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Management of tendinopathy. Am J Sports Med



Overuse disorders of tendons, or tendinopathies, present a challenge to sports physicians, surgeons, and other health care professionals dealing with athletes. The Achilles, patellar, and supraspinatus tendons are particularly vulnerable to injury and often difficult to manage successfully. Inflammation was believed central to the pathologic process, but histopathologic evidence has confirmed the failed healing response nature of these conditions. Excessive or inappropriate loading of the musculotendinous unit is believed to be central to the disease process, although the exact mechanism by which this occurs remains uncertain. Additionally, the location of the lesion (for example, the midtendon or osteotendinous junction) has become increasingly recognized as influencing both the pathologic process and subsequent management. The mechanical, vascular, neural, and other theories that seek to explain the pathologic process are explored in this article. Recent developments in the nonoperative management of chronic tendon disorders are reviewed, as is the rationale for surgical intervention. Recent surgical advances, including minimally invasive tendon surgery, are reviewed. Potential future management strategies, such as stem cell therapy, growth factor treatment, and gene transfer, are also discussed.
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2010;92:2604-2613. doi:10.2106/JBJS.I.01744 J Bone Joint Surg Am.
Nicola Maffulli, Umile Giuseppe Longo and Vincenzo Denaro
Novel Approaches for the Management of Tendinopathy
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The Journal of Bone and Joint Surgery
Current Concepts Review
Novel Approaches for the Management
of Tendinopathy
By Nicola Maffulli, MD, MS, PhD, FRCS(Orth), Umile Giuseppe Longo, MD, and Vincenzo Denaro, MD
Investigation performed at the Centre for Sports and Exercise Medicine, Queen Mary University of London, London,
England; and Campus Biomedico University, Rome, Italy
äTendinopathy is a failed healing response of the tendon.
äDespite an abundance of therapeutic options, very few randomized prospective, placebo-controlled trials have
been carried out to assist physicians in choosing the best evidence-based management.
äEccentric exercises have been proposed to promote collagen fiber cross-link formation within the tendon, thereby
facilitating tendon remodeling. Overall results suggest a trend for a positive effect of eccentric exercises, with no
reported adverse effects. Combining eccentric training and shock wave therapy produces higher success rates
compared with eccentric loading alone or shock wave therapy alone.
äThe use of injectable substances such as platelet-rich plasma, autologous blood, polidocanol, corticosteroids,
and aprotinin in and around tendons is popular, but there is minimal clinical evidence to support their use.
äThe aim of operative treatment is to excise fibrotic adhesions, remove areas of failed healing, and make multiple
longitudinal incisions in the tendon to detect intratendinous lesions and to restore vascularity and possibly
stimulate the remaining viable cells to initiate cell matrix response and healing.
äNew operative procedures include endoscopy, electrocoagulation, and minimally invasive stripping. The aim of
these techniques is to disrupt the abnormal neoinnervation to interfere with the pain sensation caused by ten-
äRandomized controlled trials are necessary to better clarify the best therapeutic options for the management of
Evolving Concepts in Tendinopathy: New Theories
Tendinopathies account for a substantial proportion of overuse
injuries associated with sports
and are a common cause of
. Most major tendons, such as the Achilles, patellar,
rotator cuff, and forearm extensor tendons (among others), are
vulnerable to overuse, which induces pathological changes in
the tendon
The term ‘‘tendinopathy’’ is a generic descriptor of the
clinical conditions (both pain and pathological characteristics)
associated with overuse in and around tendons
. The histo-
logical descriptive terms ‘‘tendinosis’’ (a degenerative patho-
logical condition with a lack of inflammatory change) and
‘‘tendonitis’’ or ‘‘tendinitis’’ (implying an inflammatory pro-
cess) should be used only after histopathological confirmation
However, it should be kept in mind that, despite the use of the
term ‘‘tendinosis,’ at histopathological examination the essence
of a tendinopathic lesion is a failed healing response, with
haphazard proliferation of tenocytes, intracellular abnormali-
ties in tenocytes, disruption of collagen fibers, and a subsequent
increase in noncollagenous matrix
. Tendinopathic tendons
Disclosure: The authors did not receive any outside funding or grants in support of thei r research for or preparation of this work. Neither they nor a member
of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.
