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Kim YT, Lee KJ, Kim SH. Biceps Rerouting Regardless of a Biceps-Labral Lesion During Rotator Cuff Repair Results in Lower Retear Rates and Comparable Clinical Outcomes to Subpectoral Biceps Tenodesis. Arthroscopy 2024:S0749-8063(24)00068-9. [PMID: 38311266 DOI: 10.1016/j.arthro.2024.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 01/09/2024] [Accepted: 01/12/2024] [Indexed: 02/10/2024]
Abstract
PURPOSE To evaluate the radiographic and clinical outcomes when rerouting a pathologic biceps during arthroscopic rotator cuff repair by comparing it with concomitant subpectoral biceps tenodesis (SPBT). METHODS This retrospective, historical cohort study was conducted with patients who underwent an arthroscopic repair of a full-thickness rotator cuff tear, with intraoperative confirmation of biceps pathology including partial tears, subluxation, pulley lesions, or type II SLAP lesions. Until May 2018, such patients were treated with concomitant subpectoral tenodesis (group SPBT). Afterward, biceps rerouting (BR) was done regardless of biceps pathology (group BR) without biceps or SLAP repair. Radiographic parameters, including fatty degeneration, acromiohumeral distance, Sugaya classification, and retears, were evaluated using preoperative and 1-year postoperative magnetic resonance imaging results. Clinical evaluation with a minimum 2-year follow-up included pain visual analog scale, American Shoulder and Elbow Surgeons, Simple Shoulder Test, and Constant-Murley scores. Whether individual patients exceeded these scores' minimal clinically important difference also was determined. RESULTS A total of 64 patients (group SPBT = 32; group BR = 32) were included in the final analysis. The duration of clinical follow-up was 36.2 ± 9.3 months in group SPBT and 29.4 ± 6.9 months in the BR group (P = .002). Compared with group SPBT, group BR demonstrated a significantly lower retear rate (SPBT vs BR: 34.4% vs 12.5%, P = .039). In the BR group, 8 of 32 (25%) patients demonstrated a postoperative LHBT tear. The 4 cuff retears in group BR only took place within these patients. Other postoperative radiographic and clinical outcomes were comparable between the groups. Within each group, significant postoperative improvements were demonstrated (P < .05 for all clinical scores). CONCLUSIONS Even in the presence of a pathologic LHBT and/or a type II SLAP lesion, augmenting the rotator cuff repair with BR significantly reduced retear rates while achieving clinical scores comparable with SPBT in a minimum 2-year follow-up. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Yong Tae Kim
- Department of Orthopaedic Surgery, Hallym University Dongtan Sacred Heart Hospital, Gyeonggi, Korea
| | - Kyung Jae Lee
- Department of Orthopaedic Surgery, Chung-Ang University Hospital, Seoul, Korea
| | - Sae Hoon Kim
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, Korea.
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2
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Alakhdar Y, Cook J, Gallego D, Querol F, Chulvi-Medrano I, Alberola A, Hernández-Sánchez S. Association Between COL5a1, COL11a1, and COL11a2 Gene Variations and Rotator Cuff Tendinopathy in Young Athletes. Clin J Sport Med 2023; 33:e152-e156. [PMID: 34009784 DOI: 10.1097/jsm.0000000000000937] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 03/25/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Tendinopathy is a prevalent condition in young athletes and in older nonathletic people. Recent tendinopathy research has shown a growing interest in the role played by genetic factors, basically genes involved in collagen synthesis and regulation, in view of collagen disorganization typically present in tendon pathologies. DESIGN A case-control, genotype-phenotype association study. SETTING La Ribera Hospital, Valencia, Spain. PARTICIPANTS A group of 137 young athletes (49 with rotator cuff tendon pathology and 88 healthy counterparts) who played upper-limb-loading sports were clinically and ultrasound (US) assessed for rotator cuff tendinopathy were included. INTERVENTION Genetic analysis was performed to determine whether there was a relationship between rotator cuff pathology and the genotype. MAIN OUTCOME MEASURES We hypothesized that the following single nucleotide polymorphisms: COL5a1 rs12722, COL11a1 rs3753841, COL11a1 rs1676486, and COL11a2 rs1799907 would be associated with rotator cuff tendinopathy. RESULTS A direct relationship between CC genotype and bilateral US pathological images was statistically significant (χ 2 = 0.0051) and confirmed by the Fisher test, with a correlation coefficient of 0.345 and a Cramer's v of 0.26. CONCLUSION A significant association was found between COL5a1 rs12722 genotype and rotator cuff pathology, with the CC genotype conferring increased risk of tendon abnormalities and being associated with rotator cuff pathology.
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Affiliation(s)
- Yasser Alakhdar
- Department of Physiotherapy, University of Valencia, Valencia, Spain
| | - Jill Cook
- La Trobe Sport and Exercise Medicine Research Centre, Faculty of Health Science, La Trobe University, Victoria, Australia
| | - Diana Gallego
- Department of Physiotherapy, Faculty of Health, European University, Valencia, Spain
| | - Felipe Querol
- Department of Physiotherapy, University of Valencia, Valencia, Spain
| | - Iván Chulvi-Medrano
- Physical and Sports Education Department, Faculty of Physical Activity and Sport Sciences, University of Valencia, Valencia, Spain
| | - Antonio Alberola
- Department of Physiology, University de Valencia, Valencia, Spain ; and
| | - Sergio Hernández-Sánchez
- Center for Translational Research in Physiotherapy, Department of Pathology and Surgery, Physiotherapy Area, Miguel Hernandez University, San Juan, Alicante, Spain
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Quintero D, Perucca Orfei C, Kaplan LD, de Girolamo L, Best TM, Kouroupis D. The roles and therapeutic potentialof mesenchymal stem/stromal cells and their extracellular vesicles in tendinopathies. Front Bioeng Biotechnol 2023; 11:1040762. [PMID: 36741745 PMCID: PMC9892947 DOI: 10.3389/fbioe.2023.1040762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 01/04/2023] [Indexed: 01/20/2023] Open
Abstract
Tendinopathies encompass a highly prevalent, multi-faceted spectrum of disorders, characterized by activity-related pain, compromised function, and propensity for an extended absence from sport and the workplace. The pathophysiology of tendinopathy continues to evolve. For decades, it has been related primarily to repetitive overload trauma but more recently, the onset of tendinopathy has been attributed to the tissue's failed attempt to heal after subclinical inflammatory and immune challenges (failed healing model). Conventional tendinopathy management produces only short-term symptomatic relief and often results in incomplete repair or healing leading to compromised tendon function. For this reason, there has been increased effort to develop therapeutics to overcome the tissue's failed healing response by targeting the cellular metaplasia and pro-inflammatory extra-cellular environment. On this basis, stem cell-based therapies have been proposed as an alternative therapeutic approach designed to modify the course of the various tendon pathologies. Mesenchymal stem/stromal cells (MSCs) are multipotent stem cells often referred to as "medicinal signaling cells" due to their immunomodulatory and anti-inflammatory properties that can produce a pro-regenerative microenvironment in pathological tendons. However, the adoption of MSCs into clinical practice has been limited by FDA regulations and perceived risk of adverse events upon infusion in vivo. The introduction of cell-free approaches, such as the extracellular vesicles of MSCs, has encouraged new perspectives for the treatment of tendinopathies, showing promising short-term results. In this article, we review the most recent advances in MSC-based and MSC-derived therapies for tendinopathies. Preclinical and clinical studies are included with comment on future directions of this rapidly developing therapeutic modality, including the importance of understanding tissue loading and its relationship to any treatment regimen.
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Affiliation(s)
- Daniel Quintero
- Department of Orthopaedics, UHealth Sports Medicine Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Carlotta Perucca Orfei
- Laboratorio di Biotecnologie Applicate all’Ortopedia, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Lee D. Kaplan
- Department of Orthopaedics, UHealth Sports Medicine Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Laura de Girolamo
- Laboratorio di Biotecnologie Applicate all’Ortopedia, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Thomas M. Best
- Department of Orthopaedics, UHealth Sports Medicine Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Dimitrios Kouroupis
- Department of Orthopaedics, UHealth Sports Medicine Institute, Miller School of Medicine, University of Miami, Miami, FL, United States,Diabetes Research Institute & Cell Transplant Center, Miller School of Medicine, University of Miami, Miami, FL, United States,*Correspondence: Dimitrios Kouroupis,
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Lee YJ, Park E, Park KS, Lim JH, Kim S, Kim MS, Eom TJ. Quantification method to objectively evaluate the fibrous structural status of tendons based on polarization-sensitive OCT. JOURNAL OF BIOPHOTONICS 2022; 15:e202200065. [PMID: 35766447 DOI: 10.1002/jbio.202200065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/27/2022] [Accepted: 06/27/2022] [Indexed: 06/15/2023]
Abstract
Histological analysis is widely used to evaluate injured tendons; however, it has the limitation of being semi-quantitative. Hence, we developed a quantification method to objectively evaluate the fibrous structure of tendons, exhibiting the optical property of birefringence, using polarization-sensitive optical coherence tomography (PS-OCT). We used a partial-rupture rat model in which the middle 0.75 cm of the Achilles tendon was cut with a blade. Rats were sacrificed at 2, 4 or 6 weeks after the injury, and PS-OCT and histological analyzes were performed. The PS-OCT phase retardation images and score well represented the structural changes of the injured tendon according to the wound healing state. Therefore, the proposed novel quantification method using PS-OCT can be used to evaluate the fibrous structural status of tendons.
