Tendonopathy

1. Tendonopathy NYSAFP Winter Weekend January 28, 2012 Todd S. Shatynski, MD, CAQSM tshatynski@caportho.com

2. Objectives • Understand the anatomy of a musculo-tendinous unit and locations of injury • Review the process that occurs to cause tendon degeneration • Evaluate the current categorization of tendon pathology • Assess the current evidence behind traditional and emerging treatments

3. Anatomy of a Tendon • Tight, parallel collagen bundles • Transmit forces muscle -> bone • Great tensile strength • Poor resistance to compression and shear forces • Surrounded by paratenon +/- sheath

4. Anatomy • Paratenon – contains tendon vasculature • Originates from musculotendinous and bone-tendon junctions • Coiled vasculature allows stretch • Sheath – avascular tendons • Allows change of direction when crossing over bony prominences

5. “Tendonitis” • Rotator cuff tendonitis • Medial epicondylitis (Golfer’s elbow) • Lateral epicondylitis (Tennis elbow) • Dequervain’s tenosynovitis • Hamstring tendonitis • Adductor tendonitis • Patellar tendonitis (Jumper’s knee) • Achilles tendonitis • Plantar fasciitis

6. Tendon Overload/Overuse • Tissue deformation begins as strain increases due to friction, torsion, compression • Most common in tendons with large mechanical demands (achilles, patellar) • Originally termed “tendonitis” implying inflammatory reaction • Actually spectrum of injury involving acute and chronic components

7. Where’s the inflammation? • “Histologic analysis reveals no inflammatory cells” • Nirschl, Clin Sports Med, 1992 • “Microdialysis and gene technology has clarified there is no chemical inflammation in Achilles’ tendinosis.” • Alfredson, Clin Sports Med, 2003

8. Where is the inflammation? • Maybe the paratenon… • Ultrasound guided corticosteroid paratenon injection of Achilles, patellar tendonitis (by MRI) provided significant pain relief compared to blind placebo • Ultrasound guidance used to avoid intratendinous injection • Fredberg, Scand J Rheumatol, 2004

9. Biochemical Hypothesis • Khan, et al. Br J Sports Med, 2000 • Painful tendon reveals fascicles containing nerve fibers with sympathetic nerve markers (usually only seen in nervous system): • Substance P • Acetylcholine • Catecholamines

10. Molecular analysis • IL-1 beta induces expression of cytokines • Cytokines induce matrix destructive enzymes (metalloproteases MMP-1, etc) • Increased lactate (ischemia signal) and glutamate (pain mediator) • Chronic overuse leads to degeneration and premature cell death (apoptosis) • Tsuzaki, et al. J Ortho Res, 2003; Cook, et al. Phys Sportsmed, 2000; Capasso, et al. Sports Exerc Inj, 1997; Arnoczky, et al. J Orthop Res, 2002; Yuan, et al. J Orthop Res, 2002; Alfredson, Clin Sports Med, 2003; Ireland, et al. Matrix Biol, 2001.

11. Classification • Tendonopathy = chronic tendon pain • Tendonitis • Tendonosis • Paratenonitis • Insertional tendonitis

12. Which one is it? • “…tendinosis was first used by German workers in the 1940’s, its recent usage comes from the work of Giancarro Puddo in the early 1970’s.” • N. Maffuli, Clin J Sports Med, 2003 • “Degenerative tendinosis occurs over time when tendon damage exceeds the rate of the tendon’s intrinsic ability to heal” • Budoff & Nirschl, Op Techniques in Sp Med, 2001

13. HistopathologyKhan, Sports Med, 1999 • Tendonitis – • Symptomatic degeneration with vascular disruption and inflammatory repair response • Collagen disorientation/disorganization with tear, fibroblastic proliferation, hemorrhage, and organizing granulation tissue • + Inflammatory cells • Animal models

14. Histopathology • Tendonopathy • Intratendonous degeneration due to aging, microtrauma, or vascular compromise • Collagen disorientation/disorganization with fiber separation by increased mucoid ground substance, possibly neovascularization, focal necrosis or calcification • No inflammatory cells

15. Histopathology • Paratenonitis • Inflammation of outer layer of the tendon (paratenon) • Acute edema and hyperemia of paratenon with infiltration of inflammatory cells • Production of fibrous exudate in the tendon sheath • Mild mononuclear infiltrate • Inflammatory cells in paratenon only

16. Histopathology • Peratenonitis with tendinosis • Intratendinous degeneration • Paratenonitis with mucoid degeneration and scattered inflammatory cells in paratenon

17. Healthy Glistening white Hierarchical, parallel, tightly packed collagen fibers Reflectivity under polarized light No extracellular matrix Vasculature, tenocytes inconspicuous Symptomatic Grey, amorphous Discontinuous, disorganized collagen fibers No reflectivity under polarized light Mucoid ground substance present Less tenocytes, appear plump Appearances…