J Bone Joint Surg Am. 2010;92:2604-13 ddoi:10.2106/JBJS.I.01744
have an increased rate of matrix remodeling, leading to a me-
chanically less stable tendon that is probably more susceptible
to damage
. Histological studies of surgical specimens from
patients with established tendinopathy consistently show either
absent or minimal inflammation
. They generally also show
hypercellularity, a loss of the tightly bundled collagen fiber
appearance, an increase in proteoglycan content, and com-
monly neovascularization
. Inflammation seems to play a
role only in the initiation, but not in the propagation and
progression, of the disease process
. Competing theories have
been proposed to explain the pathogenesis of tendinopathy at
specific stages and presentations of the condition
. A con-
tinuum of tendon pathology from asymptomatic tendons to
tendon tears has been proposed
Failed healing and tendinopathic features have been as-
sociated with chronic overload, but the same histopathological
characteristics also have been described when a tendon is un-
loaded: stress shielding seems to exert a deleterious effect
Unloading a tendon induces cell and matrix changes similar to
those seen in an overloaded state and decreases the mechanical
integrity of the tendon
Despite an abundance of therapeutic options, very few
randomized prospective, placebo-controlled trials have been
conducted to assist physicians in choosing the best evidence-
based management
. Treatments that have been investigated
with use of a randomized controlled trial design include
nonsteroidal anti-inflammatory medications
, eccentric ex-
, glyceryl trinitrate patches
, sclerosing injections
aprotinin injections
, and shock wave treat-
. What may appear clinically as an acute tendinopathy
is actually a well-advanced failure of a chronic healing response
in which there is neither histological nor biochemical evidence
of inflammation
. The available literature suggests that, in the
absence of an overt inflammatory process, there is no rational
basis for the use of nonsteroidal anti-inflammatory drugs in
chronic tendinopathy
In this Current Concepts Review, we report the best
available evidence for the management of tendinopathy and
provide a comprehensive and up-to-date review of the devel-
opment of future modalities for treatment.
Nonoperative Management Options
Eccentric Exercises
Eccentric exercises have been proposed to promote collagen
fiber cross-link formation within the tendon, thereby facili-
tating tendon remodeling (see Appendix)
. Evidence of his-
tological changes following a program of eccentric exercise is
lacking, and the mechanisms by which eccentric exercises may
help to relieve the pain of tendinopathy remain unclear.
Eccentric exercises have been proposed to counteract the
failed healing response that underlies tendinopathy by pro-
moting collagen fiber cross-linkage within the tendon, thereby
facilitating tendon remodeling
. The concept of eccentric ex-
ercises is based on the structural adaptation of the musculo-
tendinous units to protect them from increased stresses and
thus prevent reinjury.
The basic principles in an eccentric loading regimen are
unknown, although it has been speculated that forces generated
during eccentric loading are of a greater magnitude than those
in concentric exercises
. It is possible that eccentric exercises
do not just exert a beneficial mechanical effect, but also act
on pain mediators, decreasing their presence in tendinopathic
tendons. Although microdialysis has shown raised intra-
tendinous glutamate levels
and substance P and neurokinin-1
to be significantly higher in Achilles tendons with
painful tendinopathy than in normal, pain-free tendons, and
treatment with eccentric training has shown good clinical re-
sults with diminished tendon pain during activity, in vivo
results have shown that successful treatment with eccentric
training is not associated with lowered intratendinous gluta-
mate levels
. Also, as the exercise regimen is supposed to
produce pain and if the patient does not experience pain load is
added to produce pain during the exercise, it is possible that
progressive habituation to painful stimuli occurs
. Color
Doppler sonography demonstrated decreased neovasculariza-
tion following eccentric training intervention
Excellent clinical results have been reported both in
athletic and sedentary patients
, although these results were
not reproduced by other study groups
. In general, the
overall trend suggests a positive effect of eccentric exercises,
with no reported adverse effects
. In one study, the combina-
tion of eccentric training and shock wave therapy produced
success rates that were higher than those with eccentric loading
alone or shock wave therapy alone
Extracorporeal Shock Wave Therapy
Extracorporeal shock wave therapy to address the failed healing
response of a tendon is becoming more widely used among the
medical community (see Appendix)
. Typical characteristics
are high peak-pressure amplitudes (500 bar) with rise times of
<10 ns, a short life cycle (10 ms), and a frequency spectrum (16
to 20 MHz) ranging from the audible to the far ultrasonic
. This rapid rise is followed by periods of pressure dis-
sipation and negative pressure before a gradual return to the
ambient pressure. The shock wave entering the tissue may be
reflected or dissipated, depending on the properties of the
tissue. The energy of the shock wave may act through me-
chanical forces generated directly or indirectly via cavitation
The rationale for the clinical use of extracorporeal shock wave
therapy is stimulation of soft-tissue healing and inhibition of
pain receptors.