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Affiliation(s)
- Yong-Jae Lee
- Advanced Photonics Research Institute, Gwangju Institute of Science and Technology, Gwangju, South Korea
- Engineering Research Center for Color-modulated Extra-sensory Perception Technology, Pusan National University, Busan, South Korea
| | - Eunwoo Park
- Department of Convergence IT Engineering, Pohang University of Science and Technology, Pohang, South Korea
| | - Kwan Seob Park
- Physical Measurement Laboratory, National Institute of Standard and Technology, Gaithersburg, Maryland, USA
| | - Jun-Hyuk Lim
- Department of Orthopedic Surgery, Chonnam National University Hospital, Chonnam National University College of Medicine, Gwangju, South Korea
| | - Sungmin Kim
- Department of Orthopedic Surgery, Chonnam National University Hospital, Chonnam National University College of Medicine, Gwangju, South Korea
| | - Myung-Sun Kim
- Department of Orthopedic Surgery, Chonnam National University Hospital, Chonnam National University College of Medicine, Gwangju, South Korea
| | - Tae Joong Eom
- Engineering Research Center for Color-modulated Extra-sensory Perception Technology, Pusan National University, Busan, South Korea
- Department of Cogno-Mechatronics Engineering, Pusan National University, Busan, South Korea
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Tendinopathies and Pain Sensitisation: A Meta-Analysis with Meta-Regression. Biomedicines 2022; 10:biomedicines10071749. [PMID: 35885054 PMCID: PMC9313266 DOI: 10.3390/biomedicines10071749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/11/2022] [Accepted: 07/18/2022] [Indexed: 12/02/2022] Open
Abstract
The presence of pain sensitisation has been documented and reported as being a possible cause of treatment failure and pain chronicity in several musculoskeletal conditions, such as tendinopathies. The aim of the present study is to analyse existing evidence on pain sensitisation in tendinopathies comparing the local and distant pain thresholds of healthy and affected subjects with distinct analysis for different tendinopathies. PubMed, Cochrane Central Register, Scopus, and Web Of Science were systematically searched after registration on PROSPERO (CRD42020164124). Level I to level IV studies evaluating the presence of pain sensitisation in patients with symptomatic tendinopathies, documented through a validated method, were included. A meta-analysis was performed to compare local, contralateral, and distant pain thresholds between patients and healthy controls with sub-analyses for different tendinopathies. Meta-regressions were conducted to evaluate the influence of age, activity level, and duration of symptoms on results. Thirty-four studies out of 2868 were included. The overall meta-analysis of local pressure pain thresholds (PPT) documented an increased sensitivity in affected subjects (p < 0.001). The analyses on contralateral PPTs (p < 0.001) and distant PPTs (p = 0.009) documented increased sensitivity in the affected group. The results of the sub-analyses on different tendinopathies were conflicting, except for those on lateral epicondylalgia. Patients’ activity level (p = 0.02) and age (p = 0.05) significantly influenced local PPT results. Tendinopathies are characterized by pain sensitisation, but, while features of both central and peripheral sensitisation can be constantly detected in lateral epicondylalgia, results on other tendinopathies were more conflicting. Patients’ characteristics are possible confounders that should be taken into account when addressing pain sensitisation.
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Ribbans WJ, September AV, Collins M. Tendon and Ligament Genetics: How Do They Contribute to Disease and Injury? A Narrative Review. Life (Basel) 2022; 12:life12050663. [PMID: 35629331 PMCID: PMC9147569 DOI: 10.3390/life12050663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 04/24/2022] [Accepted: 04/26/2022] [Indexed: 12/15/2022] Open
Abstract
A significant proportion of patients requiring musculoskeletal management present with tendon and ligament pathology. Our understanding of the intrinsic and extrinsic mechanisms that lead to such disabilities is increasing. However, the complexity underpinning these interactive multifactorial elements is still not fully characterised. Evidence highlighting the genetic components, either reducing or increasing susceptibility to injury, is increasing. This review examines the present understanding of the role genetic variations contribute to tendon and ligament injury risk. It examines the different elements of tendon and ligament structure and considers our knowledge of genetic influence on form, function, ability to withstand load, and undertake repair or regeneration. The role of epigenetic factors in modifying gene expression in these structures is also explored. It considers the challenges to interpreting present knowledge, the requirements, and likely pathways for future research, and whether such information has reached the point of clinical utility.
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Affiliation(s)
- William J. Ribbans
- School of Health, The University of Northampton, Northampton NN1 5PH, UK
- The County Clinic, Northampton NN1 5DB, UK
- Correspondence: ; Tel.: +44-1604-795414
| | - Alison V. September
- Division of Physiological Sciences, Department of Human Biology, Health Sciences Faculty, University of Cape Town, Cape Town 7700, South Africa; (A.V.S.); (M.C.)
- Health Through Physical Activity, Lifestyle and Sport Research Centre (HPALS), Department of Human Biology, Health Sciences Faculty, University of Cape Town, Cape Town 7700, South Africa
- International Federation of Sports Medicine (FIMS), Collaborative Centre of Sports Medicine, Department of Human Biology, University of Cape Town, Cape Town 7700, South Africa
| | - Malcolm Collins
- Division of Physiological Sciences, Department of Human Biology, Health Sciences Faculty, University of Cape Town, Cape Town 7700, South Africa; (A.V.S.); (M.C.)
- Health Through Physical Activity, Lifestyle and Sport Research Centre (HPALS), Department of Human Biology, Health Sciences Faculty, University of Cape Town, Cape Town 7700, South Africa
- International Federation of Sports Medicine (FIMS), Collaborative Centre of Sports Medicine, Department of Human Biology, University of Cape Town, Cape Town 7700, South Africa
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7
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Daniels SP, De Tolla JE, Azad A, Fritz J. Imaging Evaluation of Medial and Lateral Elbow Pain: Acute and Chronic Tendon Injuries of the Humeral Epicondyles. Semin Musculoskelet Radiol 2021; 25:589-599. [PMID: 34706389 DOI: 10.1055/s-0041-1731790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Medial and lateral elbow pain are often due to degenerative tendinosis and less commonly due to trauma. The involved structures include the flexor-pronator tendon origin in medial-sided pain and the extensor tendon origin in lateral-sided pain. Multimodality imaging is often obtained to verify the clinically suspected diagnosis, evaluate the extent of injury, and guide treatment decisions. Image-guided procedures can provide symptom relief to support physical therapy and also induce tendon healing. Surgical debridement and repair are typically performed in refractory cases, resulting in good to excellent outcomes in most cases. In this article, we review and illustrate pertinent anatomical structures of the distal humerus, emphasizing the structure and contributions of the flexor-pronator and extensor tendon origins in acute and chronic tendon abnormalities. We also discuss approaches to image-guided treatment and surgical management of medial and lateral epicondylitis.
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Affiliation(s)
- Steven P Daniels
- Department of Radiology, New York University Grossman School of Medicine, New York University, New York, New York
| | - Jadie E De Tolla
- Department of Orthopedic Surgery, New York University Grossman School of Medicine, New York University, New York, New York
| | - Ali Azad
- Department of Orthopedic Surgery, New York University Grossman School of Medicine, New York University, New York, New York
| | - Jan Fritz
- Department of Radiology, New York University Grossman School of Medicine, New York University, New York, New York
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8
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Yilmaz E. A prospective, comparative study of subacromial corticosteroid injection and subacromial corticosteroid injection plus suprascapular nerve block in patients with shoulder impingement syndrome. Arch Orthop Trauma Surg 2021; 141:733-741. [PMID: 32356170 DOI: 10.1007/s00402-020-03455-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Efforts are recently focused on the management of shoulder impingement syndrome (SIS) with a conservative and targeted approach because of its psychosocial impact, reduction in the quality of life, the cost to the economy and its negative effect on daily activities. Therefore, many studies have been designed to evaluate and compare the effectiveness of different treatments. The main purpose of this study was to identify the effect of combination of subacromial corticosteroid injection (SCI) and suprascapular nerve block (SSNB) on shoulder impingement syndrome (SIS). MATERIALS AND METHODS 66 patients with SIS were randomly divided into two groups (33 patients per group): Group 1: SCI; Group 2: SCI plus SSNB. The estimation of the severity of pain by the visual analogue scale (VAS) and shoulder disability using quick DASH (Disabilities of the Arm, Shoulder and Hand) were assessed at baseline and 1, 3 months post-injection. RESULTS The mean age of patients was 55.55 ± 10.42 years in Group 1 and 57.24 ± 12.75 years in Group 2. In steroid group, pre- and post-treatment (at 1 and 3 months) VAS/quickDASH scores were 8.64 ± 0.99/78.03 ± 9.24, 2.09 ± 0.84/15.58 ± 7.23 and 3.06 ± 1.12/25.06 ± 8.74, respectively. In steroid plus SSNB group, pre- and post-treatment (at 1 and 3 months) VAS/quickDASH scores were 8.45 ± 0.90/75.15 ± 9.86, 1.24 ± 0.43/10.88 ± 2.14 and 1.51 ± 0.56/15.51 ± 5.04, respectively. Both treatment groups showed a significant relief of pain at 1 and 3 months post-injection (p < 0.05). However, the VAS and quickDASH scores at 1 and 3 months were significantly lower in Group 2 versus Group 1 (p < 0.05). CONCLUSION The combination of SCI and SSNB seems to produce the long-term effect in pain relief and functional improvement.
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Affiliation(s)
- Ebru Yilmaz
- Department of Physical Medicine and Rehabilitation, Kocaeli Government Hospital, Gunes Street 41300, Kocaeli, Turkey.
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9
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Mersmann F, Laube G, Marzilger R, Bohm S, Schroll A, Arampatzis A. A Functional High-Load Exercise Intervention for the Patellar Tendon Reduces Tendon Pain Prevalence During a Competitive Season in Adolescent Handball Players. Front Physiol 2021; 12:626225. [PMID: 33776790 PMCID: PMC7987778 DOI: 10.3389/fphys.2021.626225] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 02/18/2021] [Indexed: 01/31/2023] Open
Abstract
Imbalances of muscle strength and tendon stiffness may increase the risk for patellar tendinopathy in growing athletes. The present study investigated if a functional high-load exercise intervention, designed to facilitate tendon adaptation and reduce muscle-tendon imbalances, may prevent patellar tendon pain in adolescent male handball players (12–14 years). Tendon pain prevalence (using VISA-P scores), knee extensor strength, vastus lateralis (VL) architecture and patellar tendon mechanical properties were measured at four measurement time points (M1–M4) over a season. The control group (CON; n = 18; age 13.1 ± 0.7 yrs, height 170 ± 8 cm, mass 58 ± 10 kg) followed the usual strength training plan, including muscular endurance and explosive strength components. In the experimental group (EXP; n = 16; 13.1 ± 0.6 yrs, 169 ± 11 cm, 58 ± 16 kg), two sessions per week with functional high-load exercises for the patellar tendon were integrated in the strength training schedule, aiming to provide repetitive high-intensity loading of at least 3 s loading duration per repetition. While in the control group 30% of the athletes reported a clinically significant aggravation of symptoms, all players in the experimental group remained or became pain-free at M2 until the end of the season. There was a similar increase of strength (normalized to body mass; CON: 3.1%, d = 0.22; EXP: 6.8%, d = 0.47; p = 0.04) and VL thickness (CON: 4.8%, d = 0.28; EXP: 5.7%, d = 0.32; p < 0.001) in both groups, but no significant changes of tendon stiffness or maximum tendon strain. Further, both groups demonstrated similar fluctuations of tendon strain over time. We conclude that functional high-load exercises can reduce the prevalence of patellar tendon pain in adolescent athletes even without a reduction of tendon strain.
