Article

Overuse Tendon Injuries:: Where Does the Pain Come From?

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Abstract

Failure to appreciate how pain arises in tendinopathies may be limiting medical progress. It is assumed that tendon overuse causes inflammation, and thus pain. We critically review the inflammatory model of pain in tendinopathy and find that it does not withstand scrutiny. The generally proposed alternative model is that of mechanical discontinuity of collagen fibers, but this as well is inconsistent with numerous surgical observations. We review data suggesting that pain of tendinopathy may be largely due to yet unidentified biochemical factors activating peritendinous nociceptors when they are exposed to the environs as a result of tendon overuse injury. The noxious agent could include matrix substances and minor collagens. Glutamate can mediate pain, and this is present in higher concentrations in subjects with Achilles tendinopathy than in controls. Chondroitin sulphate is another candidate. Examining alternative models of pain, particularly a mixed biochemical-mechanical model, may allow significant progress in management of these troublesome conditions. (C) 2000 Lippincott Williams & Wilkins, Inc.

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... Achilles tendon degeneration is evident with an increased signal on magnetic resonance imaging (MRI) [64], and with hypoechoic regions on ultrasound (US) [65]. These areas of abnormal imaging correspond to areas of altered collagen fibers' structure, and increased interfibrillar ground substance, which have been shown to consist of hydrophilic glycosaminoglycans [60,66]. ...
... The source of pain is still under investigation: classically, pain has been attributed to inflammatory processes, but now it is evident that tendinopathies are not classical inflammatory conditions. Recently, the combination of mechanical and biochemical causes has become more interesting [64,74]. Tendon degeneration, with mechanical breakdown of collagen fibers, could theoretically explain the pain mechanism. ...
... Tendons, in these patients, showed no signs of inflammation, as indicated by the normal prostaglandin E2 levels [75]. Substance P and chondroitin sulfate may also be involved in pain generation in tendinopathy [64,74]. ...
Chapter
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In the past three decades, the incidence of Achilles tendinopathy has risen as a result of greater participation in recreational and competitive sporting activities [1]. However, this condition does not involve only athletes: in one series of 58 patients, nearly one-third did not participate in vigorous physical activity [2].
... De tendinitis wordt gebruikt om een inflammatoire aandoening van de pees aan te duiden, die diverse (para)medici frequent gediagnosticeren bij peesklachten. De gedachte dat pijn een inflammatoire basis moet hebben, ligt wellicht ingebakken sinds deze associatie is geopperd toen Celcus rapporteerde ".. rubor et tumor cum calor et dolor…" (17) . Echter, al sinds 1976 is door Puddu bij de zogenaamde 'achillespees tendinitis' al een gebrek aan inflammatoire aanwijzingen aangetoond (afwezigheid van inflammatoire cellen, zoals leukocyten en macrofagen) (2,15,16,17 ) . ...
... De gedachte dat pijn een inflammatoire basis moet hebben, ligt wellicht ingebakken sinds deze associatie is geopperd toen Celcus rapporteerde ".. rubor et tumor cum calor et dolor…" (17) . Echter, al sinds 1976 is door Puddu bij de zogenaamde 'achillespees tendinitis' al een gebrek aan inflammatoire aanwijzingen aangetoond (afwezigheid van inflammatoire cellen, zoals leukocyten en macrofagen) (2,15,16,17 ) . Drie jaar later werd door Nirschl hetzelfde gebrek aan inflammatie gevonden bij de 'epicondylitis lateralis', en sindsdien is dit voor tal van andere '-itis' condities gedocumenteerd (17) . ...
... Echter, al sinds 1976 is door Puddu bij de zogenaamde 'achillespees tendinitis' al een gebrek aan inflammatoire aanwijzingen aangetoond (afwezigheid van inflammatoire cellen, zoals leukocyten en macrofagen) (2,15,16,17 ) . Drie jaar later werd door Nirschl hetzelfde gebrek aan inflammatie gevonden bij de 'epicondylitis lateralis', en sindsdien is dit voor tal van andere '-itis' condities gedocumenteerd (17) . Perugia et. ...
Article
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Het is al eeuwen bekend dat ons bewegingsapparaat, net zoals dat van vele andere organismen, zich uitermate efficiënt aanpast aan de mechanische belasting die het ondergaat. Deze relatie tussen mechanische stimuli en weefseldifferentiatieprocessen wordt onderzocht in een nieuw (of hernieuwd) wetenschapsgebied: de mechanobiologie. Dit artikel bespreekt de invloed van de mechanobiologie op het mechanisch steunweefsel en geeft een overzicht van de diverse weefseladaptaties die zich afspelen in ons lichaam. Een verdieping in de theorie van dit continue adaptatieproces geeft een belangrijke legitimatie voor het fysiotherapeutisch handelen, aangezien fysiotherapeuten dagelijks bezig zijn met het toedienen van mechanische stimuli op het bewegingsapparaat. Hierdoor kan het wetenschapsgebied der mechanobiologie in de toekomst van essentieel belang zijn voor het fysiotherapeutisch vakgebied.
... De gedachte dat pijn een inflammatoire basis moet hebben, komt wellicht door het rijtje dat Celsus rapporteerde: '… rubor et tumor cum calor et dolor …' . 15 In 1976 echter toonde Puddu bij de zogenaamde achillespeestendinitis een gebrek aan inflammatoire aanwijzingen aan (afwezigheid van inflammatoire cellen zoals leukocyten en macrofagen). 15,16,17,18 Drie jaar later vond Nirschl hetzelfde gebrek aan inflammatieverschijnselen bij de epicondylitis lateralis, en sindsdien is dit voor tal van andere gevallen van '-itis' gedocumenteerd. ...
... 15 In 1976 echter toonde Puddu bij de zogenaamde achillespeestendinitis een gebrek aan inflammatoire aanwijzingen aan (afwezigheid van inflammatoire cellen zoals leukocyten en macrofagen). 15,16,17,18 Drie jaar later vond Nirschl hetzelfde gebrek aan inflammatieverschijnselen bij de epicondylitis lateralis, en sindsdien is dit voor tal van andere gevallen van '-itis' gedocumenteerd. 15 De meeste peesaandoeningen blijken te worden gekenmerkt door gedesorganiseerd collageen bindweefsel met microrupturen, verhoogde aanwezigheid van collageen type III (reparatief collageen), hyper-of neovascularisatie met proliferatie van capillairen, en verhoging van het aantal tenocyten en myofibroblasten. ...
... 15,16,17,18 Drie jaar later vond Nirschl hetzelfde gebrek aan inflammatieverschijnselen bij de epicondylitis lateralis, en sindsdien is dit voor tal van andere gevallen van '-itis' gedocumenteerd. 15 De meeste peesaandoeningen blijken te worden gekenmerkt door gedesorganiseerd collageen bindweefsel met microrupturen, verhoogde aanwezigheid van collageen type III (reparatief collageen), hyper-of neovascularisatie met proliferatie van capillairen, en verhoging van het aantal tenocyten en myofibroblasten. Hierbij wordt gesproken van een 'degeneratief ' proces, dat in navolging van Puddu 'tendinose' wordt genoemd. ...
