/s, and thereafter hydroxylysyl pyridinoline and lysyl pyridinoline cross-link content was evaluated in a high-performance liquid chromatography system. Data for each group were analyzed with a 2-way analysis of variance (time x incubation) for ultimate stress (mean +/- standard deviation). RESULTS In the high-concentration groups, strength was reduced after 3 (16.6 +/- 4.6 MPa) and 7 (8.6 +/- 1.7 MPa) days compared to the controls (30.2 +/- 5.0 MPa and 25.6 +/- 4.6 MPa, respectively; P < .05). In the low-concentration groups, strength was reduced after 3 (12.0 +/- 3.1 MPa) and 7 days (10.9 +/- 2.5 MPa) compared to the controls (31.5 +/- 5.0 MPa and 32.4 +/- 5.6 MPa, respectively; P < .05). The amount of cross-linking was unaffected by the intervention. CONCLUSION Data show that the tensile strength of isolated fascicles is markedly reduced after 3- and 7-day incubation in both high and low concentration of corticosteroids, although the observed effect on whole tendon remains unknown. CLINICAL RELEVANCE Corticosteroids may weaken specific regions of the injected tendon and leave it more prone to rupture. This weakening effect is manifested in the individual collagen fascicles that constitute the tendon.
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Affiliation(s)
- Bjarki Thor Haraldsson
- Institute of Sports Medicine Copenhagen, Bispebjerg Hospital, Bispebjerg Bakke 23, 2400 Copenhagen NV, Denmark
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Bianchi S, Martinoli C, Abdelwahab IF. Imaging findings of spontaneous detachment of the deltoid muscle as a complication of massive rotator cuff tear. Skeletal Radiol 2006; 35:410-5. [PMID: 16328380 DOI: 10.1007/s00256-005-0046-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2005] [Revised: 09/10/2005] [Accepted: 09/12/2005] [Indexed: 02/02/2023]
Abstract
A tear at the origin of the deltoid muscle is uncommon and usually occurs as a complication of shoulder surgery. We report a case of spontaneous deltoid detachment as a complication of massive rotator cuff tear in a 70-year-old woman evaluated by standard radiographs, ultrasound, arthrography and MR-arthrography. We present the multimodality imaging findings with review of the literature. We found that ultrasound is an accurate modality in detecting and assessing spontaneous detachment of the deltoid muscle. As ultrasound is a noninvasive, low-cost, and universally available imaging modality we suggest using ultrasound as the first modality for evaluation of spontaneous detachment of the deltoid muscle.
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Affiliation(s)
- Stefano Bianchi
- Clinique et Fondation des Grangettes, Institut de Radiologie, Geneva, Switzerland.
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Abstract
Primary disorders of tendons are common and constitute a high proportion of referrals to rheumatologists. Certain tendons are particularly vulnerable to degenerative pathology; these include the Achilles, patella, elements of the rotator cuff, forearm extensors, biceps brachi and tibialis posterior tendons. Disorders of these tendons are often chronic and can be difficult to manage successfully in the long term. Significant advances have been made in understanding the pathophysiology of these conditions. Histopathological evidence, together with advances in imaging techniques, has made us more appreciative of the degenerative (rather that inflammatory) nature of these conditions. Additionally the presence of neovascularization is now well-recognized in long-standing tendinopathy. We review the mechanical, vascular and developing neural theories that attempt to explain the aetiology of degenerative tendinopathy. We also explore theories of why specific tendons (such as the Achilles and supraspinatus tendons) are particularly prone to degenerative pathology. Traditionally, treatments have placed a heavy emphasis on anti-inflammatory strategies, which are often inappropriate. Recently, however, significant advances in the practical management of tendon disorders have been made. In particular the advent of 'eccentric loading' training programmes has revolutionized the treatment of Achilles tendinopathy in some patients. This concept is currently being extended to include other commonly injured tendons. Other current treatments are reviewed, as are potential future treatments.
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Affiliation(s)
- J D Rees
- Institute of Orthopaedics and Musculo-Skeletal Science, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK.
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