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Affiliation(s)
- Falk Mersmann
- Department of Training and Movement Sciences, Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin School of Movement Science, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Gunnar Laube
- Department of Training and Movement Sciences, Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin School of Movement Science, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Robert Marzilger
- Department of Training and Movement Sciences, Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin School of Movement Science, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Sebastian Bohm
- Department of Training and Movement Sciences, Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin School of Movement Science, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Arno Schroll
- Department of Training and Movement Sciences, Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin School of Movement Science, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Adamantios Arampatzis
- Department of Training and Movement Sciences, Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin School of Movement Science, Humboldt-Universität zu Berlin, Berlin, Germany
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10
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Influence of genetic factors in elbow tendon pathology: a case-control study. Sci Rep 2020; 10:6503. [PMID: 32300121 PMCID: PMC7162873 DOI: 10.1038/s41598-020-63030-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 03/18/2020] [Indexed: 11/09/2022] Open
Abstract
Elbow tendinopathy is a common pathology of the upper extremity that impacts both athletes and workers. Some research has examined the genetic component as a risk factor for tendinopathy, mainly in the lower limbs. A case-control study was designed to test for a relationship between certain collagen gene single nucleotide polymorphisms (SNPs) and elbow tendon pathology. A sample of 137 young adult athletes whose sports participation involves loading of the upper limb were examined for the presence of structural abnormalities indicative of pathology in the tendons of the lateral and medial elbow using ultrasound imaging and genotyped for the following SNPs: COL5A1 rs12722, COL11A1 rs3753841, COL11A1 rs1676486, and COL11A2 rs1799907. Anthropometric measurements and data on participants’ elbow pain and dysfunction were collected using the Disabilities of the Arm, Shoulder and Hand and the Mayo Clinic Performance Index for the Elbow questionnaires. Results showed that participants in the structural abnormality group had significantly higher scores in pain and dysfunction. A significant relationship between COL11A1 rs3753841 genotype and elbow tendon pathology was found (p = 0.024), with the CT variant associated with increased risk of pathology.
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11
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Nakase J, Oshima T, Takata Y, Shimozaki K, Asai K, Tsuchiya H. No superiority of dextrose injections over placebo injections for Osgood-Schlatter disease: a prospective randomized double-blind study. Arch Orthop Trauma Surg 2020; 140:197-202. [PMID: 31713082 DOI: 10.1007/s00402-019-03297-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Indexed: 12/22/2022]
Abstract
PURPOSE Osgood-Schlatter disease (OSD) is a traction apophysitis of the tibial tuberosity. Patellar tendinopathy and deep infrapatellar bursitis have recently been shown to contribute to pain in patients with OSD. We compared the effects of dextrose injection and saline injection. METHODS We performed a clinical trial from April 2012 to January 2016 and included 49 knees from 37 boys and 1 girl (mean age, 12.3 ± 1.1 years) for whom conventional conservative therapy for > 1 month was ineffective. They were randomly assigned to receive double-blind injections of 1% lidocaine (1 mL) with 20% dextrose (1 mL; dextrose group) or 1% lidocaine (1 mL) with saline (1 mL; saline group). Injections were administered monthly for 3 months by a single investigator. The Victorian Institute of Sport Assessment (VISA) score was used to evaluate anterior knee pain. RESULTS Overall, 43 knees were included; 6 knees were lost to follow-up. The mean pre-injection VISA scores in the dextrose and saline groups were 58.7 ± 18.3 and 63.4 ± 16.4, respectively. No significant differences were found between the two groups at any time point. The mean VISA score before injections significantly increased at the 1-month follow-up in both groups (P < .01). The injection had no adverse effects. CONCLUSIONS We were not able to show the efficacy of dextrose injections compared to that of saline. LEVEL OF EVIDENCE Randomized controlled trial. Level I.
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Affiliation(s)
- Junsuke Nakase
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takaramachi, Kanazawa, 920-8641, Japan.
| | - Takeshi Oshima
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takaramachi, Kanazawa, 920-8641, Japan
| | - Yasushi Takata
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takaramachi, Kanazawa, 920-8641, Japan
| | - Kengo Shimozaki
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takaramachi, Kanazawa, 920-8641, Japan
| | - Kazuki Asai
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takaramachi, Kanazawa, 920-8641, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takaramachi, Kanazawa, 920-8641, Japan
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Rodas G, Soler R, Balius R, Alomar X, Peirau X, Alberca M, Sánchez A, Sancho JG, Rodellar C, Romero A, Masci L, Orozco L, Maffulli N. Autologous bone marrow expanded mesenchymal stem cells in patellar tendinopathy: protocol for a phase I/II, single-centre, randomized with active control PRP, double-blinded clinical trial. J Orthop Surg Res 2019; 14:441. [PMID: 31842921 PMCID: PMC6916077 DOI: 10.1186/s13018-019-1477-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 11/14/2019] [Indexed: 02/08/2023] Open
Abstract
Introduction Patellar tendon overuse injuries are common in athletes. Imaging may show a change in tissue structure with tendon thickening and disruption of the intratendinous substance. We wish to test the hypothesis that both autologous bone marrow expanded mesenchymal stem cells and autologous leukocyte-poor platelet-rich plasma (LP-PRP) implanted into the area of the disrupted tendinopathic patellar tendon will restore function, but tendon regeneration tissue will only be observed in the subjects treated with autologous bone marrow expanded mesenchymal stem cells. Methods and analysis This is a single-centre, pilot phase I/II, double-blinded clinical trial with randomisation with active control. Twenty patients with a diagnosis of patellar tendinopathy with imaging changes (tendon thickening and disruption of the intratendinous substance at the proximal portion of the patellar tendon) will be randomised in a 1:1 ratio to receive a local injection of either bone-marrow autologous mesenchymal stem cells (MSC), isolated and cultured under GMP at The Institute of Biology and Molecular Genetics (IBGM) (Spain) or P-PRP. The study will have two aims: first, to ascertain whether a clinically relevant improvement after 3, 6 and 12 months according to the visual analogue scale (VAS), Victorian Institute of Sport Assessment for patellar tendons (VISA-P) and dynamometry scales (DYN) will be achieved; and second, to ascertain whether the proposed intervention will restore tendon structure as determined by ultrasonography (US), Doppler ultrasonography (DUS), and innovative MRI and ultrasound techniques: Magnetic Resonance T2 FAT SAT (UTE, Ultrashort Echo TE) sequence and Ultrasound Tissue Characterization (UTC). Patients who are randomised to the P-PRP treatment group but do not achieve a satisfactory primary endpoint after 6 months will be offered treatment with MSC. Trial registration NCT03454737.
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Affiliation(s)
- Gil Rodas
- Medical Department, Football Club Barcelona, C/Aristides Maillol, s/n 08028, Barcelona, Spain.,Medicine and Exercise Sport Unit, Hospital Clínic and Sand Joan de Deu, Barcelona University, C/Villarroel 170, 08036, Barcelona, Spain
| | - Robert Soler
- ITRT Institut Terapia Regenerativa Tissular Centro Médico Teknon, C/Vilana 12. 08022, Barcelona, Spain
| | - Ramón Balius
- Consell Català del'Esport, Unitat d'Esporti Salut Av Països Catalans, 40-48, 08950, Esplugues, Spain
| | - Xavier Alomar
- Diagnóstico por la Imagen, Clínica Creu Blanca, Passeig de la Reina Elisenda de Montcada, 17, 08034, Barcelona, Spain
| | - Xavier Peirau
- ITRT Institut Terapia Regenerativa Tissular Centro Médico Teknon, C/Vilana 12. 08022, Barcelona, Spain.,Institut Nacional d'Educació Física de Catalunya (INEFC), Partida Caparrella s/n, 25192, Lleida, Lleida, Spain
| | - Mercedes Alberca
- Instituto de Biología y Genética Molecular (IBGM), Universidad Valladolid y CSIC Edificio IBGM, C/ Sanz y Forés, s/n, 47003, Valladolid, Spain.,Red TerCel de Terapia Celular, Instituto de Salud Carlos III, Hospital Clínico Universitario Virgen de la Arrixaca. Servicio de Hematología. Edf. General, Ctra. Madrid-Cartagena s/n, 30120, Murcia, Spain
| | - Ana Sánchez
- Instituto de Biología y Genética Molecular (IBGM), Universidad Valladolid y CSIC Edificio IBGM, C/ Sanz y Forés, s/n, 47003, Valladolid, Spain.,Red TerCel de Terapia Celular, Instituto de Salud Carlos III, Hospital Clínico Universitario Virgen de la Arrixaca. Servicio de Hematología. Edf. General, Ctra. Madrid-Cartagena s/n, 30120, Murcia, Spain
| | - Javier García Sancho
- Instituto de Biología y Genética Molecular (IBGM), Universidad Valladolid y CSIC Edificio IBGM, C/ Sanz y Forés, s/n, 47003, Valladolid, Spain.,Red TerCel de Terapia Celular, Instituto de Salud Carlos III, Hospital Clínico Universitario Virgen de la Arrixaca. Servicio de Hematología. Edf. General, Ctra. Madrid-Cartagena s/n, 30120, Murcia, Spain
| | - Clementina Rodellar
- LAGENBIO, Facultad de Veterinaria, Lab. Genética Bioquímica. Facultad de Veterinaria, Universidad de Zaragoza, C/Miguel Servet 177, 50013, Zaragoza, Spain
| | - Antonio Romero
- LAGENBIO, Facultad de Veterinaria, Lab. Genética Bioquímica. Facultad de Veterinaria, Universidad de Zaragoza, C/Miguel Servet 177, 50013, Zaragoza, Spain
| | | | - Lluís Orozco
- ITRT Institut Terapia Regenerativa Tissular Centro Médico Teknon, C/Vilana 12. 08022, Barcelona, Spain
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, University of Salerno School of Medicine, Surgery and Dentistry, Salerno, Italy. .,Centre for Sports and Exercise Medicine, Queen Mary University of London, London, UK. .,School of Pharmacy and Bioengineering, Keele University School of Medicine, Stoke on Trent, UK.
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13
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Casartelli NC, Bizzini M, Maffiuletti NA, Sutter R, Pfirrmann CW, Leunig M, Naal FD. Exercise Therapy for the Management of Femoroacetabular Impingement Syndrome: Preliminary Results of Clinical Responsiveness. Arthritis Care Res (Hoboken) 2019; 71:1074-1083. [PMID: 30133164 DOI: 10.1002/acr.23728] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 08/14/2018] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To investigate the responsiveness to exercise therapy of patients with femoroacetabular impingement syndrome (FAIS), and to investigate differences in hip function, strength, and morphology between responders versus nonresponders. METHODS Patients with FAIS underwent 12 weeks of semi-standardized and progressive exercise therapy. A good therapy outcome (responders) versus a poor therapy outcome (nonresponders) was determined at week 18 with the Global Treatment Outcome questionnaire for hip pain. Hip function was evaluated using the Hip Outcome Score (HOS) activities of daily living (ADL) and Sport at baseline, and at weeks 6, 12, and 18. Hip muscle strength and dynamic pelvic control were evaluated using dynamometry and video analysis, respectively, at baseline, week 12, and week 18. Hip morphology was evaluated with imaging at baseline. RESULTS Thirty-one patients (mean age 24 years) were included. Sixteen patients (52%) were responsive and 15 patients (48%) were not responsive to exercise therapy. Only responders improved HOS ADL and HOS Sport by 10 points (95% confidence interval [95% CI] 7, 14; P < 0.001) and by 20 points (95% CI 15, 25; P < 0.001), respectively, and hip abductor strength by 0.27 Nm/kg (95% CI 0.18, 0.36; P < 0.001). The prevalence of patients showing good dynamic pelvic control only increased in responders (44%; P = 0.029). The prevalence of severe cam morphology was higher in nonresponders than in responders (40% versus 6%; P = 0.037). CONCLUSION Half of patients with FAIS benefit from exercise therapy in the short term. Responsiveness to hip abductor strength and dynamic pelvic control improvements is associated with a good therapy outcome, whereas the presence of severe cam morphology is associated with a poor therapy outcome.