Article
Het is al eeuwen bekend dat ons bewegingsapparaat, net zoals dat van vele andere organismen, zich uitermate efficiënt aanpast aan de mechanische belasting die het ondergaat. Deze relatie tussen mechanische stimuli en weefseldifferentiatieprocessen wordt onderzocht in een nieuw (of hernieuwd) wetenschapsgebied: de mechanobiologie. Dit artikel bespreekt de invloed van de mechanobiologie op het mechanisch steunweefsel en geeft een overzicht van de diverse weefseladaptaties die zich afspelen in ons lichaam. Een verdieping in de theorie van dit continue adaptatieproces geeft een belangrijke legitimatie voor het fysiotherapeutisch handelen, aangezien fysiotherapeuten dagelijks bezig zijn met het toedienen van mechanische stimuli op het bewegingsapparaat. Hierdoor kan het wetenschapsgebied der mechanobiologie in de toekomst van essentieel belang zijn voor het fysiotherapeutisch vakgebied
... One theory to explain the cause of pain in lateral epicondylitis is that the continued overload of the common extensor tendon and deconditioned muscles causes an inflammatory response. The release of inflammatory mediators excites nociceptors, perpetuating pain stimulation (Khan & Cook 2000). Khan & Cook (2000) suggested that tendinopathy pain may also be caused by additional biochemical factors, such as matrix substances, minor collagens, glutamate, (Khan & Cook 2000). ...
... The release of inflammatory mediators excites nociceptors, perpetuating pain stimulation (Khan & Cook 2000). Khan & Cook (2000) suggested that tendinopathy pain may also be caused by additional biochemical factors, such as matrix substances, minor collagens, glutamate, (Khan & Cook 2000). Furthermore, research has shown an excess of both blood vessels and fibroblasts (neovessels/angiogenesis) in the tendon of the ECRB muscle immediately distal to its origin in cases of lateral epicondylitis. ...
... The release of inflammatory mediators excites nociceptors, perpetuating pain stimulation (Khan & Cook 2000). Khan & Cook (2000) suggested that tendinopathy pain may also be caused by additional biochemical factors, such as matrix substances, minor collagens, glutamate, (Khan & Cook 2000). Furthermore, research has shown an excess of both blood vessels and fibroblasts (neovessels/angiogenesis) in the tendon of the ECRB muscle immediately distal to its origin in cases of lateral epicondylitis. ...
... Schließlich können wir der Frage nachgehen, woher der Schmerz bei einer Tendinopathie stammt, wobei derzeit die einzige ehrliche Antwort ist, dass wir es nicht wissen [15,16]. Offenbar sind die klassischen Entzündungs-oder Kollagendegenerationstheorien wohl ungeeignete Erklärungen, da schmerzhafte chronische Tendinopathien oft ohne Entzündungen einhergehen und andererseits Sehnendegenerationen asymptomatisch verlaufen. ...
... Offenbar sind die klassischen Entzündungs-oder Kollagendegenerationstheorien wohl ungeeignete Erklärungen, da schmerzhafte chronische Tendinopathien oft ohne Entzündungen einhergehen und andererseits Sehnendegenerationen asymptomatisch verlaufen. In einer alternativen neueren Erklärung wird eine mechanische oder biochemische Ursache postuliert [11,15,16,20] ...
Article
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Overuse tendon injury is one of the most common injuries in sports. The etiology as well as the pathophysilogical mechanisms leading to tendinopathy are of crucial medical importance. At the moment intrinsic and extrinsic factors are assumed as mechanisms of overuse tendon injury. Except for the acute, extrinsic trauma, the chronic overuse tendon injury is a multifactorial process. There are many other factors, such as local hypoxia, less of nutrition, impaired metabolism and local inflammatory that may also contribute to the development of tissue damage. The exact interaction of these factors cannot be explained entirely at the moment. Further studies will be necessary in order to get more information.
... The main symptom of Achilles tendinopathy is pain, but again the underlying mechanism is not fully understood. In the past it was assumed to arise through inflammation or via collagen fibre separation or degeneration, 21,22 but chronically painful Achilles tendons show no evidence of inflammation, and some that show clear intratendinous defects on MRI or ultrasound are not painful. [21][22][23][24] Since tendinopathies are degenerative rather than inflammatory conditions, pain may originate from a combination of mechanical and biochemical factors. ...
... In the past it was assumed to arise through inflammation or via collagen fibre separation or degeneration, 21,22 but chronically painful Achilles tendons show no evidence of inflammation, and some that show clear intratendinous defects on MRI or ultrasound are not painful. [21][22][23][24] Since tendinopathies are degenerative rather than inflammatory conditions, pain may originate from a combination of mechanical and biochemical factors. 23 Microdialysis sampling revealed twofold higher lactate levels in tendinopathic tendons than in controls. ...
... Typischerweise findet sich im Röntgenbild eine Prominenz des dorsoproximalen Tuber calcanei, die an sich nicht pathologisch ist und deshalb Pseudoexostose (nach dem Erstbeschreiber: Haglund-Pseudoexostose) genannt wird. Als Messwert zur Beurteilung der Geometrie des dorsalen Kalkaneus ist der Fowler'sche Winkel beschrieben [4]. Je größer der Fowler'sche Winkel, desto mehr Raum ergibt sich retrokalkanear-präachillär, d. h. ...
... Die konkrete Ursache der postoperativen Schmerzentstehung ist jedoch sicherlich multifaktoriell und in ihrer Entstehung nicht geklärt [4,11]. ...
Article
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Retrocalcaneal bursitis in athletes is frequently misdiagnosed. Results of conservative treatment are not very promising. This investigation evaluates the results of 39 consecutive cases in 38 patients surgically treated due to chronic retrokalkaneal bursitis in a sport specific population. Preoperative MRI and ultrasound investigation showed corresponding lesions (focal degeneration, partial rupture) of the anterior Achilles tendon. This is possibly the result of a previously undescribed impingement lesion produced by the Haglund's bone and the chronically inflamed retrocalcaneal bursa. During operation this lesion was additionally adressed in 85% of the cases. Follow up was done after 32 months. Success rate was 54%. VISA-A Score at follow up was 80,6 points. Training and competitional activities were started at 16 weeks and 9 months respectively. Unsatisfying results were analysed. In two cases Haglund's bone resection was incomplete and had to be removed in a reoperation. Additionally one deep wound infection had to be revised. Due to the distal Achilles tendon fiber extensions around the medial and lateral calcaneal bone, an unintended Achilles tendon lesion, induced by the edge of the osteotome seems to be possible. Two calcanear stress fractures complicated the postoperative rehabilitation.
... This might have led to the inclusion of other conditions that cause anterior knee pain such as patellofemoral pain syndrome or infrapatellar bursitis. On the other hand, the relation between tendon abnormalities on imaging and experienced tendon pain is not one to one [11,12]. Ultrasound imaging, for example, can show tendon abnormalities like an increased tendon diameter and hypoechoic areas, but this only increases the likelihood of the diagnosis and does not provide conclusive evidence for a JK diagnosis. ...
Article
The literature on the relation between jump biomechanics and jumper's knee indicates that a jump with horizontal displacement poses a threat for developing jumper's knee. Subjects with jumper's knee have been shown to display a stiff landing pattern characterized by a small range of motion. However, up to now only cross-sectional studies have been conducted. 6 teams from sports involving repetitive landing were followed prospectively for 2 years. At baseline athletes performed the Landing Error Scoring System jump and 3D kinematics and kinetics were obtained. A comparison was made between subjects who developed jumper's knee and those who did not develop it. 3 subjects developed jumper's knee during the study. Leg stiffness during landing was high compared to the mean of the healthy controls. No common kinematic patterns could be identified in these 3 subjects. The results suggest that athletes with high leg stiffness during landing might have an increased risk for developing jumper's knee, yet this conclusion is based on a very small sample. Subjects who develop jumper's knee do not show a common landing technique. Further research is needed to investigate whether leg stiffness can be used to identify athletes at risk and as a target variable to be used in prevention. © Georg Thieme Verlag KG Stuttgart · New York.