There is no consensus on the use of repetitive low-energy
extracorporeal shock wave therapy, which does not require
local anesthesia, versus the use of high-energy extracorporeal
shock wave therapy, which requires local or regional anesthe-
. In several well-conducted randomized controlled trials,
low-energy extracorporeal shock wave therapy was adminis-
tered once a week for three or four consecutive weeks, with
final assessment undertaken twelve weeks after the last shock
wave therapy session
. At the time of a four-month follow-
up, eccentric loading and low-energy shock wave therapy
showed comparable results
, whereas eccentric loading alone
was less effective than the combination of eccentric loading and
repetitive low-energy shock wave treatment
When used, high-energy extracorporeal shock wave
therapy is administered only one time.
Low-energy shock wave therapy has been proposed for
tendinopathy to stimulate soft-tissue healing and inhibit pain
. Low-energy shock wave therapy or eccentric
training for the management of Achilles tendinopathy pro-
duced comparable results in a randomized controlled trial
and both management modalities showed outcomes superior
to those of no intervention
. However, the results of low-energy
shock wave therapy were disappointing in another study
Use of Injectable Substances
A wide variety of substances have been injected and are rou-
tinely injected in and around tendons.
High-Volume Injections: Normal Saline Solution, Corticosteroids,
and Anesthetics
Neovascularization is a characteristic feature of Achilles and
patellar tendinopathy; it is generally accompanied by nerve
ingrowth and normally is not present in patients without ten-
don pathology
. The ingrowth of new blood vessels and as-
sociated nerves from the peritendinous tissues may be a source
of pain
. Histopathological studies showed immunoreactions
for neurokinin-1 receptor and alpha-1-adrenoreceptor in bi-
opsy specimens from the ventral area of tendinopathic Achil-
and patellar
tendons as well as elevated levels of the
neurotransmitter glutamate and the presence of its receptor,
N-methyl-d-aspartate receptor type 1
The hypothesized rationale behind this management mo-
dality was that high-volume injections of normal saline solution,
corticosteroids, or anesthetics would produce local mechanical
effects causing new blood vessels to stretch, break, or occlude.
Occluding and possibly breaking these vessels would lead to the
accompanying nerve supply also being damaged by either trauma
or ischemia, therefore decreasing the pain in patients with resis-
tant Achilles tendinopathy.
Preliminary studies showed that high-volume injectio n of
normal saline solution, corticosteroids, or anesthetics reduces
pain and improves short and long-term function in patients
with Achilles
or patellar
tendinopathy, regardless of their
symptoms (see Appendix). High-volume injection is safe and
relatively inexpensive, with the potential to offer an alternative
to operative treatment, resulting in a quicker return to sports
Hydrocortisone acetate is used in the high-volume in-
jections, primarily to prevent an acute mechanical inflamma-
tory reaction produced by the large amount of fluid injected in
the proximity of the tendon. The injection is performed under
ultrasound guidance, so that corticosteroids have no direct
action on the tendon itself. The role of corticosteroids in the
management of tendinopathy is still debated. Meta-analysis of
the effects of corticosteroids has shown that published data are
insufficient to determine the risk of rupture following cortico-
steroid injections
, and we do not advocate their intraten-
dinous injection
Platelet-Rich Plasma
Platelet-rich plasma is a bioactive component of whole blood,
which is now being widely tested in different fields of medicine
for its possibilities in aiding the regeneration of tissue with poor
healing potential
The use of platelet-rich plasma to help wound-healing
has been proposed since the early 1980s
. Its use in orthopaedic
surgery, especially for augmentation of bone-grafting, began
during the present decade, although to date there is no defin-
itive evidence that it improves bone healing
. The use of
platelet-rich plasma to improve tendon healing has been ad-
vocated only recently
. In general, the concentration of
platelets in platelet-rich plasma is higher than that in blood
Dense granules may play a role in tissue modulation and
regeneration by releasing their content of adenosine, serotonin,
histamine, and calcium. The alpha granules release transforming
growth factor-b, platelet-derived growth factor, and vascular
endothelial growth factor, with concentrations increasing line-
arly with increasing platelet concentration. The released cyto-
kines bind to transmembrane receptors on the surface of local
or circulating cells and induce intracellular signaling. This may
result in the production of proteins responsible for cellular che-
motaxis, matrix synthesis, and proliferation
Tendon healing occurs through three overlapping phases
(inflammation, proliferation, and remodeling), which are
controlled by a variety of growth factors
. The rationale for
the use of platelet-rich plasma to promote tendon healing is the
high content of these cytokines and cells in hyperphysiologic
doses of platelet-rich plasma. Several studies on the application
of platelet-rich plasma to promote tendon healing are ongoing
worldwide, although the exact mechanisms by which platelet-
rich plasma promotes tendon healing are still not clear (see
Appendix). One of the main advantages is that platelet-rich
plasma is autologous and is prepared at the time of treatment
(point of care) and therefore has an excellent safety profile. De
Vos e t a l.
performed a stratified, block-randomized, double-
blind, placebo-controlled trial of fifty-four patients with Achilles
tendinopathy treated, at a single center, with exercises (usual
care) as well as injection of either platelet-rich plasma or saline
solution (the placebo group). The authors concluded that,
compared with the saline-solution injection, the platelet-rich-
plasma injection did not result in greater pain relief or im-
provement in activity.