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Affiliation(s)
- Nicola C Casartelli
- Schulthess Clinic and Laboratory of Exercise and Health, Swiss Federal Institute of Technology, Zurich, Switzerland
| | | | | | - Reto Sutter
- Orthopaedic University Hospital Balgrist and University of Zurich, Zurich, Switzerland
| | - Christian W Pfirrmann
- Orthopaedic University Hospital Balgrist and University of Zurich, Zurich, Switzerland
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14
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Hong AJ, Agarwalla A, Liu JN, Gowd AK, McMillan S, Sethi PM, Amin NH. Neurological structures and mediators of pain sensation in anterior cruciate ligament reconstruction. Ann Anat 2019; 225:28-32. [PMID: 31195095 DOI: 10.1016/j.aanat.2019.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/03/2019] [Accepted: 05/28/2019] [Indexed: 02/05/2023]
Abstract
Anterior cruciate ligament (ACL) tears is a devastating injury and one of the most common knee injuries experienced by athletes in the United States. Although patients reach maximal subjective improvement by one-year following ACL reconstruction, many patients often experience moderate to severe post-operative pain. Opioids, intra-articular injections, and regional anesthesia have been previously implemented to mediate post-operative pain. However, chronic opioid usage has become an epidemic in the United States. Alternative analgesic modalities, such as nerve blocks, have been implemented in clinical practice to provide adequate pain relief and minimize opioid usage. Periarticular injections targeted towards local neurological structures performed concomitantly with nerve blocks provides superior pain relief and satisfaction than isolated nerve blocks. Therefore, it is imperative for physicians to understand local neurological anatomy around the knee joint in order to provide adequate analgesia while minimizing opioid consumption. This purpose of this investigation is to summarize (1) neurogenic origins of pain generators and mediators in sites affected by ACL reconstruction and autograft harvest sites and (2) analgesia utilized in ACL reconstruction.
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Affiliation(s)
- Andrew J Hong
- School of Medicine, Loma Linda University, Loma Linda, CA, United States.
| | - Avinesh Agarwalla
- Department of Orthopaedic Surgery, Westchester Medical Center, Valhalla, NY, United States.
| | - Joseph N Liu
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States.
| | - Anirudh K Gowd
- Department of Orthopaedic Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, NC, United States.
| | - Sean McMillan
- Our Lady of the Lourdes Health System, Burlington, NJ, United States.
| | - Paul M Sethi
- Orthopaedic and Neurosurgery Specialists for Clinical Research and Education, Greenwich, CT, United States.
| | - Nirav H Amin
- Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States.
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15
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Challoumas D, Kirwan PD, Borysov D, Clifford C, McLean M, Millar NL. Topical glyceryl trinitrate for the treatment of tendinopathies: a systematic review. Br J Sports Med 2018; 53:251-262. [PMID: 30301735 PMCID: PMC6362607 DOI: 10.1136/bjsports-2018-099552] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2018] [Indexed: 12/03/2022]
Abstract
Objective To produce a best evidence synthesis of the clinical effects of topical glyceryl trinitrate (GTN) in the treatment of tendinopathies. Design A systematic review of published randomised controlled trials (RCTs) of the use of GTN in patients with tendinopathy. Data sources MEDLINE, Embase, Scopus and CINAHL from database inception to January 2018. Methods We examined RCTs comparing the effects of topical GTN with either placebo or other treatments on tendinopathy. Overall quality of each eligible study was determined based on a combined assessment of internal validity, external validity and precision. The level of evidence for each assessed parameter was rated based on the system by van Tulder et al. Results A total of 10 eligible RCTs were identified including patients with tendinopathy of the rotator cuff (n=4), wrist extensors (n=3), Achilles (n=2) and patellar (n=1) tendons. For all tendinopathies, improvements in pain were significant when comparing GTN versus placebo in the short term (<8 weeks; poor evidence). Significant improvements in midterm outcomes for treatment with GTN versus placebo included the following: patient satisfaction (strong evidence); chances of being asymptomatic with activities of daily living (strong evidence); range of movement (moderate evidence); strength (moderate evidence); pain (at night and with activity; poor evidence) and local tenderness (poor evidence). Patients treated with topical GTN reported a higher incidence of headaches than those who received placebo (moderate evidence). Conclusions and relevance Treatment of tendinopathies with topical GTN for up to 6 months appears to be superior to placebo and may therefore be a useful adjunct to the treating healthcare professions.
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Affiliation(s)
- Dimitris Challoumas
- Institute of Infection, Immunity and Inflammation, College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Paul D Kirwan
- School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland.,Physiotherapy Department, Connolly Hospital, Dublin, Ireland
| | - Dmytro Borysov
- Institute of Infection, Immunity and Inflammation, College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | | | - Michael McLean
- Institute of Infection, Immunity and Inflammation, College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Neal L Millar
- Institute of Infection, Immunity and Inflammation, College of Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
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16
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Current trends in tendinopathy: consensus of the ESSKA basic science committee. Part II: treatment options. J Exp Orthop 2018; 5:38. [PMID: 30251203 PMCID: PMC6153202 DOI: 10.1186/s40634-018-0145-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 07/26/2018] [Indexed: 01/01/2023] Open
Abstract
The treatment of painful chronic tendinopathy is challenging. Multiple non-invasive and tendon-invasive methods are used. When traditional non-invasive treatments fail, the injections of platelet-rich plasma autologous blood or cortisone have become increasingly favored. However, there is little scientific evidence from human studies supporting injection treatment. As the last resort, intra- or peritendinous open or endoscopic surgery are employed even though these also show varying results. This ESSKA basic science committee current concepts review follows the first part on the biology, biomechanics and anatomy of tendinopathies, to provide a comprehensive overview of the latest treatment options for tendinopathy as reported in the literature.
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17
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Braun C, Hanchard NC, Handoll HH, Betthäuser A. Predicting the outcome of conservative treatment with physiotherapy in adults with shoulder pain associated with partial-thickness rotator cuff tears - a prognostic model development study. BMC Musculoskelet Disord 2018; 19:329. [PMID: 30205818 PMCID: PMC6134519 DOI: 10.1186/s12891-018-2239-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 08/17/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Rotator cuff disorders represent the commonest type of painful shoulder complaints in clinical practice. Although conservative treatment including physiotherapy is generally recommended as first-line treatment, little is known about the precise treatment indications for subgroups of rotator cuff disorders, particularly people with shoulder pain associated with partial-thickness tears of the rotator cuff, PTTs: "symptomatic PPTs". The aim of this study was to develop a prognostic model for predicting the outcome of a phase of conservative treatment primarily with physiotherapy in adults with symptomatic PTTs. METHODS A prospective observational cohort study was conducted in an outpatient setting in Germany. Ten baseline factors were selected to evaluate nine pre-defined multivariable candidate prognostic models (each including between two and nine factors) in a cohort of adults with symptomatic atraumatic PTTs undergoing a three-month phase of conservative treatment primarily with physiotherapy. The primary outcome was change in the Western Ontario Rotator Cuff Index. The models were developed using linear regression and an information-theoretic analysis approach: Akaike's Information Criterion (AICC). RESULTS Eight candidate models were analyzed using data from 61 participants. Two "best models" were identified: smoking & pain catastrophizing and disability & pain catastrophizing. However, none of the models had a satisfactory performance or precision. CONCLUSIONS We could not determine a prognostic model with satisfactory performance and precision. Further high-quality prognostic model studies with larger samples are needed, but should be underpinned, and thus preceded, by robust research that enhances knowledge of relevant prognostic factors. STUDY REGISTRATION DRKS00004462 . Registered 08 April 2014; retrospectively registered (prior to the analysis).
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Affiliation(s)
- Cordula Braun
- School of Health and Social Care, Teesside University, Middlesbrough, UK. .,Present address: Faculty of Health and Physiotherapy, Buxtehude, Germany. .,Faculty of Health, Harburger Str. 6, 21614, Buxtehude, Germany.
| | - Nigel C Hanchard
- School of Health and Social Care, Teesside University, Middlesbrough, UK
| | - Helen H Handoll
- School of Health and Social Care, Teesside University, Middlesbrough, UK
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18
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Maffulli N, Oliva F, Maffulli GD, Giai Via A, Gougoulias N. Minimally Invasive Achilles Tendon Stripping for the Management of Tendinopathy of the Main Body of the Achilles Tendon. J Foot Ankle Surg 2018; 56:938-942. [PMID: 28659242 DOI: 10.1053/j.jfas.2017.05.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Indexed: 02/03/2023]
Abstract
Achilles tendinopathy is a common cause of disability. New nerves fibers grow from the paratenon into the Achilles tendon, and they could play a central role in the development of pain. We report the results of minimally invasive Achilles tendon stripping for Achilles tendinopathy in 47 active patients. The Victorian Institute of Sports Assessment-Achilles questionnaire score improved from 53.8 preoperatively to 85.3 postoperatively (p < .001). After a mean follow-up period of 40.5 months, 41 patients had resumed sporting activities at an average of 3.5 months postoperatively. A sural nerve injury was recorded in 5 patients (10.6%), and all 5 complications occurred during the first 12 cases. As a result, the technique was slightly modified, and no sural nerve neuropathy was observed subsequently. One superficial infection (2.1%) was recorded. Minimally invasive Achilles tendon stripping seems to be an effective, technically simple, and inexpensive treatment of Achilles tendinopathy. Further randomized controlled trials involving more patients are needed to confirm these outcomes.