... The role of inflammatory components in chronic Achilles tendinopathy has been investigated widely. Using both light and electron microscopy and biochemical analysis of substrates such as prostaglandin PGE2, Alfredson, Thorsen and Lorentzon, 60 Ajis et al 61 and Khan et al [62][63][64] found no evidence of 'classical' inflammatory cells in human chronic tendon injuries. However, more recent work suggests that interaction between polymorphisms within three interleukin genes, IL-1β, IL-1RN and IL-6, and the COL5A1 rs12722 CC genotype polymorphism may modulate the risk of Achilles tendinopathy. ...
Article
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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. Cite this article: Bone Joint J 2013;95-B:305–13.
... Instead, research has shown that PT and other tendinopathies are more likely a degenerative failed healing response to injury. This tendon degeneration is characterized by collagen loss and disorganization; fibroblast proliferation and fibrosis; increased ground substance;27 changes in matrix metalloprotease and metalloprotease-disintegrin expression;28 abnormal tenocyte morphology;23 hypoxia leading to increased levels of lactate, hypoxia-inducible factor, and vascular endothelial growth factor (VEGF);3,29 increased neovascularization;30 decreased sympathetic and increased sensory nerve growth;6,31 as well as changes in other matrix and signaling molecules.28 However, it is unclear if these degenerative processes themselves cause pain. ...
Article
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The pain of patellar tendinopathy (PT) may be mediated by neuronal glutamate and sodium channels. Lidocaine and tetracaine block both of these channels. This study tested the self-heated lidocaine-tetracaine patch (HLT patch) in patients with PT confirmed by physical examination to determine if the HLT patch might relieve pain and improve function. Thirteen patients with PT pain of ≥14 days' duration and baseline average pain scores ≥4 (on a 0-10 scale) enrolled in and completed this prospective, single-center pilot study. Patients applied one HLT patch to the affected knee twice daily for 2-4 hours for a total of 14 days. Change in average pain intensity and interference (Victorian Institute of Sport Assessment [VISA]) scores from baseline to day 14 were assessed. No statistical inference testing was performed. Average pain scores declined from 5.5 ± 1.3 (mean ± standard deviation) at baseline to 3.8 ± 2.5 on day 14. Similarly, VISA scores improved from 45.2 ± 14.4 at baseline to 54.3 ± 24.5 on day 14. A clinically important reduction in pain score (≥30%) was demonstrated by 54% of patients. The results of this pilot study suggest that topical treatment that targets neuronal sodium and glutamate channels may be useful in the treatment of PT.
... Han pasado tres décadas desde la publicación de Curvin y Stanish quienes propusieron el ejercicio excéntrico como parte de un programa de tratamiento para el manejo clínico de la tendinosis, y diversas revisiones narrativas no sistemáticas han recomendado el ejercicio excéntrico como modalidad terapéutica para la TP 22,29,50 . Sin embargo, la evidencia actual basada en RS de ensayos clínicos aleatorizados han establecido que el ejercicio excéntrico no es superior a otras modalidades de ejercicio terapéutico (ejercicio concéntrico o stretching) en el manejo de la ...
Article
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Chronic patellar tendinopathy affects mainly overhead athletes with knee extensor mechanism. In recent decades eccentric exercise has become an indication for routine clinical management of this condition. There will be a synthesis of evidence through a systematic review of randomized clinical trials that have compared an eccentric exercise program declined versus a standard for the management of these patients. The aim of this review is to determine whether there is scientific evidence that proves that declined eccentric exercise is more effective than standard eccentric exercise in the treatment of chronic patellar tendinopathy patients. The search strategy included randomized controlled trials (RCTs) and controlled clinical trials (CCTs); the databases used were MEDLINE, CINAHL, PEDro, CENTRAL, LILACS. The results were four articles that met our eligibility criteria. We conclude that there is conflicting evidence that eccentric exercise declined to be more effective than standard eccentric exercise in pain management and improved functionality, the short, medium and long term in patients with chronic patellar tendinopathy.
... Historically the term "Achilles tendinitis" has extensively been used to characterize any acute or chronic pain syndrome of the Achilles tendon and its surrounding structures (Leach et al., 1981;Schepsis et al., 1994). Later the suffix "-itis" was abandoned as inflammation was rarely found in histologic sections from specimens with Achilles tendon overuse injuries (Jozsa and Kannus, 1997;Khan and Cook, 2000). Further classifications were proposed with respect to specific clinical and histological findings. ...
... 52 Eccentric training regimes in which the tendon is subjected to sustained physiologic load have gained popularity in the treatment of tendinopathy. 54 Eccentric exercise has been reported to be successful in 90% of active or sporting individuals with tendinopathy 55 but less successful in a more sedentary population. 56 Loading a tendon with eccentric exercise may be appropriate for treating tendinopathy in an athlete, but it may not be the best option for treating fluoroquinolone-induced tendon conditions, at least in the early stages of symptoms. ...
Article
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Context: Fluoroquinolone antibiotics have been used for several decades and are effective antimicrobials. Despite their usefulness as antibiotics, a growing body of evidence has accumulated in the peer-reviewed literature that shows fluoroquinolones can cause pathologic lesions in tendon tissue (tendinopathy). These adverse effects can occur within hours of commencing treatment and months after discontinuing the use of these drugs. In some cases, fluoroquinolone usage can lead to complete rupture of the tendon and substantial subsequent disability. Objective: To discuss the cause, pharmacology, symptoms, and epidemiology of fluoroquinolone-associated tendinopathy and to discuss the clinical implications with respect to athletes and their subsequent physiotherapy. Data sources: We searched MEDLINE, Cumulative Index to Nursing and Allied Health (CINAHL), Allied and Complementary Medicine Database (AMED), and SPORTDiscus databases for available reports of fluoroquinolone-related tendinopathy (tendinitis, tendon pain, or rupture) published from 1966 to 2012. Search terms were fluoroquinolones or quinolones and tendinopathy, adverse effects, and tendon rupture. Included studies were written in or translated into English. Non-English-language and non-English translations of abstracts from reports were not included (n = 1). Study selection: Eligible studies were any available reports of fluoroquinolone-related tendinopathy (tendinitis, tendon pain, or rupture). Both animal and human histologic studies were included. Any papers not focusing on the tendon-related side effects of fluoroquinolones were excluded (n = 71). Data extraction: Data collected included any cases of fluoroquinolone-related tendinopathy, the particular tendon affected, type of fluoroquinolone, dosage, and concomitant risk factors. Any data outlining the adverse histologic effects of fluoroquinolones also were collected. Data synthesis: A total of 175 papers, including 89 case reports and 8 literature reviews, were identified. Conclusions: Fluoroquinolone tendinopathy may not respond well to the current popular eccentric training regimes and may require an alternative, staged treatment approach. Clinicians, athletes, athletic trainers, and their medical support teams should be aware of the need to discuss and possibly discontinue these antibiotics if adverse effects arise.