Autologous Blood Injection
An injection of autologous blood for the management of ten-
dinopathy has been reported
. The aim of this treatment is to
provide cellular and humoral mediators to induce healing in
areas where the healing response has failed (see Appendix). The
use of autologous blood injection is thought to lead to tendon
healing through collagen regeneration and the stimulation of a
well-ordered angiogenic response
. It has been hypothesized
that transforming growth factor-band basic fibroblast growth
factor carried in the blood will act as humoral mediators to
induce the healing cascade
. Although the results of labora-
tory studies are encouraging, such studies have always involved
healthy tendons or surgically induced lesions, given the lack of
a good experimental model for tendinopathy. At present, it is
unclear whether these results can be extrapolated to tendino-
pathic tendons
. So-called needling of the tendon has been
described in conjunction with the use of autologous blood.
However, it could be difficult to distinguish between the effect
of needling and the effect of autologous blood injection
In patients with chronic painful Achilles tendinopathy, there is
neovascularization outside and inside the ventral part of the
tendinopathic area
. Local anesthetic injected in the area of
neovascularization outside the tendon may result in a pain-free
tendon, indicating that this area is involved in pain generation.
These are the bases for the injection of the sclerosing substance
polidocanol (Aetoxisclerol; Kreussler Pharma, Wiesbaden,
Germany) under ultrasonography and color Doppler guidance
in the area with neovessels outside the tendon
Injections with polidocanol in a randomized controlled
trial showed the potential to reduce tendon pain during activity
in patients with chronic painful midportion Achilles tendino-
pathy (see Appendix)
In Achilles and patellar tendinopathy, there is evidence of
neural ingrowth in conjunction with neovascularization. In-
jections of polidocanol close to the tendon seem to be re-
markably safe.
Of 150 patients in whom Achilles tendinopathy had been
managed with polidocanol, two experienced a complication
One patient who had insertional Achilles tendinopathy sus-
tained a total rupture in the proximal part of the tendon at the
end of an 800-m running race, and the other patient sustained
a partial rupture in the midportion of the tendon, where he
previously had received four intratendinous corticosteroid
Intratendinous Injections of Corticosteroids
The use of corticosteroid injections ishighly controversial
There is a lack of good-quality research data to support the
widespread use of these drugs. There are numerous case reports
of tendon rupture after corticosteroid injections in patients
Animal studies have suggested that local corticosteroid injections
may lead to a reduction in tendon strength
, but this finding is
not universal
At present, there is insufficient evidence from which to
draw firm conclusions on the utility of local corticosteroid
treatments for Achilles tendinopathy (see Appendix). Three
randomized controlled trials
showed different results in
terms of the effects of local corticosteroids on healing, with two
studies demonstrating some benefit
and the other showing
. A meta-analysis of the effects of corticosteroid injections
showed little benefit
. The safety of corticosteroid injections can
be enhanced with the use of ultrasound imaging needle guid-
ance. With the high-volume-injection technique, the needle is
kept extratendinous and outside the peritendinous space
that the fluid is injected only in the Kager triangle (for the
Achilles tendon) or in the Hoffa body (for the patellar tendon).
Operative Treatment
The objectives of operative treatment are to excise fibrotic ad-
hesions, remove or debride areas of failed healing, restore vas-
cularity, and possibly stimulate viable cells to initiate protein
synthesis and to promote healing
. Recent studies have shown
that multiple longitudinal tenotomies trigger neoangiogenesis in
the Achilles tendon, with increased blood flow
. This would
result in improved nutrition and a more favorable environment
for healing.
Multiple percutaneous longitudinal tenotomies can be
performed when conservative management has failed in patients
who have isolated tendinopathy with no involvement of the
paratenon and a well-defined nodular lesion <2.5 cm long
This procedure may be ultrasound guided to confirm the precise
location of the area of tendinopathy
. It is a simple procedure
and can be performed in an ambulatory setting with the use of
local anesthesia and without a tourniquet.