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Affiliation(s)
- Nicola Maffulli
- Professor, Department of Musculoskeletal Disorders, Faculty of Medicine, University of Salerno, Salerno, Italy; Professor, Queen Mary University of London, Barts, United Kingdom; Professor, The London School of Medicine and Dentistry, William Harvey Research Institute, Centre for Sports and Exercise Medicine, Mile End Hospital, London, United Kingdom.
| | - Francesco Oliva
- Orthopedist, Department of Orthopaedics and Traumatology, University of Rome Tor Vergata, Rome, Italy
| | - Gayle D Maffulli
- Assistant Professor, Surgical Trials Unit, Curis Consulting, London, United Kingdom
| | - Alessio Giai Via
- Orthopedist, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Donato, Milano, Italy
| | - Nikolaos Gougoulias
- Orthopedist, Department of Orthopaedics, Frimley Health National Health Service Foundation Trust, Frimley Park Hospital, Camberley, United Kingdom
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19
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20
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Bhattacharjee TT, Nicodemo MC, Sant'Anna LB, Lo Schiavo Arisawa EA, Raniero L. Tendinopathy diagnosis and treatment monitoring using attenuated total reflectance-Fourier transform infrared spectroscopy. JOURNAL OF BIOPHOTONICS 2018; 11:e201700256. [PMID: 29160619 DOI: 10.1002/jbio.201700256] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 11/19/2017] [Indexed: 06/07/2023]
Abstract
Tendinopathy, an important sports injury afflicting athletes and general public, is associated with huge economic losses. The currently used diagnostic tests are subjective, show moderate sensitivity and specificity; while treatment failures persist despite advances in therapy. This highlights the need for tendinopathy diagnostic and treatment monitoring tools. This study investigates tendon injury, natural healing and effect of treatment using ATR-FTIR complemented with histopathology. Control (C), injured (I) and treated (T) rat tendons were extracted 3, 7, 14 and 28 days post-injury/treatment, representing phases of healing; and subjected to hematoxylin & eosin staining as well as spectroscopy. While C showed no change, I- and T-related histological changes could be clearly observed in stained sections. ATR-FTIR spectra highlighted the biochemical changes within groups. Multivariate analysis could classify C, I and T with 75%; different days between groups with 84%; and different days within group with 65% efficiency. Results suggest that such analysis can not only identify C, I or T but also different phases of healing. Difference between I and T at different time points also suggest change in rate of healing. Further studies may help develop this technique for clinical diagnosis and treatment monitoring in future.
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Affiliation(s)
- Tanmoy T Bhattacharjee
- Laboratory of Nanosensors, Research and Development Institute (IPD), University of Paraíba Valley (UNIVAP), São Paulo, Brazil
| | - Mariana C Nicodemo
- Biostimulation and Tissue Repair Laboratory, Research and Development Institute (IPD), University of Paraíba Valley (UNIVAP), São Paulo, Brazil
| | - Luciana B Sant'Anna
- Histology and Regenerative Therapy Laboratory, Research and Development Institute (IPD), University of Paraíba Valley (UNIVAP), São Paulo, Brazil
| | - Emilia A Lo Schiavo Arisawa
- Biostimulation and Tissue Repair Laboratory, Research and Development Institute (IPD), University of Paraíba Valley (UNIVAP), São Paulo, Brazil
| | - Leandro Raniero
- Laboratory of Nanosensors, Research and Development Institute (IPD), University of Paraíba Valley (UNIVAP), São Paulo, Brazil
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21
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Lipman K, Wang C, Ting K, Soo C, Zheng Z. Tendinopathy: injury, repair, and current exploration. DRUG DESIGN DEVELOPMENT AND THERAPY 2018; 12:591-603. [PMID: 29593382 PMCID: PMC5865563 DOI: 10.2147/dddt.s154660] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Both acute and chronic tendinopathy result in high morbidity, requiring management that is often lengthy and expensive. However, limited and conflicting scientific evidence surrounding current management options has presented a challenge when trying to identify the best treatment for tendinopathy. As a result of shortcomings of current treatments, response to available therapies is often poor, resulting in frustration in both patients and physicians. Due to a lack of understanding of basic tendon-cell biology, further scientific investigation is needed in the field for the development of biological solutions. Optimization of new delivery systems and therapies that spatially and temporally mimic normal tendon physiology hold promise for clinical application. This review focuses on the clinical importance of tendinopathy, the structure of healthy tendons, tendon injury, and healing, and a discussion of current approaches for treatment that highlight the need for the development of new nonsurgical interventions.
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Affiliation(s)
| | - Chenchao Wang
- Division of Growth and Development, Section of Orthodontics, School of Dentistry, University of California, Los Angeles, CA, USA.,First Hospital of China Medical University, Shenyang, China.,Division of Plastic and Reconstructive Surgery, Department of Orthopaedic Surgery, Orthopaedic Hospital Research Center, University of California, Los Angeles, CA, USA
| | - Kang Ting
- Division of Growth and Development, Section of Orthodontics, School of Dentistry, University of California, Los Angeles, CA, USA
| | - Chia Soo
- Division of Plastic and Reconstructive Surgery, Department of Orthopaedic Surgery, Orthopaedic Hospital Research Center, University of California, Los Angeles, CA, USA
| | - Zhong Zheng
- Division of Growth and Development, Section of Orthodontics, School of Dentistry, University of California, Los Angeles, CA, USA
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22
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High-Accuracy Positioning in Urban Environments Using Single-Frequency Multi-GNSS RTK/MEMS-IMU Integration. REMOTE SENSING 2018. [DOI: 10.3390/rs10020205] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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23
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Different Achilles Tendon Pathologies Show Distinct Histological and Molecular Characteristics. Int J Mol Sci 2018; 19:ijms19020404. [PMID: 29385715 PMCID: PMC5855626 DOI: 10.3390/ijms19020404] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 01/25/2018] [Accepted: 01/26/2018] [Indexed: 12/29/2022] Open
Abstract
Reasons for the development of chronic tendon pathologies are still under debate and more basic knowledge is needed about the different diseases. The aim of the present study was therefore to characterize different acute and chronic Achilles tendon disorders. Achilles tendon samples from patients with chronic tendinopathy (n = 7), chronic ruptures (n = 6), acute ruptures (n = 13), and intact tendons (n = 4) were analyzed. The histological score investigating pathological changes was significantly increased in tendinopathy and chronic ruptures compared to acute ruptures. Inflammatory infiltration was detected by immunohistochemistry in all tendon pathology groups, but was significantly lower in tendinopathy compared to chronic ruptures. Quantitative real-time PCR (qRT-PCR) analysis revealed significantly altered expression of genes related to collagens and matrix modeling/remodeling (matrix metalloproteinases, tissue inhibitors of metalloproteinases) in tendinopathy and chronic ruptures compared to intact tendons and/or acute ruptures. In all three tendon pathology groups markers of inflammation (interleukin (IL) 1β, tumor necrosis factor α, IL6, IL10, IL33, soluble ST2, transforming growth factor β1, cyclooxygenase 2), inflammatory cells (cluster of differentaition (CD) 3, CD68, CD80, CD206), fat metabolism (fatty acid binding protein 4, peroxisome proliferator-activated receptor γ, CCAAT/enhancer-binding protein α, adiponectin), and innervation (protein gene product 9.5, growth associated protein 43, macrophage migration inhibitory factor) were detectable, but only in acute ruptures significantly regulated compared to intact tendons. The study gives an insight into structural and molecular changes of pathological processes in tendons and might be used to identify targets for future therapy of tendon pathologies.
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24
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Albano D, Martinelli N, Bianchi A, Romeo G, Bulfamante G, Galia M, Sconfienza LM. Posterior tibial tendon dysfunction: Clinical and magnetic resonance imaging findings having histology as reference standard. Eur J Radiol 2017; 99:55-61. [PMID: 29362151 DOI: 10.1016/j.ejrad.2017.12.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 10/24/2017] [Accepted: 12/08/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To investigate the correlation between MRI, clinical tests, histopathologic features of posterior tibial tendon (PTT) dysfunction in patients with acquired adult flatfoot deformity surgically treated with medializing calcaneal osteotomy and flexor digitorum longus tendon transposition. MATERIALS AND METHODS Nineteen patients (11 females; age: 46 ± 15 year, range 18-75) were pre-operatively evaluated using the single heel rise (HR) and the first metatarsal rise (FMR) sign tests. Two reviewers graded the PTT tears on a I-III scale and measured the hindfoot valgus angle on the pre-operative MRI of the ankle. The specimens of the removed portion of PTT were histologically analysed by two pathologists using the Bonar and Movin score. Linear regression, Spearman's rank-order, and intraclass correlation coefficient (ICC) statistics were used. RESULTS ICC for MRI was excellent (0.952). Correlation between FMR and HR tests was at limit of significance (r = 0.454; P = 0.051). The HR and FMR tests were significantly correlated to the Movin score (r = 0.581; P = 0.009 and r = 0.538; P = 0.018, respectively) and were not significantly correlated to the Bonar score (both with a r = 0.424; P = 0.070). PTT tendinopathy grading at MRI was significantly correlated to the FMR test (p = 0.041) but not to the hindfoot valgus angle (p = 0.496), the HR test (p = 0.943), the Bonar score (p = 0.937), and the Movin score (p = 0.436). The hindfoot angle was not correlated to any of the other variables (p > 0.264). CONCLUSION For PTT dysfunction, there is high correlation between HR and FMR test and histology evaluated using the Movin score, while no correlation was seen for the Bonar score. Semiquantitative grading of PTT dysfunction at MRI only correlates to the FMR and not to histology. The hindfoot valgus angle is not correlated to any of the considered variables.
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Affiliation(s)
- Domenico Albano
- Department of Radiology, Di.Bi.Med., University of Palermo, Via del Vespro 127, 90127, Palermo, Italy
| | - Nicolò Martinelli
- Foot and Ankle Surgery Unit, Istituto Clinico Città Studi, Milano, Italy
| | - Alberto Bianchi
- Foot and Ankle Surgery Unit, Istituto Clinico Città Studi, Milano, Italy
| | - Giovanni Romeo
- Foot and Ankle Surgery Unit, Istituto Clinico Città Studi, Milano, Italy
| | - Gaetano Bulfamante
- Department of Health Sciences, San Paolo Hospital Medical School University of Milan, Via di Rudinì 8, 20142, Milan, Italy
| | - Massimo Galia
- Department of Radiology, Di.Bi.Med., University of Palermo, Via del Vespro 127, 90127, Palermo, Italy
| | - Luca Maria Sconfienza
- Department of Biomedical Sciences for Health, University of Milano, Via Pascal 36, 20135, Milano, Italy; Unit of Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Galeazzi, Via R. Galeazzi 4, 20166, Milano, Italy.
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Affiliation(s)
- Nicola Maffulli
- Department of Trauma and Orthopaedic Surgery, Keele University School of Medicine, Thornburrow Drive, Hartshill, Stoke-on-Trent ST4 7QB, UK.
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Abstract
BACKGROUND Posterior tibial tendinopathy (PTT) is the most common cause of acquired (progressive) flatfoot deformity in adults. To date, PTT research has mainly focused on management rather than on causal mechanisms. The etiology of PTT is likely to be multifactorial because both intrinsic and extrinsic risk factors have been reported. We sought to critically evaluate reported etiologic factors for PTT and consider the concept of genetic risk factors. METHODS A detailed review of the literature published after 1936 was undertaken using English-language medical databases. RESULTS No clear consensus exists as to the relative importance of the risk factors reported, and neither has any consideration been given to a possible genetic basis for PTT. CONCLUSIONS To date, studies have examined various intrinsic and extrinsic risk factors implicated in the etiology of PTT. The interaction of these factors with an individual's genetic background may provide valuable data and help offer a more complete risk profile for PTT. A properly constructed genetic association study to determine the genetic basis of PTT would provide a novel and alternative approach to understanding this condition.