18. Microscopy

19. General Tendon Injury • Ruptures – Male:Female (4-7xs) • Wong, et al. Am J Sports Med, 2002 • Anabolic steroids increase rupture risk • More common in blood type O, less common in type A • Josza, et al. JBJS, 1989; Kujala, et al. Injury, 1992; Maffuli, et al. Clin J Sports Med, 2000. • Tendon ruptures increased with oral quinolone use • Kibler, et al. Clinics in Sports Med, 2002

20. Exercise Response • Tendonopathy improves with exercise but worsens after • Allows exercise to continue • Inhibits healing response

21. “Tennis elbow” • Lateral epicondylitis (-osis) • Extensor carpi redialis brevis tendinosis • 9x more common than medial • Pain with resisted extension • More common in older players • Occupational injury very common • Intensity, conditioning, warm-up, training changes • Grip size, string tension, racket size/rigidity

22. Classic treatment • Reduce stresses across tissue • Rest • Counterforce brace • Improve quality of tissue and balance • Strength and endurance • Eccentric strengthening • Balanced flexibility • Optimize technique, equipment,

23. Treatment • NSAIDS and Corticosteroids? • Prolotherapy (irritant injection) • Dextrose, Sodium morrhuate • Blood • Injectable healing factors • Platelet rich plasma (PRP) • Stem cells • Mechanical adjuvants • Deep massage • Extracorporeal Ultrasound • Needle tenotomy • Surgery

24. Anti-inflammatory techniques • Cryotherapy – acutely • Ultrasound guided paratenon and bursal injections of corticosteroid may be temporarily beneficial • Never inject corticosteroid into tendon • Increases risk for rupture

25. Anti-inflammatory techniques • Achilles tendonopathy – oral NSAID (piroxicam) no benefit over placebo • Astrom, Westlin, Acta Orthop Scand, 1992. • NSAIDS may permit patient to ignore pain and cause further injury • NSAIDS may reduce healing response

26. Injected Corticosteroid • Well-established efficacy in short term relief of pain • Safe, limited side effects • Long term degeneration? • Ineffective if used in isolation without use of PT modalities

27. Topicals • Topical Nitric Oxide • Not FDA approved • Topical Glyceryl trinitrate with hand rehab • 81% asymptomatic (vs 60%) at 6 months • Less pain, improved strength • Paoloni, Am J Sports Med, 2003; Paoloni, JBJS, 2004.

28. Newer concepts: Anti-antiinflammatory approach • Deep friction massage • Prolotherapy • Injection of blood or platelets • Hyperbaric oxygen • Injectable growth factors • Radiofrequency coblation • Extracoporeal shockwave therapy • Minimally invasive release/needle tenotomy/barbotage

29. Platelet Rich Plasma • NFL, MLB, MLS, PGA • Patients own blood extracted, spun in centrifuge and PRP injected into diseased tissue • Limited evidence, thus rarely covered by health insurance

30. Platelet Rich Plasma (PRP) • Peerbooms, et al. Am J Sports Med, 2010 • DBRCT 100 patients lateral epicondylitis • Eccentric exercise with PRP or Corticosteroid • 73% vs 51% improved at 1 year

31. PRP Lateral Epicondylitis • Hechtman, et al. Orthopedics, 2011 • 30 patients, Symptoms >6mos, unresponsive to conservative therapy (inc steroid injection) • 1 PRP injection • Overall success 90% = 25% reduction in pain scores at 1 year followup

32. PRP for Achilles? • DeVos, et al. JAMA 2010. • DBRCT 54 patients • Eccentric exercise with PRP or Saline injection • No statistical difference in outcomes

33. Why the difference?Castillo, et al. AJSM, 2011. • >16 different platelet separation systems = different platelet-rich concentrates • Varying amount of starting blood volume, spin times • Varying WBC concentrations (↑ or ↓) • Thus varying growth factor concentrations • Needs more study!

34. Prolotherapy • Sclerosing therapy • Reduces neovascularization but not tendon thickness • Ohberg, Alfredson, Br J Sports Med, 2002. • Review article suggests promise and evidence of effectiveness in tendonopathy • Distel, Best, PMR, 2011.

35. Extracorporeal Shockwave Therapy (ESWT) • Approved for multiple locations • Review article (patellar tendon) • Van Leeuwen, et al. Br J Sports Med, 2009. • Variable treatment protocols • Positive outcomes – safe, effective • Uncertain mechanism • Availability?

36. Minimally Invasive Release • Dry needling, Needle tenotomy • Saline barbotage for calcifications • Percutaneous longitudinal tenotomy • Maffuli, Am J Sports Med, 1999; Wilder, Clin Sports Med, 2004.