... 25 In rotator cuff tendinopathy, substance P has been shown to correlate with pain, and the neural density in the subacromial bursa has been shown to correlate with rest pain. 25 An increased release of substance P was found in pathologic ATs 26,27 in animal studies. So the peripheral neuronal phenotype is currently considered an important factor in the pathogenesis of painful human tendinopathy. ...
Article
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Achilles tendinopathy is common both in athletic and nonathletic individuals, and the incidence has risen in the last few decades. Although Achilles tendinopathy has been extensively studied, there is a clear lack of properly conducted scientific research to clarify its cause, pathology, natural history, and optimal management. The treatment of Achilles tendinopathy lacks evidence-based support, and tendinopathy sufferers are at risk of long-term morbidity with unpredictable clinical outcome. Most patients respond to conservative treatments. When conservative management is unsuccessful, surgery is recommended. Similar results have been reported with both open and minimal invasive techniques. However minimal invasive techniques appear to reduce the risks of infection and provide better cosmetic results. Achilles tendon rupture is frequent in young athletes and middle aged people who practice recreational activities, and it is a serious injury. The management should take into account the age, occupation, and level of sporting activity. Open surgery provides good functional results and a lower re-rupture rate, but it is frequently associated with a higher risk of superficial skin breakdown and wound problems. Percutaneous repair aims to provide good functional outcome while decreasing the problems associated with open surgery in terms of wound healing and skin breakdown. Percutaneous repair followed by early functional rehabilitation is becoming increasingly common, and should be considered in selected patients.
... The role of inflammation in chronic tendinopathy has long been debated [101]. Early research utilising microscopic examination of tendinopathic tissue and biochemical analysis reported no evidence of the normal elements associated with 'classical' inflammation in chronic tendon injuries [102][103][104][105]. Animal work indicated that early tendinosis was associated with tenocyte stimulation rather than apoptosis and modulated by growth factors such as insulin-like growth factor 1 (IGF-1) [106]. ...
Article
Full-text available
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.
... Han pasado tres décadas desde la publicación de Curvin y Stanish quienes propusieron el ejercicio excéntrico como parte de un programa de tratamiento para el manejo clínico de la tendinosis, y diversas revisiones narrativas no sistemáticas han recomendado el ejercicio excéntrico como modalidad terapéutica para la TP 22,29,50 . Sin embargo, la evidencia actual basada en RS de ensayos clínicos aleatorizados han establecido que el ejercicio excéntrico no es superior a otras modalidades de ejercicio terapéutico (ejercicio concéntrico o stretching) en el manejo de la ...
Article
Full-text available
Chronic patellar tendinopathy affects mainly overhead athletes with knee extensor mechanism. In recent decades eccentric exercise has become an indication for routine clinical management of this condition. There will be a synthesis of evidence through a systematic review of randomized clinical trials that have compared an eccentric exercise program declined versus a standard for the management of these patients. The aim of this review is to determine whether there is scientific evidence that proves that declined eccentric exercise is more effective than standard eccentric exercise in the treatment of chronic patellar tendinopathy patients. The search strategy included randomized controlled trials (RCTs) and controlled clinical trials (CCTs); the databases used were MEDLINE, CINAHL, PEDro, CENTRAL, LILACS. The results were four articles that met our eligibility criteria. We conclude that there is conflicting evidence that eccentric exercise declined to be more effective than standard eccentric exercise in pain management and improved functionality, the short, medium and long term in patients with chronic patellar tendinopathy.
... The role of inflammation in chronic tendinopathy has long been debated [101]. Early research utilising microscopic examination of tendinopathic tissue and biochemical analysis reported no evidence of the normal elements associated with 'classical' inflammation in chronic tendon injuries [102][103][104][105]. Animal work indicated that early tendinosis was associated with tenocyte stimulation rather than apoptosis and modulated by growth factors such as insulin-like growth factor 1 (IGF-1) [106]. ...
... Seit Celsus den Zusammenhang "rubor et tumor cum calore et dolore" darstellte, wird Schmerz in Verbindung mit einer Entzündung gebracht. Doch die veraltete Annahme, entzündliche Prozesse spielten bei der Genese des Schmerzes einer Tendinopathie eine Rolle, konnte widerlegt werden.Neben fehlender histopathologischer Anzeichen zeigte Alfredson normale Prostaglandin E2-Level, dafür aber erhöhte Glutamatlevel in ATs[5,41]. PGE2 ist ein Entzündungsmediator, der bei akuten Entzündungen im Gewebe erhöht ist. Die erhöhten Glutamatlevel, die Alfredson nachweisen konnte, sind wahrscheinlich an der Entstehung des Schmerzes beteiligt.Glutamat ist einer der wichtigsten Neurotransmitter im neuronalen Schmerzsystem, der unter anderem bei der Schmerzübertragung mitwirkt[52]. ...
Thesis
Die chronische Achillessehnentendinopathie ist ein häufiges Krankheitsbild bei jungen aktiven Menschen bis ins mittlere Alter. Neben mangelndem Wissen über die Hintergründe, herrscht zudem noch Unklarheit über die optimale Therapie dieser Erkrankung. Unter den zahlreichen konservativen Behandlungsmöglichkeiten zählt das exzentrische Krafttraining zu den etabliertesten Varianten. Dieses ist jedoch nicht immer leicht durchzuführen und bedarf einer guten Compliance von Seiten des Patienten. Injektionstherapien zählen ebenso zu den Therapiemöglichkeiten. Es besteht eine große Vielfalt an verschiedenen Substanzen und Verfahren. Die Sklerotherapie, die ursprünglich aus der Dermatologie kommt und die mit ihr verwandte Prolotherapie, zählen zu den vielversprechenden Optionen unter ihnen. Allerdings sind ihre Effektivität und ihre Sicherheit noch unklar. Ziel der Studie war es die bestehende Literatur für Sklero- und Prolotherapie zur Behandlung der Achillessehnentendinopathie systematisch zu durchsuchen, zu analysieren und auszuwerten. Die Suche erfolgte hauptsächlich als elektronische Datenbanksuche nach den PRISMA-Leitlinien. Die Auswahlkriterien für die Studien wurden nach dem PICOS-Schema gestellt. Neben Menschenstudien stellten auch Tierstudien einen Bestandteil der Übersichtsarbeit dar, um ein besseres Verständnis über die Wirkungsweise, sowie mögliche Nebenwirkungen der Therapien zu erlangen. Die Suche ergab insgesamt 1104 Treffer. Nach Screening standen 18 Artikel zur qualitativen Synthese zur Verfügung. Sechs dieser 18 Artikel waren für eine Meta-Analyse geeignet. Der durchschnittliche Coleman-Score der 13 Menschenstudien betrug 50. Vier RCTs hatten ein geringes Risiko für ein Selektionsbias. Drei der RCTs zeigten eine signifikante Reduzierung der Schmerzen auf einer visuell-analogen Skala (VAS), ein RCT zeigte einen signifikanten Anstieg des VISA-A-Scores. 12 der 13 Menschenstudien berichteten von positiven Ergebnissen hinsichtlich Schmerzerleichterung und Patientenzufriedenheit. Nur eine Studie konnte diese Ergebnisse nicht bestätigen. Die Meta-Analyse zeigte ein eindeutiges Ergebnis für die Intervention (gewichtete Mittelwertdifferenz D = -4,67 cm, 95% CI -5,56 bis -3,76cm (p < 0,01)). In allen Studien mit insgesamt mindestens 1013 Injektionen wurden nur zwei leichte und ein schweres unerwünschtes Ereignis berichtet. Diese systematische Übersichtsarbeit zeigt, dass die Sklerotherapie und die Prolotherapie eine effektive und sichere Behandlungsmethode für die Achillessehnentendinopathie darstellen kann. Nichtsdestotrotz benötigt es weiterhin mehr qualitativ hochwertige Studien, insbesondere randomisierte, kontrollierte Studien mit Langzeitergebnissen, um diese Empfehlung zu untermauern.