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Affiliation(s)
- Paul Beeson
- Division of Podiatry, The University of Northampton, Park Campus, Boughton Green Road, Northampton, Northamptonshire, NN2 7AL, England. (E-mail: )
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Wegener RL, Brown T, O’Brien L. A randomized controlled trial of comparative effectiveness of elastic therapeutic tape, sham tape or eccentric exercises alone for lateral elbow tendinosis. HAND THERAPY 2016. [DOI: 10.1177/1758998316656660] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction Lateral elbow tendinosis is a condition that is well known to cause difficult challenges for hand therapists due to its long-term recovery and morbidity. Elastic therapeutic tape is commonly used as a treatment modality, despite limited evidence. Methods A randomized controlled trial was conducted to evaluate the effectiveness of elastic therapeutic tape, in conjunction with eccentric exercises, in the treatment of lateral elbow tendinosis. Forty participants with this condition (12 men, 28 women) were randomly allocated to three groups: (i) elastic therapeutic tape and eccentric exercises, (ii) sham tape and eccentric exercises, and (iii) eccentric exercises alone. All groups received education on activity modification techniques. Interventions were undertaken over a 12-week period (four weekly sessions and four fortnightly sessions) and outcome measures were recorded at baseline, three months and six months post randomisation. Results At three and six months, improvements were made in all three groups as assessed with the Patient-Rated Tennis Elbow Evaluation, the Short Form 36, pain-free grip strength, and the Occupational Self Assessment. However, there were no statistically significant differences between groups in any of these measures. There were no significant side effects or symptom exacerbation with using the elastic therapeutic tape. Conclusions Whilst all groups improved on key outcomes, it is possible that exercise alone and/or natural recovery were responsible for improvements. It is positive to note that the use of elastic therapeutic tape was well tolerated by participants and not associated with any significant side effects or symptom exacerbation.
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Affiliation(s)
- Raewyn L Wegener
- Department of Occupational Therapy, Faculty of Medicine, Nursing and Health Sciences, Monash University – Peninsula Campus, Frankston, VIC, Australia
| | - Ted Brown
- Department of Occupational Therapy, Faculty of Medicine, Nursing and Health Sciences, Monash University – Peninsula Campus, Frankston, VIC, Australia
| | - Lisa O’Brien
- Department of Occupational Therapy, Faculty of Medicine, Nursing and Health Sciences, Monash University – Peninsula Campus, Frankston, VIC, Australia
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Casartelli NC, Maffiuletti NA, Bizzini M, Kelly BT, Naal FD, Leunig M. The management of symptomatic femoroacetabular impingement: what is the rationale for non-surgical treatment? Br J Sports Med 2016; 50:511-2. [DOI: 10.1136/bjsports-2015-095722] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2016] [Indexed: 11/04/2022]
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Engineering Tendon: Scaffolds, Bioreactors, and Models of Regeneration. Stem Cells Int 2015; 2016:3919030. [PMID: 26839559 PMCID: PMC4709784 DOI: 10.1155/2016/3919030] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Accepted: 09/20/2015] [Indexed: 12/23/2022] Open
Abstract
Tendons bridge muscle and bone, translating forces to the skeleton and increasing the safety and efficiency of locomotion. When tendons fail or degenerate, there are no effective pharmacological interventions. The lack of available options to treat damaged tendons has created a need to better understand and improve the repair process, particularly when suitable autologous donor tissue is unavailable for transplantation. Cells within tendon dynamically react to loading conditions and undergo phenotypic changes in response to mechanobiological stimuli. Tenocytes respond to ultrastructural topography and mechanical deformation via a complex set of behaviors involving force-sensitive membrane receptor activity, changes in cytoskeletal contractility, and transcriptional regulation. Effective ex vivo model systems are needed to emulate the native environment of a tissue and to translate cell-matrix forces with high fidelity. While early bioreactor designs have greatly expanded our knowledge of mechanotransduction, traditional scaffolds do not fully model the topography, composition, and mechanical properties of native tendon. Decellularized tendon is an ideal scaffold for cultivating replacement tissue and modeling tendon regeneration. Decellularized tendon scaffolds (DTS) possess high clinical relevance, faithfully translate forces to the cellular scale, and have bulk material properties that match natural tissue. This review summarizes progress in tendon tissue engineering, with a focus on DTS and bioreactor systems.
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Nasu H, Nimura A, Yamaguchi K, Akita K. Distribution of the axillary nerve to the subacromial bursa and the area around the long head of the biceps tendon. Knee Surg Sports Traumatol Arthrosc 2015; 23:2651-7. [PMID: 24942295 DOI: 10.1007/s00167-014-3112-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 05/29/2014] [Indexed: 11/24/2022]
Abstract
PURPOSE Patients with a shoulder disorder often complain of pain on the anterior or lateral aspect of the shoulder. Such pain has been thought to originate from the suprascapular nerve. However, taking into consideration the distinctive course of the axillary nerve, the axillary nerve is likely to supply branches to the structure around the shoulder joint. This study was conducted to clarify the division, course, and distribution of the branches which originate from the axillary nerve and innervate structures around the shoulder joint. METHODS The division, course, and distribution of the branches which originate from the axillary nerve and innervate structures around the shoulder joint were examined macroscopically by dissecting 20 shoulders of 10 adult Japanese cadavers. RESULTS The thin branches from the anterior branch of the axillary nerve were distributed to the subacromial bursa and the area around the long head of the biceps tendon. The branches from the main trunk of the axillary nerve or the branch to the teres minor muscle were distributed to the infero-posterior part of the shoulder joint. CONCLUSION The pain on the anterior or lateral aspect of the shoulder, which has been thought to originate from the suprascapular nerve, might be related to the thin branches which originate from the axillary nerve and innervate the subacromial bursa and the area around the long head of the biceps tendon. CLINICAL RELEVANCE These results would be useful to consider the cause of the shoulder pain or to prevent the residual pain after the biceps tenodesis.
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Affiliation(s)
- H Nasu
- Department of Clinical Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
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Gellhorn AC, Gillenwater C, Mourad PD. Intense focused ultrasound stimulation of the rotator cuff: evaluation of the source of pain in rotator cuff tears and tendinopathy. ULTRASOUND IN MEDICINE & BIOLOGY 2015; 41:2412-2419. [PMID: 26058842 DOI: 10.1016/j.ultrasmedbio.2015.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 04/27/2015] [Accepted: 05/05/2015] [Indexed: 06/04/2023]
Abstract
The objective of this preliminary study was to evaluate the ability of individual 0.1-s long pulses of intense focused ultrasound (iFU) emitted with a carrier frequency of 2 MHz to evoke diagnostic sensations when applied to patients whose shoulders have rotator cuff tears or tendinopathy. Patients were adults with painful shoulders and clinical and imaging findings consistent with rotator cuff disease. iFU stimulation of the shoulder was performed using B-mode ultrasound coupled with a focused ultrasound transducer that allowed image-guided delivery of precisely localized pulses of energy to different anatomic areas around the rotator cuff. The main outcome measure was iFU spatial average-temporal average intensity (I_SATA), and location required to elicit sensation. In control patients, iFU produced no sensation throughout the range of stimulation intensities (≤2000 W/cm(2) I_SATA). In patients with rotator cuff disease, iFU was able to induce sensation in the tendons of the rotator cuff, the subacromial bursa, and the subchondral bone in patients with chronic shoulder pain and rotator cuff disease, with an average ± standard deviation intensity equaling 680 ± 281 W/cm(2) I_SATA. This result suggests a primary role for these tissues in the pathogenesis of shoulder pain related to rotator cuff tendinopathy.
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Affiliation(s)
- Alfred C Gellhorn
- Division of Rehabilitation Medicine, Weill Cornell Medical College, New York, New York, USA; Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA.
| | - Cody Gillenwater
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Pierre D Mourad
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA; Division of Engineering and Mathematics, University of Washington, Bothell, Washington, USA
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Wegener RL, Brown T, O’Brien L. The use of elastic therapeutic tape and eccentric exercises for lateral elbow tendinosis: a case series. HAND THERAPY 2015. [DOI: 10.1177/1758998315580823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction ‘Lateral elbow tendinosis’ or ‘lateral elbow tendinopathy’ have been suggested to be more appropriate diagnostic terms instead of ‘lateral epicondylitis’ as the condition is degenerative rather than inflammatory. For this reason, it is important that interventions target this degeneration at the common extensor tendon. Methods A descriptive, retrospective review of a series of four patients with lateral elbow tendinosis was conducted to examine functional outcomes with the use of elastic therapeutic tape, eccentric exercises and activity modification techniques. Results All patients recorded improved changes in pain and grip strength within three months of treatment using elastic therapeutic tape, eccentric exercises and activity modification techniques. Conclusions There may be clinical benefit in the use of elastic therapeutic tape, in conjunction with eccentric exercises and activity modification techniques, for the treatment of lateral elbow tendinosis. More rigorous and comprehensive studies are recommended to further investigate this intervention.
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Affiliation(s)
- Raewyn L Wegener
- Faculty of Medicine, Nursing and Health Sciences, Monash University – Peninsula Campus, Frankston, Australia
| | - Ted Brown
- Faculty of Medicine, Nursing and Health Sciences, Monash University – Peninsula Campus, Frankston, Australia
| | - Lisa O’Brien
- Faculty of Medicine, Nursing and Health Sciences, Monash University – Peninsula Campus, Frankston, Australia
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Christensen J, Alfredson H, Andersson G. Protease-activated receptors in the Achilles tendon-a potential explanation for the excessive pain signalling in tendinopathy. Mol Pain 2015; 11:13. [PMID: 25880199 PMCID: PMC4369088 DOI: 10.1186/s12990-015-0007-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 02/20/2015] [Indexed: 01/07/2023] Open
Abstract
Background/Aim Tendinopathies are pathological conditions of tissue remodelling occurring in the major tendons of the body, accompanied by excessive nociceptive signalling. Tendinopathies have been shown to exhibit an increase in the number of mast cells, which are capable of releasing histamine, tryptase and other substances upon activation, which may play a role in the development of tendinopathies. This study set out to describe the distribution patterns of a family of receptors called protease-activated receptors (PARs) within the Achilles tendon. These four receptors (PAR1, PAR2, PAR3, PAR4) are activated by proteases, including tryptase released from mast cells, and are involved in fibrosis, hyperalgesia and neovascularisation, which are changes seen in tendinopathies. Method In order to study which structures involved in tendinopathy that these proteases can affect, biopsies from patients suffering of mid-portion Achilles tendinosis and healthy controls were collected and examined using immunohistochemistry. Tendon cells were cultured to study in vitro expression patterns. Results The findings showed a distribution of PARs inside the tendon tissue proper, and in the paratendinous tissue, with all four being expressed on nerves and vascular structures. Double staining showed co-localisation of PARs with nociceptive fibres expressing substance P. Concerning tenocytes, PAR2, PAR3, and PAR4, were found in both biopsies of tendon tissue and cultured tendon cells. Conclusions This study describes the expression patterns of PARs in the mid-portion of the Achilles tendon, which can help explain the tissue changes and increased pain signalling seen in tendinopathies. These findings also show that in-vitro studies of the effects of these receptors are plausible and that PARs are a possible therapeutic target in the future treatment strategies of tendinopathy.