... The diagnosis involves more than 1 million physician visits in the USA and affects sedentary and athletic patient populations [4,5]. The available literature reports that the term fasciitis has been changed to fasciopathy in the last two decades [6,7]. The literature postulates that the condition to be more of a degenerative process affecting the plantar fascia rather than localized tissue inflammation. ...
Article
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Background The biggest challenge in treating this diagnosis is the lack of literature focusing on regional interdependence. The current literature suggests a narrow and localized approach targeting plantar fascia and ankle/foot complex. The literature available on conservative treatment focused on utilizing various inflammatory modalities such as injections and extracorporeal shockwave therapy. The surgical approach targets Baxter’s nerve decompression techniques and releases techniques to the gastrocnemius and plantar fascia. The article focuses on utilizing manual therapy techniques to the lumbosacral spine and plantar fascia. In addition, the neurodynamic flossing targeted lateral plantar nerve mobility. Case presentation The patient is a 54-year-old African American female seen for right heel pain at Texas’s outpatient orthopedic physical therapy clinic. The patient had the diagnosis of plantar fasciopathy with negative Windlass testing. The patient was provided manual therapy interventions to the lumbosacral spine and plantar fascia to improve weight-bearing patterns and overall functional outcomes. Conclusion The manual therapy interventions to the lumbosacral spine and plantar fascia and flossing techniques to the lateral plantar nerve improved symptoms of heel pain. The patient showed improved outcomes with this approach.
... In chronic cases, deep friction massage should be accompanied by stretching to restore tissue elasticity and reduce the strain. Rest, physiotherapeutic interventions, [6] and eccentric exercise [2] are initials ABSTRACT Background: A soft tissue injury most likely to be experienced with sprains, strains, contusions, tendonitis and bursitis. It results in more pain and stiffness of concerned area that hampers patient's routine activity. ...
... In chronic cases, deep friction massage should be accompanied by stretching to restore tissue elasticity and reduce the strain. Rest, physiotherapeutic interventions, [6] and eccentric exercise [2] are initials ABSTRACT Background: A soft tissue injury most likely to be experienced with sprains, strains, contusions, tendonitis and bursitis. It results in more pain and stiffness of concerned area that hampers patient's routine activity. ...
Article
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Background: A soft tissue injury most likely to be experienced with sprains, strains, contusions, tendonitis and bursitis. It results in more pain and stiffness of concerned area that hampers patient’s routine activity. If such cases managed improperly that result in more deformities so it requires proper and early management. Early management of STI (soft tissue injury) is described in Ayurveda classics and provide better functional restoration. Murivenna oil is traditionally practiced in traumatology by Ayurveda practitioners. Method: A 30 year female patient diagnosed of Achillis tendinopathy was managed with Murivenna oil (Ayurveda medicament) Parisheka (pouring oil on affected part) procedure performed daily for 10 minutes followed by simple bandaging with gauze for 4 weeks. Variables like pain, stiffness and ROM (range of movement) along with disability index were assessed before and after treatment. Result: Murivenna oil Parisheka revealed tremendous results in improving pain, stiffness and movement of part. Conclusion: The active principle in Murivenna oil provides synergistic action in relieving the symptoms of soft tissue injuries. KEYWORDS: Ayurveda, Murivenna oil, Soft tissue injury, Tendinitis.
... 8 Although the literature is laden with studies investigating its clinical, radiological and pathophysiological nature, its biomechanical aetiology remains debatable. 9,10 Tendinopathies, in general, are considered to be caused by both extrinsic and intrinsic factors. 11,12 It is postulated that biomechanically, patellar tendinopathy is caused by excessive tensile stresses and strains in the patellar tendon. ...
Article
Full-text available
Patellar tendinopathy is among the most widespread patellar tendon diseases in athletes that participate in activities involving running and jumping. Although their symptoms can be detected, especially at the inferior pole of the patella, their biomechanical cause remains unknown. In this study, a three‐dimensional finite element model of knee complex was developed to investigate principal stress and strain distributions in the patellar tendon during 0°‐90° knee flexion and slow and fast level‐ground walking. Results indicate that the patellar tendon is subjected to tensile stress and strains during all three activities. During flexion, its central proximal posterior region exhibited highest peak stress and strain, followed by central distal posterior, central distal anterior and central proximal anterior region. Similar trends and magnitudes were reported during slow and fast walking. The region with highest principal stresses and strains, central proximal anterior region, also corresponds to the most commonly reported patellar tendinopathy lesion site, suggesting that principal stress and strain are good indicators of lesion site location. Additional factors such as regional variations in material properties and frequency and duration of cyclic loading also need to be considered when determining the biomechanical aetiology of patellar tendinopathy.
... Effectiveness of the currently available treatment options is quite variable [5]. It is thus important to prevent PT in athletes and to develop better injury treatment options [2,6]. ...
Article
Disorders of the patellofemoral joint are common and usually respond to nonoperative treatment. In some cases, conservative treatment fails and surgical intervention may be considered. Over the past year, new approaches to the surgical treatment of patellar tendinopathy, patellar cartilage lesions, and patellar instability have been reported. The outcomes of these studies are limited by a lack of knowledge of the natural history of these disorders, poor study design, and inconsistent outcome criteria. Whether a role for more aggressive treatment of these disorders is warranted awaits further study.
Article
Fourier transform-second-harmonic generation (FT-SHG) imaging is used to quantitatively assess the structural organization of collagen fibers in tendonitis-induced horse tendons. Fiber orientation, isotropy, and the ratio of forward to backward SHG signal (F/B ratio) are used to differentiate the fiber organization between the normal and diseased horse tendons. Each second-harmonic generation (SHG) image is divided into several smaller regions of interest (ROI) and the aforementioned quantitative metrics are calculated across the whole grid. ROIs are further labeled as dark (no or minimal presence of fibers), isotropic (random fiber organization), or anisotropic (regular fiber organization) regions. Results show that the normal tendon possesses minimal isotropic regions and small standard deviations in the histograms of orientation and F/B ratio, indicating an intact and highly regular fiber organization. However, the tendonitis-induced horse tendons possess higher number of dark and isotropic regions, and larger standard deviations of the measured parameters, suggesting significantly disoriented and disorganized collagen fibers. This type of quantification would be highly beneficial in diagnosing and determining the stage of tendonitis in clinical settings. Not limited to tendonitis, the technique could also be applied to other diseases that structurally affect collagen fibers. The advantage of FT-SHG over the conventional polarization microscopy is also discussed.
Chapter
The evolution of understanding of Achilles tendon pathology to be a largely degenerative process rather than inflammatory has stimulated debate on the possible etiology. Current theoretical models of Achilles tendinosis do not adequately explain the etiology, pathology, and response to exercise as treatment. Tendon rupture occurs predominantly in pathogenic tendons and is more common in sedentary subjects compared to athletes, casting doubt on exercise overload as the main causative factor. However, new animal models show the importance of neural function for tendon and ligament healing and blocking neural function leads to col-lagen degradation. Human microdialysis studies show higher concentrations of excitatory neuro-transmitters in painful tendons. Tendon pathology also appears to be associated with patients who have had sciatica. Clinical reports of altered neural dynamics in patients with tendinosis, together with anecdotal reports of treating altered neuropathic signs facilitating recovery, raise the question of a possible neuropathic etiology. Altered neural function may cause tendon degeneration in the human, as displayed in the animal models, and may also explain the presence or absence of pain accompanying tendinosis in some patients where pain-producing fibers are not involved. However, all these require further investigation. This chapter discusses the rationale behind the theoretical basis for a neuropathic etiology of degenerative tendinopathy and outlines an appropriate clinical assessment and management protocol. Further research questions are identified and this chapter attempts to stimulate the academic debate on our shortcomings of current theoretical models.
Article
Disorders of the Achilles tendon are among the most frequent musculoskeletal injuries in athletes as well as in the general population. It is very important to differentiate the different clinical pictures summarized under the general term achillodynia and to understand the pathogenesis in order to undertake the correct therapeutic measures. In the case of insertional tendinopathies in particular, a rheumatological origin should be clarified. Doppler ultrasound is the most important diagnostic tool. Evidence-based treatment methods include various training programs, shock wave treatment, diverse injection and surgical procedures, each of which are discussed in detail in this article.
Article
Many treatments have been proposed for tendinopathies but not always with proof of efficacy. Basically, the underlying problem is tendon overload leading to destruction and disorganization of the collagen fibers composing the tendon. Damage can thus take several weeks for repair. Proposed solutions include: rest, cold, ultrasound, laser, deep transversal massage, shock waves, stretching, excentric work, and many more. We reviewed the pertinent literature in order to determine whether all the effects attributed to these different techniques are based on scientific evidence. For certain techniques, we noted an obvious lack of serious studies. We were thus able to draw up a list of techniques with demonstrated efficacy which can be proposed for evidence-based treatment of tendinopathies: rest, cold, stretching, excentric work. If the results obtained with these methods is disappointing, shock wave treatment may be appropriate. For us, our profession must strive for more widespread use of evidence-based physical therapy.
Article
Patellar tendinopathy disrupts athletic careers in several sports and is resistant to many forms of conservative treatment. Outcome after conservative treatment has been minimally investigated, and the effect of these treatments on the pathology of overuse tendinopathy are not well understood. The clinical assessment of patellar tendinopathy appears straightforward, but evidence suggests that the importance of imaging and palpation in diagnosis and ongoing assessment may be overestimated. There is a lack of clinically relevant research on which to base treatment. However, the principles of management for patellar tendinopathy derived from clinical experience include load modification, musculotendinous rehabilitation, and intervention to improve the shock absorbing capacity of the limb. The role of electrophysical agents, massage, and stretching in the treatment of patellar tendinopathy are also discussed. The progression of treatment is based on clinical grounds due to a lack of reliable subjective and objective tools to assess recovery. The failure of some conservative programs could be due to either athlete compliance or practitioner expertise. The management of patellar tendinopathy is complex, and if the physiotherapist addresses all the principles of treatment, the chance of success could be increased.<br /
Article
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Musculoskeletal soft tissue injuries such as Achilles tendinopathy and anterior cruciate ligament ruptures are common among elite athletes, recreational athletes and physically active individuals. The consequences of injury may be devastating and prevent the recreational or competitive athlete from reaching their potential or lead to a premature end to their careers. Although these injuries have been well described at a clinical level, the biological mechanisms causing these injuries are poorly understood. A further understanding of the biological mechanisms underlying the injury will assist the treatment and management of these injuries. In addition, understanding the biology is an important prerequisite in developing models that can be used to effectively identify risk, as well as, implement personalised prevention, treatment and rehabilitation programmes. Both intrinsic, including genetic variants, and extrinsic risk factors have nevertheless been implicated in the aetiology of these injuries. To date, several patents have been filed which involve the use of specific polymorphisms and regions within specific genes to be used in a genetic test for either tendon or ligament injury risk. The objective of this manuscript will be to review the evidence for the genetic predisposition to soft tissue injury, as well as the application of this data in the prevention, treatment and management of musculoskeletal soft tissue injuries.
Article
Introduction: Supraspinatus tendinopathy is a common condition and there are several popular modalities for its treatment, including ultrasound and transverse frictions. The null hypothesis to be tested in this study was that there is no significant difference in the outcome measure when ultrasound therapy is used, as opposed to transverse frictions alone in the treatment of supraspinatus tendinopathy. Patients and Methods: Twenty-three subjects with supraspinatus tendinopathy participated in the trial: 11 subjects were allocated to group 1 (exercise and frictions) and 12 subjects to group 2 (exercise, frictions and ultrasound). Results: The data suggest acceptance of the null hypothesis. Outcome measures were not altered if ultrasound was combined with transverse frictions in the treatment of supraspinatus tendinopathy, as opposed to carrying out transverse frictions alone. Both groups showed a significant improvement from baseline to 6 weeks. Conclusions: This pilot trial suggests that the addition of ultrasound does not improve the outcome significantly when compared to using transverse frictions and exercise alone in the treatment of supraspinatus tendinopathy.
Conference Paper
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PURPOSE Tendinosis of the common extensor tendon of the lateral elbow is a notoriously difficult problem to treat. We report our experience with ultrasound (US) guided percutaneous needle tenotomy (PNT) for this condition. We have previously reported our experience with another cohort of patients that, unlike this one, received an injection of corticosteroid mixed with bupivacaine after the needling procedure. We attempt to demonstrate that the excellent results observed with the previous cohort could also be obtained without the corticosteroid injection. METHOD AND MATERIALS We performed US guided PNT on 57 consecutive patients who had persistent pain and disability resulting from common extensor tendinosis. Under local anesthetic and US guidance an 18 or 20 gauge needle was advanced into the tendon, and the tip was used to repeatedly fenestrate the tendinotic tissue. Calcifications present at the origin and/or within the mid-substance of the tendon were mechanically fragmented, and the adjacent bony surface abraded. After the procedure, patients were instructed to perform passive stretches, and to undergo physical therapy. During a subsequent telephone interview, patients answered questions about their experience with the procedure and their perceptions of procedure outcome. RESULTS 52/57 (91%) were contacted by telephone and agreed to participate in the study. There were 31 women and 21 men, age range 36 to 61 years, mean age 49 years. 30/52 (58%) of the respondents reported excellent outcomes, 18/52 (35%) good, 1/52 (2%) fair, and 3/52 (6%) poor. Average follow-up time from date of procedure to date of interview was 22 months, range 7-38 months. No adverse events were reported in any of the 50 patients. 47/52 (90%) stated that they would refer a friend or close relative for the procedure. CONCLUSION US guided PNT for lateral elbow tendinosis is a safe and effective procedure that can be performed under local anesthesia on an outpatient basis. The results from this cohort of patients are comparable to the previous cohort that received corticosteroid injections. We therefore conclude that it is not necessary to perform subsequent corticosteroid injection after PNT. CLINICAL RELEVANCE/APPLICATION Please refer to conclusion.