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Affiliation(s)
- Jens Christensen
- Department of Integrative Medical Biology, Section for Anatomy, Umeå University, Umeå, SE-90187, Sweden.
| | - Håkan Alfredson
- Department of Community Medicine and Rehabilitation, Sports Medicine, Umeå University, Umeå, SE-90187, Sweden. .,ISEH, UCLH, London, UK. .,Pure Sports Clinic, London, UK.
| | - Gustav Andersson
- Department of Integrative Medical Biology, Section for Anatomy, Umeå University, Umeå, SE-90187, Sweden. .,Department of Surgical and Perioperative Science, Section for Hand and Plastic Surgery, Umeå University, Umeå, SE-90187, Sweden.
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Kroonen LT, Ferguson C, Ketschke RA. Longitudinal split tear of the extensor pollicis brevis tendon: report of 2 cases. J Hand Surg Am 2015; 40:236-9. [PMID: 25446412 DOI: 10.1016/j.jhsa.2014.09.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 09/17/2014] [Accepted: 09/18/2014] [Indexed: 02/02/2023]
Abstract
Two patients presented with radial-sided wrist pain and longitudinal split tears of the extensor pollicis brevis tendon. Surgical debridement and repair was performed on the first patient with good results. Early diagnosis in the second patient led to successful treatment with immobilization alone. If diagnostic maneuvers for de Quervain tenosynovitis produce pain in a location other than the radial styloid, advanced imaging should be considered to identify other anatomic causes for the pain.
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Affiliation(s)
- Leo T Kroonen
- Division of Hand and Microvascular Surgery, Department of Orthopaedic Surgery, Naval Medical Center San Diego, San Diego, CA.
| | - Christopher Ferguson
- Division of Hand and Microvascular Surgery, Department of Orthopaedic Surgery, Naval Medical Center San Diego, San Diego, CA
| | - Rhett A Ketschke
- Division of Hand and Microvascular Surgery, Department of Orthopaedic Surgery, Naval Medical Center San Diego, San Diego, CA
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Radnovich R, Trudeau J, Gammaitoni AR. A randomized clinical study of the heated lidocaine/tetracaine patch versus subacromial corticosteroid injection for the treatment of pain associated with shoulder impingement syndrome. J Pain Res 2014; 7:727-35. [PMID: 25525385 PMCID: PMC4266383 DOI: 10.2147/jpr.s63118] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Treatment for pain due to shoulder impingement syndrome (SIS) typically begins conservatively with nonsteroidal anti-inflammatory drugs and physical therapy and can include subacromial injection of corticosteroids, particularly in patients unresponsive to conservative measures. The heated lidocaine/tetracaine (HLT) patch has been reported to reduce SIS pain in a small case series. Methods This was a prospective, randomized, open-label clinical trial in which adult patients with SIS pain lasting at least 14 days, with an average intensity of ≥4 on a 0–10 scale (0= no pain, 10= worst pain) were randomized to treatment with the HLT patch or a single subacromial injection of triamcinolone acetonide (10 mg). Patients in the HLT patch group applied a single HLT patch to the shoulder for 4 hours twice daily, with a 12-hour interval between treatments during the first 14 days, and could continue to use the patch on an as-needed basis (up to twice daily) during the second 14-day period. No treatment was allowed in the final 14-day period. At baseline and at days 14, 28, and 42, patients rated their pain and pain interference with specific activities (0–10 scale). Results Sixty patients enrolled in the study (average age =51 years, range 18–75, n=21 female). Average pain scores declined from 6.0±1.6 at baseline to 3.5±2.4 at day 42 in the HLT patch group (n=29, P<0.001) and from 5.6±1.2 to 3.2±2.6 in the injection group (n=31, P<0.001). Similar improvements were seen in each group for worst pain; pain interference with general activity, work, or sleep; and range of motion. No significant between-group differences were seen for any pain or pain interference scores at any time point. Conclusion These results suggest that short-term, noninvasive treatment with the HLT patch has similar efficacy to subacromial corticosteroid injections for the treatment of pain associated with SIS.
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Biernat R, Trzaskoma Z, Trzaskoma L, Czaprowski D. Rehabilitation protocol for patellar tendinopathy applied among 16- to 19-year old volleyball players. J Strength Cond Res 2014; 28:43-52. [PMID: 23669814 DOI: 10.1519/jsc.0b013e31829797b4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The aim of the study was to investigate the efficacy of rehabilitation protocol applied during competitive period for the treatment of patellar tendinopathy. A total of 28 male volleyball players were divided into two groups. Fifteen from experimental group (E) and 13 from control group (C) fulfilled the same tests 3 times: before the training program started (first measurement), after 12 weeks (second measurement) and after 24 weeks (third measurement). The above-mentioned protocol included the following: USG imagining with color Doppler function, clinical testing, pain intensity evaluation with VISA-P questionnaire, leg muscle strength and power and jumping ability measurements. The key element of the rehabilitation program was eccentric squat on decline board with additional unstable surface. The essential factor of the protocol was a set of preventive functional exercises, with focus on eccentric exercises of hamstrings. Patellar tendinopathy was observed in 18% of the tested young volleyball players. Implementation of the presented rehabilitation protocol with eccentric squat on decline board applied during sports season lowered the pain level of the young volleyball players. Presented rehabilitation protocol applied without interrupting the competitive period among young volleyball players together with functional exercises could be an effective method for the treatment of patellar tendinopathy.
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Affiliation(s)
- Ryszard Biernat
- 1Józef Rusiecki Higher School in Olsztyn, Olsztyn, Poland; 2The Jozef Pilsudski University of Physical Education in Warsaw, Warsaw, Poland; and 3Department of Biomechanics, Kinesiology and Informatics, Faculty of Physical Education and Sport Sciences, Semmelweis University, Budapest, Hungary
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The paratendineous tissues: an anatomical study of their role in the pathogenesis of tendinopathy. Surg Radiol Anat 2013; 36:561-72. [PMID: 24318515 DOI: 10.1007/s00276-013-1244-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 11/21/2013] [Indexed: 10/25/2022]
Abstract
The aim of this paper was to examine the macroscopic and microscopic characteristics of the paratendineous tissues (paratenon, epitenon and endotenon) of the calcaneal tendon to better understand their role in the pathogenesis of "tendinopathy". Ten non-embalmed legs from cadavers were used. Histological and immunohistochemical studies were done at the middle third of the tendon. Magnetic resonance images of the hind foot were made in 60 living subjects to analyze the morphological alterations of tendon and paratenon. The paratenon is a thick fibrous layer with few elastic fibers, continuous with the crural fascia, well vascularized and innervated. It forms a sheath around the tendon similar to a synovial layer, but less organized. Indeed, it has no complete epithelium, but only some cells producing hyaluronan, called fasciacytes. Crural fascia and paratenon can be clearly observed by MRI, appearing as homogeneous, low signal intensity bands, sharply defined in the context of subcutaneous tissue in T1-weighted sequences. The mean thickness of the crural fascia was 1.11 mm in healthy subjects and 1.30 mm in patients (p < 0.005). The mean value of paratenon thickness in patients was 1.34 mm, 0.85 in healthy (p < 0.0001). The paratenon is more highly vascularized and innervated than the tendon, supporting the hypothesis that it is the origin of pain in tendinopathy. The imaging study suggests that, an increase in the thickness of the paratenon more than 1.35 mm is predictive of paratendinopathy, even before tendon damage.
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Littlewood C, Malliaras P, Bateman M, Stace R, May S, Walters S. The central nervous system – An additional consideration in ‘rotator cuff tendinopathy’ and a potential basis for understanding response to loaded therapeutic exercise. ACTA ACUST UNITED AC 2013; 18:468-72. [DOI: 10.1016/j.math.2013.07.005] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 07/02/2013] [Accepted: 07/15/2013] [Indexed: 01/13/2023]
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Abstract
STUDY DESIGN Cross-sectional observational study. OBJECTIVES To investigate the presence of soft tissue hyperemia in plantar fasciitis with power Doppler ultrasound. BACKGROUND Localized hyperemia is an established feature of tendinopathy, suggesting that neurovascular in-growth may contribute to tendon-associated pain in some patients. The presence of abnormal soft tissue vascularity can be assessed with Doppler ultrasound, and a positive finding can assist with targeted treatment plans. However, very little is known regarding the presence of hyperemia in plantar fasciitis and the ability of routine Doppler ultrasound to identify vascular in-growth in the plantar fascia near its proximal insertion. METHODS This observational study included 30 participants with plantar fasciitis unrelated to systemic disease and 30 age- and sex-matched controls. Ultrasound examination was performed with a 13- to 5-MHz linear transducer, and power Doppler images were assessed by 2 blinded investigators. RESULTS Hyperemia of the plantar fascia was present in 8 of 30 participants with plantar fasciitis and in 2 of 30 controls. The between-group difference for hyperemia, using a 4-point scale, was statistically significant, with participants with plantar fasciitis showing increased Doppler ultrasound signal compared to controls (Mann-Whitney U, P = .03). However, the majority of participants with plantar fasciitis with evidence of hyperemia demonstrated very mild color changes, and only 3 were found to have moderate or marked hyperemia. CONCLUSION Mild hyperemia can occur with plantar fasciitis, but most individuals will not exhibit greater soft tissue vascularity when assessed with routine Doppler ultrasound. Clinicians treating plantar fasciitis should not consider a positive Doppler signal as essential for diagnosis of the condition but, rather, as a feature that may help to refine the treatment plan for an individual patient.