Article
Achilles tendinopathy is a common overuse injury in athletes, especially older athletes. This condition is difficult to treat and often becomes chronic. This evidence based review summarized the current pathophysiological principles guiding research as well as clinical practice and synthesized the search results to determine if eccentric exercises were effective in the treatment of patients with Achilles tendinopathy. Seven studies were identified, but only two were randomized clinical trials (level A evidence) with the rest controlled clinical studies or prospective cohort studies (level B evidence). Only one study reported follow-up one year beyond the intervention period. Based on a crossectinal analysis of post treatment outcomes, there was modest but significant clinical benefits following eccentric exercise training, but insufficient evidence to predict the long-term effects of eccentric exercise training for the management of Achilles tendinopathy. Although randomized clinical trials with a large subject population are still needed, eccentric exercise paired with biomedical training techniques should be integrated into treatment guidelines for patients with Achilles tendonitis.
Article
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Introduction: Co-occurrence grey level matrix (GLCM) is a textural analysis method that have been useful to discriminate patterns, but no used on tendon ultrasound image. Objective: Textural analysis of patellar tendon ultrasonograph. Method: Longitudinal analytic study with 16 subjects (8 women and 8 men) young, healthy and sedentary people with training by means wholebody vibration platform (Fitvibe Medical) for 2 days x 14 weeks. Cross-sectional of patellar tendon ultrasonographics were taken with a Sonosite-180 ultrasonograph (L 5-10 MHz). By means GLCM algorithm of Image J v1.38 it were calculated five textural parameters: Uniformity (ASM), Contrast, Correlation, Homogeneity (IDM) and Entropy in four orientations (0o, 90o, 180o and 270o) and three distances between pixels (d=1, 5 and 10 pixels). Wilcoxon test (C.I. 95%) for related samples was applied (SPSS 15.0). Results: Entropy (d=5) was the most sensible to detect textural changes; perhaps ASM and Contrast can be also useful. It seems that distances between pairs of pixels that the algorithm uses affects the results. Conclusions: The use of GLCM in the textural analysis of tendon ultrasonography is innovating and it appears like a useful tool as much to evaluate the histological evolution of tendon tissue, like coming up and detecting future pathologies precociously. But more analyses will be necessary to study how different parameters affect texture and how they are related to each other and which can be the best adjustments of the algorithm to detect changes in textural patterns.
Article
Formerly known as ‘jumper’s knee’, patellar tendinopathy gives rise to considerable functional deficit and disability in recreational as well as professional athletes. It can interfere with their performance, often perseveres throughout the sporting career and may be the primary cause to end it. The diagnosis of patellar tendinopathy is primarily a clinical one but new imaging techniques, such as Doppler ultrasonography, may provide additional diagnostic value. Current therapeutic protocols are characterised by wide variability ensuing from anecdotal experience rather than evidence. Moreover, numerous reports in recent years have shattered previous doctrines and dogmatic belief on tendon overuse. Histopathological and biochemical evidence has indicated that the underlying pathology of tendinopathy is not an inflammatory tendinitis but a degenerative tendinosis. Consequently, pain in chronic patellar tendinopathy is not inflammatory in nature, but its exact origin remains unexplained. In pursuit of pathology- and evidence-based management, conservative therapy should be shifted from anti-inflammatory strategies towards a complete rehabilitation with eccentric tendon strengthening as a key element. If conservative management fails, surgery is opted for. However, considering the heterogeneity of surgical procedures and the absence of randomised studies, no conclusive evidence can be drawn from the literature regarding the effectiveness of surgical treatment for patellar tendinopathy. Parallel with the improved knowledge on the pathophysiology and pain mechanisms in patellar tendinopathy, new treatment strategies are expected to emerge in the near future.
Article
The changes associated with increasing age result in a decline in the structure and function of human tendons. Age correlates with decrease in the number of tenoblasts and overall tenoblastic activity. Structurally, collagen fibers increase in diameter, vary in thickness, lose tensile strength, and become tougher with increasing age and so the ultimate tensile strength of a human tendon declines. Age also affects tendon blood flow and the number of capillaries per unit of surface area.The most characteristic age-related microscopic and biochemical pathological changes are degeneration of the tenocytes and collagen fibers, and accumulation of lipids, ground substance (glycosaminoglycans), and calcium deposits. Careful control and treatment of nutritional deficits and altered hormone levels, whether due to disease or pharmacological intervention, may reduce the harmful aging effects on tendon tissue. Also, participation in a well-structured, long-term exercise program may minimize or retard the effects of aging on tendons.
Article
Tendon disorders are a major problem in sports and occupational medicine. Tendons have a high tensile strength thanks to a high proportion of collagen in their fibers and a closely packed parallel arrangement in the direction of force [1].The individual collagen fibrils are arranged into fascicles which contain blood vessels, nerve fibers and lymph. Specialized fibroblasts, tenocytes, lie within these fascicles, and exhibit high structural organization [2]. At histology, tenocytes appear as star shaped cells in cross sections. In longitudinal sections, they are arranged in rows following the direction of the tendon fibers. This specialized arrangement is related to their function, as tenocytes synthesize both fibrillar and nonfibrillar components of the extracellular matrix, and are able to reabsorb collagen fibrils [3]. The fascicles themselves are enclosed by epitenon, which is surrounded by the paratenon, and the potential space between them is filled by a thin, lubricating film of fluid which allows gliding of the tendon during motion.
Thesis
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Tendinopathien der Achilles- oder Patellarsehne sind häufig in Sportarten mit zahlreichen repetitiven Belastungen im Dehnungs-Verkürzungs-Zyklus der unteren Extremität zu finden. Sowohl eine möglicherweise alterierte belastungsspezifische neuromuskuläre Antwort (NMA), als auch funktional begründete Therapiemaßnahmen mit möglichen positiven Effekten sind aktuell ungeklärt. Ziel der Arbeit war deshalb die Untersuchung der belastungsspezifischen neuromuskulären Antwort bei Athleten mit Tendinopathie der Achilles- oder Patellarsehne im Vergleich zu beschwerdefreien Athleten. Zusätzlich sollten mögliche funktionale und therapeutische Effekte eines sensomotorischen Trainings im randomisierten, kontrollierten und prospektiven Studiendesign überprüft werden. 51 Sportler mit unilateraler Tendinopathie (Achilles-/Patellarsehne n = 35/16) und 33 gesunde Sportler wurden zur Beurteilung der belastungsspezifischen neuromuskulären Antwort eingeschlossen. Zur Klärung der Effekte eines sensomotorischen Trainings im Längsschnitt konnten 26 Sportler mit Tendinopathie randomisiert zu einer Kontrollgruppe (n = 14) und einer Therapiegruppe mit sensomotorischem Training (n = 12) zugeordnet werden. Nach einer ersten biomechanischen Messung M1 (Belastungssituationen: Lauf-, Stabilisations-, Kraftbelastung) und der Erhebung der subjektiven Schmerzsymptomatik folgte eine 8-wöchige Therapiephase mit einer abschließenden Re-Test-Messung M2 identisch zu M1. Das sensomotorische Training war auf die gesamte untere Extremität ausgerichtet und wurde nach Einweisung regelmäßig kontrolliert. Die Erfassung der NMA erfolgte über die Quantifizierung der muskulären Aktivität (EMG). Zusätzlich wurde die Kinetik (z.B. Maximalkraft) belastungsspezifisch erfasst. Eine reduzierte NMA konnte für die Sportler mit Tendinopathie über veränderte EMG-Zeit- und Amplitudenmessgrößen, eine reduzierte aktive Stabilisationsfähigkeit und Maximalkraft (p < 0,05) nachgewiesen werden. In Abhängigkeit der Lokalisation (Achilles-/Patellarsehen) bzw. der Seite (Beschwerdeseite/gesunde Seite) ergaben sich keine relevanten Differenzen. Das sensomotorische Training zeigte eine Optimierung der NMA (z.B. erhöhte Maximalkraft) bei Tendinopathie der Achilles- oder Patellarsehne. Die Überprüfung der Beschwerdesymptomatik wies in allen Schmerz-Scores nach der Therapie reduzierte Werte und damit einen positiven therapeutischen Effekt gegenüber der Kontrollgruppe auf. Zusammenfassend kann eine systematisch reduzierte NMA bei Lauf-, Stabilisations- und Kraftbelastung der Sportler mit Tendinopathie nachgewiesen werden. Das sensomotorische Training ist funktional und therapeutisch als effiziente Therapiemaßnahme zu erachten.
Chapter
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IntroductionWhat do we know?Future directionsSummaryConclusions
Article
Many treatments have been proposed for tendinopathies but not always with proof of efficacy. Basically, the underlying problem is tendon overload leading to destruction and disorganization of the collagen fibers composing the tendon. Damage can thus take several weeks for repair. Proposed solutions include: rest, cold, ultrasound, laser, deep transversal massage, shock waves, stretching, excentric work, and many more. We reviewed the pertinent literature in order to determine whether all the effects attributed to these different techniques are based on scientific evidence. For certain techniques, we noted an obvious lack of serious studies. We were thus able to draw up a list of techniques with demonstrated efficacy which can be proposed for evidence-based treatment of tendinopathies: rest, cold, stretching, excentric work. If the results obtained with these methods is disappointing, shock wave treatment may be appropriate. For us, our profession must strive for more widespread use of evidence-based physical therapy.
Article
Achilles tendon complaints are a common problem in sportsmen and women. Not infrequently they become chronic. This article deals with the physiotherapeutic treatment of chronic Achilles tendon complaints based on eccentric muscle training. The systematic literature review found positive evidence of the training's effectiveness and gives an indication of treatment strategy and intensity.
Article
The clinical features, pathology, and differential diagnosis of central degeneration of the Achilles tendon are described and the aetiology discussed. Attention is drawn to the important anatomical and physiological factors involved. The results of surgical treatment of five cases of this condition are presented.
Article
Patellar tendinitis, or "jumper's knee," is a repetitive overload lesion that occurs most commonly in athletes whose sport involves eccentric loading of the patellar tendon. The prevalence of this disease is rising because of increased participation in sports, but our understanding of the underlying pathophysiology remains incomplete. The lesion shows microtears of the tendinous tissue, devitalization, and areas of focal degeneration commonly found near the bone-tendon insertion point. Though tendon imaging staging has now been proposed, staging and treatment regimens have been based solely on subjective clinical data. Therapy ranges from rest to surgical intervention. Because few controlled studies have been undertaken to examine the effectiveness of different treatments, management of the disease varies depending on the physician. Effective prevention and therapy for the future require quantitative studies of the pathophysiology of this disease. (C) Lippincott-Raven Publishers.
Article
The patellar tendon donor site of 20 patients who underwent anterior cruciate ligament (ACL) reconstruction using the patellar tendon tissue as autograft was examined with high resolution 7.5 MHz ultrasound. The patients were randomly divided into four groups and studied at 3, 6, 9 or 12 months postoperatively. The size of the postoperative tendon defect was measured just distal to the lower pole of the patella. The size of the tendon defect diminished progressively from a mean of 109 mm2 at 3 months to a mean of 23 mm2 at 12 months. Increasing echogenicity was first noticed 12 months after tendon repair. Seven patients developed clinical features postoperatively of jumper's knee (patellar tendinosis). There were no ultrasound signs that differentiated these patients from asymptomatic patients. It is concluded that ultrasound provides objective evidence of patellar tendon healing after ACL reconstruction: the surgical defect diminished in size and became echogenic after a period of 12 months.
Article
Fifty-four patients with a total of 58 partial ruptures of the Achilles tendon were treated surgically. The postoperative observation time ranged from 8 months to 7 years. Forty-six patients indicated that they were pleased with the results, 8 were satisfied, and 3 were unsatisfied (one died during the interim). Thirty-seven of the 44 patients who had been engaged in competitive sports preoperatively were able to return successfully to the activity. We recommend surgical treatment if conservative treatment for presumed tendinitis is not successful. The operative procedure may encourage revascularization to the Achilles tendon and innervation after surgical excision of the pathologic and degenerated tissue.
Article
Ultrasonography (US) was compared with soft-tissue radiography (STR) and computed tomography (CT) for demonstration of partial Achilles tendon ruptures. Thirty-nine patients suffering from chronic localized painful Achilles tendon swelling were examined. The patients had all undergone a previous clinical examination, resulting in a suspicion of a non-healed partial tear in 62 out of the 78 tendons. STR showed unspecific tendon pathology such as thickening and diffuse tendon margins. CT resulted in a better delineation of intra- as well as extratendinous abnormalities compared to STR. Various pathologic changes were seen on CT in 54 tendons and in 29 of these, localized intratendinous hypodensities indicated partial ruptures. At US, abnormal changes were observed in 69 tendons, of which 54 had discontinuity of tendon fibers, focal hypoechoic areas, and localized swelling indicating partial ruptures. In 9 cases with surgically proven partial ruptures, US was correct in all cases, while CT was false-negative in 3. STR only showed localized swelling. It was concluded that US was a better method than STR and CT for the detection of partial ruptures and the US findings correlated well with the surgical findings.
Article
Three patients with the signs and symptoms of patellar tendonitis were studied with technetium-99m utilizing the triple phase technique. The scans demonstrated characteristic abnormal radiotracer localization at the inferior pole of the patella or tibial tuberosity on early and delayed images. The regional patellar anatomy likely explains the bone scintigraphic findings in patellar tendonitis.
Article
The sensory-nerve-ending system of 40 myotendinous junctions of human palmaris longus and plantaris muscles was studied histologically. All the known four types of nerve endings were identified. The Ruffini corpuscles could be found in equally small numbers (one to five) in both the muscular and tendineal sites of the junction. Also the free nerve endings were distributed equally on both sites. The Pacini corpuscles were frequent in the tendineal site (six to 14), but rare in the muscular site (one to three). The Golgi tendon organs were, in turn, frequent in the muscular site (nine to 12) but rare in the tendineal site (one to four), respectively. Within the muscle and tendon parts of the junction, the distance between two mechanoreceptors was always more than 250 microns and the receptor distribution was homogeneous. Further studies are needed to give functional explanation for these anatomic findings.
Article
Tennis elbow is one of the most common lesions of the arm. The first description is attributed to Runge in 1873 but the name derives from 'Lawn Tennis Arm' described by Morris in 1882. The majority of cases are believed to be caused by a musculo-tendinous lesion of the common extensor origin at or near the attachment to the lateral epicondyle. While there are some comprehensive reports in the literature of patients treated by one technique or another, there are no comprehensive reports of groups of patients for whom various techniques were employed in a logical sequence until a resolution was reached. This paper presents a retrospective analysis of case notes and an analysis of questionnaires completed by the patients. In this study we found that 67% of patients who presented with tennis elbow received relief through steroid injections either alone or in combination with a tennis elbow band or nonsteroidal anti-inflammatory drugs. The use of either a tennis elbow band or non-steroidal anti-inflammatory drugs or injected steroids made no statistical difference to the outcome. We also found that the patients who did not respond adequately to conservative measures were relieved of their symptoms by surgery.