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Wilde B, Havill A, Priestley L, Lewis J, Kitchen S. The efficacy of sclerosing injections in the treatment of painful tendinopathy. PHYSICAL THERAPY REVIEWS 2013. [DOI: 10.1179/1743288x11y.0000000025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Backman LJ, Eriksson DE, Danielson P. Substance P reduces TNF-α-induced apoptosis in human tenocytes through NK-1 receptor stimulation. Br J Sports Med 2013; 48:1414-20. [PMID: 23996004 PMCID: PMC4173875 DOI: 10.1136/bjsports-2013-092438] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background It has been hypothesised that an upregulation of the neuropeptide substance P (SP) and its preferred receptor, the neurokinin-1 receptor (NK-1 R), is a causative factor in inducing tenocyte hypercellularity, a characteristic of tendinosis, through both proliferative and antiapoptotic stimuli. We have demonstrated earlier that SP stimulates proliferation of human tenocytes in culture. Aim The aim of this study was to investigate whether SP can mediate an antiapoptotic effect in tumour necrosis factor-α (TNF-α)-induced apoptosis of human tenocytes in vitro. Results A majority (approximately 75%) of tenocytes in culture were immunopositive for TNF Receptor-1 and TNF Receptor-2. Exposure of the cells to TNF-α significantly decreased cell viability, as shown with crystal violet staining. TNF-α furthermore significantly increased the amount of caspase-10 and caspase-3 mRNA, as well as both BID and cleaved-poly ADP ribosome polymerase (c-PARP) protein. Incubation of SP together with TNF-α resulted in a decreased amount of BID and c-PARP, and in a reduced lactate dehydrogenase release, as compared to incubation with TNF-α alone. The SP effect was blocked with a NK-1 R inhibitor. Discussion This study shows that SP, through stimulation of the NK-1 R, has the ability to reduce TNF-α-induced apoptosis of human tenocytes. Considering that SP has previously been shown to stimulate tenocyte proliferation, the study confirms SP as a potent regulator of cell-turnover in tendon tissue, capable of stimulating hypercellularity through different mechanisms. This gives further support for the theory that the upregulated amount of SP seen in tendinosis could contribute to hypercellularity.
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Affiliation(s)
- Ludvig J Backman
- Department of Integrative Medical Biology, Anatomy, Umeå University, Umeå, Sweden Department of Surgical and Perioperative Sciences, Sports Medicine, Umeå University, Umeå, Sweden
| | - Daniella E Eriksson
- Department of Integrative Medical Biology, Anatomy, Umeå University, Umeå, Sweden
| | - Patrik Danielson
- Department of Integrative Medical Biology, Anatomy, Umeå University, Umeå, Sweden
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Radnovich R, Marriott TB. Utility of the heated lidocaine/tetracaine patch in the treatment of pain associated with shoulder impingement syndrome: a pilot study. Int J Gen Med 2013; 6:641-6. [PMID: 23935385 PMCID: PMC3735282 DOI: 10.2147/ijgm.s47084] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Introduction Pain control is an important first step in the treatment of shoulder impingement syndrome (SIS) because fear of pain must be removed as an obstacle to participation in an appropriate physical therapy program. Methods Adult patients with SIS-associated pain of at least 2 weeks’ duration and who had an average pain score of ≥4 on the zero- to ten-point Numeric Pain Rating Scale were eligible to enroll in this 2-week pilot study. Patients were treated with the heated lidocaine/tetracaine (70 mg/70 mg) patch (HLT patch) placed over the site of shoulder tenderness each morning and evening for a period of 2 to 4 hours. Average and worst pain during the previous 24 hours and shoulder range of motion were assessed at baseline and on Day 14. Results were expressed as change and percent change from baseline to Day 14. This pilot study was not powered for rigorous statistical analysis. Results Twenty patients (seven male, 13 female; average age 51.2 ± 10.8 years [mean ± standard deviation]) enrolled in this study, and 18 patients completed the protocol. The mean average pain score at baseline was 5.5 ± 1.1 (range 4 to 8). In the per-protocol population, average and worst pain scores declined by 2.4 ± 2.0 and 3.7 ± 2.7 points, respectively. Two-thirds of the patients demonstrated a clinically meaningful ≥30% decline in average pain score, and half of the patients demonstrated a ≥50% decline in average pain score. Shoulder internal rotation increased by 29.7° ± 21.8° and abduction increased by 40.0° ± 44.2°. Application-site erythema was reported by ten patients at some time during the study. Conclusion Patients treated with the HLT patch for 14 days demonstrated clinically meaningful improvement in pain intensity and range of motion. Further controlled research is necessary to characterize the efficacy and tolerability of the HLT patch in the treatment of SIS.
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Danielson P. ROLE OF NEUROPEPTIDES AND OTHER NEUROMODULATORS IN TENDINOPATHY PATHOGENESIS. Br J Sports Med 2013. [DOI: 10.1136/bjsports-2013-092459.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Abstract
The incidence of acute and chronic conditions of the tendo Achillis appear to be increasing. Causation is multifactorial but the role of inherited genetic elements and the influence of environmental factors altering gene expression are increasingly being recognised. Certain individuals' tendons carry specific variations of genetic sequence that may make them more susceptible to injury. Alterations in the structure or relative amounts of the components of tendon and fine control of activity within the extracellular matrix affect the response of the tendon to loading with failure in certain cases. This review summarises present knowledge of the influence of genetic patterns on the pathology of the tendo Achillis, with a focus on the possible biological mechanisms by which genetic factors are involved in the aetiology of tendon pathology. Finally, we assess potential future developments with both the opportunities and risks that they may carry.
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Affiliation(s)
- W J Ribbans
- University of Northampton, School of Health, Boughton Green Road, Northampton, UK.
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Carmont MR. An interview with Michael Carmont, section editor for the surgery, traumatology, and rehabilitation section on sports traumatology research: acute, overuse and chronic problems, early return to play and long-term outcomes. Sports Med Arthrosc Rehabil Ther Technol 2013; 5:5. [PMID: 23557120 PMCID: PMC3646507 DOI: 10.1186/2052-1847-5-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 03/07/2013] [Indexed: 01/14/2023]
Affiliation(s)
- Michael R Carmont
- Princess Royal Hospital, Shrewsbury and Telford NHS Trust, Telford, United Kingdom.
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Tosounidis T, Hadjileontis C, Triantafyllou C, Sidiropoulou V, Kafanas A, Kontakis G. Evidence of sympathetic innervation and α1-adrenergic receptors of the long head of the biceps brachii tendon. J Orthop Sci 2013; 18:238-44. [PMID: 23306538 DOI: 10.1007/s00776-012-0346-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Accepted: 12/05/2012] [Indexed: 02/09/2023]
Abstract
BACKGROUND The primary purpose of this study was to investigate the sympathetic innervation of the long head of the biceps brachii tendon LHB via immunohistochemical staining for protein S-100 and neuropeptide Y (NPY) in patients with complex proximal humerus fractures, in individuals with chronic biceps tendinosis in the setting of large rotator cuff tears (RC), and in cadaveric samples with no previously reported shoulder pathology. METHODS We investigated the presence of sympathetic innervation and α1-adrenergic receptors of the long head of the biceps brachii tendon (LHB) in patients with complex proximal humerus fractures and individuals with chronic biceps tendinosis in the setting of large rotator cuff tears (RC). The correlation of morphological features with immunohistochemical evidence of neural element presence was also investigated. Forty-one LHB tendon specimens were examined. Seventeen were harvested from patients who underwent hemiarthroplasty for proximal humerus fractures, 14 were from individuals with biceps tendinosis in the context of a large RC tear, and ten were from cadaveric controls with no previous shoulder pathology. Histologic examination was performed using hematoxylin and eosin. Immunohistochemistry was used to detect the expression of the protein S-100, neuropeptide Y, and α1-adrenergic receptors, as well as to characterize the potential neural differentiation of tendon cells. RESULTS A strong correlation between the expression of NPY/S-100, α1-adrenergic/S-100, and α1-adrenergic/NPY was found. The LHB tendon has sympathetic innervation and α1-adrenergic receptors in acute and chronic pathological conditions. CONCLUSION Our results provide useful guidance on the management of tendinosis and the handling of the LHB in hemiarthroplasties for fractures.
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Affiliation(s)
- Theodoros Tosounidis
- University Hospital of Heraklion, 1 Pindarou Str, 71305 Heraklion, Crete, Greece.
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Whipple TL, Steinmann SP. Mechanisms of Action of Noninvasive Monopolar Radiofrequency: Technology Review. ACTA ACUST UNITED AC 2013. [DOI: 10.4236/ojo.2013.31006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Littlewood C. Contractile dysfunction of the shoulder (rotator cuff tendinopathy): an overview. J Man Manip Ther 2012; 20:209-13. [PMID: 24179329 PMCID: PMC3500133 DOI: 10.1179/2042618612y.0000000005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
It is now over a decade since the features defining a contractile dysfunction of the shoulder were first reported. Since this time, some progress has been made to better understand this mechanical syndrome. In response to these developments, this narrative review will explore current understanding in relation to pathology, diagnosis, treatment, and prognosis of this syndrome with reference to literature specifically relating to contractile dysfunction but also literature relating to rotator cuff tendinopathy where necessary. The review not only identifies the strengths of the mechanical diagnosis and therapy approach with reference to a contractile dysfunction of the shoulder but also identifies where further progress needs to be made.
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Affiliation(s)
- Chris Littlewood
- School of Health and Related Research, University of Sheffield, UK
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Cunha RAD, Dias AN, Santos MB, Lopes AD. Estudo comparativo de dois protocolos de exercícios excêntricos sobre a dor e a função do joelho em atletas com tendinopatia patelar: estudo controlado e aleatorizado. REV BRAS MED ESPORTE 2012. [DOI: 10.1590/s1517-86922012000300006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUÇÃO: O agachamento excêntrico em plano inclinado tem-se mostrado eficaz no tratamento conservador da tendinopatia patelar, especialmente na população atlética. Entretanto, diversos aspectos, como intensidade e dor durante a realização da terapia, ainda apresentam divergências entre autores. Objetivos: Comparar a eficácia de dois protocolos de exercício excêntrico (executado com e sem dor), na melhora da função do joelho e na intensidade da dor em atletas com tendinopatia patelar. MÉTODOS: Foram selecionados 17 atletas de ambos os gêneros com diagnóstico de tendinopatia patelar e aleatoriamente distribuídos em dois grupos de tratamento. Os voluntários do primeiro grupo realizaram exercícios de agachamento excêntrico em plano inclinado com dor no tendão patelar. Os voluntários do segundo grupo foram orientados a realizar o mesmo exercício, porém sem apresentar dor no tendão patelar durante a realização. O tratamento teve a duração de 12 semanas e a avaliação de dor e função foi realizada pelo VISA-P e pela EVA antes de iniciar o tratamento, com oito semanas de intervenção e ao término do tratamento. RESULTADOS: Houve uma melhora em ambos os grupos quando comparados os resultados das avaliações realizadas após oito e 12 semanas do início do tratamento com a avaliação inicial, porém não houve diferença significativa entre o grupo que realizou exercício com dor e o grupo que executou os exercícios sem dor. Na análise da probabilidade de obtenção de uma melhora clínica para os escores de VISA e EVA em oito e 12 semanas, não houve nenhuma diferença entre os dois grupos. CONCLUSÃO: Um programa de exercício excêntrico usando agachamento em plano inclinado, realizado com ou sem a presença de dor, foi eficaz na melhora da dor e da função em atletas com tendinopatia patelar.
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