Percutaneous longitudinal ultrasound-guided internal
tenotomy of the Achilles tendon can be also performed on an
outpatient basis. However, it requires the use of high-resolution
ultrasound to properly locate the tendinopathic area and to
place the initial stab incision
. Complications (with wound-
healing) are minimal and lead to no long-term morbidity. The
technique is not as effective in patients with pantendinopathy.
Radiofrequency Microtenotomy
Radiofrequency microtenotomy is a safe and effective proce-
dure for managing patients with chronic tendinopathy (see
Appendix). It is a technically simple procedure to perform and
has been proposed to produce a rapid and uncomplicated re-
. It is hypothesized that the mechanism of action
may be to induce acute degeneration and/or ablation of sensory
nerve fibers. Early degeneration followed by later regeneration
of nerve fibers after bipolar radiofrequency treatment may
explain long-term postoperative pain relief
Neovessel Destruction
Pathological nerve ingrowth accompanies pathological neo-
vascularization in the tendinopathic tendon, and it has been
considered as a possible cause of the pain. Some authors have
attempted to disrupt the abnormal neoinnervation to interfere
with the pain sensation caused by tendinopathy. Endoscopy
, and minimally invasive stripping
been proposed to achieve this aim. Endoscopy allows direct
visualization of the area of tendinopathy and allows use of a
motorized shaver or diathermy to destroy neovessels.
Endoscopy-Assisted Treatment
Tendoscopy may allow endoscopic access to several tendons,
including the posterior tibial tendon
, the peroneal ten-
and the Achilles tendon
(see Appendix).
This operative technique provides access to the posterior aspect
of the ankle and subtalar joints. Also, extra-articular structures
of the hindfoot such as the os trigonum, the flexor hallucis
longus, and the deep portion of the deltoid ligament can be
Thermann et al.
described a different technique of
endoscopic debridement of the ventral neovascularized area,
the peritenon, and the Achilles tendon and reported good
short-term clinical results in eight patients.
Best Modalities for Management of Tendinopathy
In general, it would be reasonable to treat a patient with ten-
dinopathy with physical therapy involving a program of eccen-
tric exercises, to be performed for twelve weeks. If the condition
does not respond to this intervention, shock wave therapy or a
nitric oxide patch might be considered, although data on their
efficacy are limited. If the condition does not respond to those
interventions, injections could be considered. The use of oper-
ative treatment should be discussed with the patient after at least
three to six months of nonoperative management. Moreover,
patients should understand that symptoms may recur with ei-
ther conservative or operative approaches.
The Future and Conclusions
In the last few decades, biomaterials have become critical
components in the development of effective new medical
therapies for wound care
. Many new tissue-engineered
materials have been introduced, including artificial polymers,
biodegradable films, and biomaterials derived from animal or
human tissues
Biological scaffolds are protein-based extracellular matri-
ces, usually derived from human or animal connective tissues
Advantages of biological scaffolds include a well-defined three-
dimensional microstructure (allowing host cell integration) and
natural porosity (which provides a much larger space for host
cell attachment, proliferation, and migration and assists gas and
metabolite diffusion). These proprieties allow biological scaf-
folds to quickly interact with host tissue and induce new tissue
formation faster than synthetic scaffolds. Limitations of bio-
logical scaffolds are their poor mechanical properties, undefined
rate of degradation, variation in biocompatibility, propensity to
induce an inflammatory response, and potential for implant
On the other hand, synthetic scaffolds are manufactured
from chemical compounds
, which permit better control of
the chemical and physical properties, leading to stronger me-
chanical strength and consistency in quality. However, the
biocompatibility of synthetic scaffolds is very poor, as they can
never be absorbed or integrated into host tissue. High inci-
dences of postoperative infection, and chronic immune re-
sponses, have been reported with the use of such materials
A genetic component has been implicated in tendino-
pathies, but investigations into the genetic factors involved in
their etiology are still in their infancy
. An enhanced un-
derstanding of these factors holds the promise of new ap-
proaches to the prevention and management of these common
conditions. Additional randomized controlled trials are nec-
essary to better clarify the best therapeutic options for the
management of tendinopathy.
Tables summarizing the studies on the various treatments
of tendinopathy are available with the electronic version
of this article on our web site at (go to the article
citation and click on ‘‘Supporting Data’’). n
Nicola Maffulli, MD, MS, PhD, FRCS(Orth)
Centre for Sports and Exercise Medicine,
Queen Mary University of London,
Barts and The London School of Medicine and Dentistry,
Mile End Hospital,
275 Bancroft Road,
London E1 4DG,
E-mail address:
Umile Giuseppe Longo, MD
Vincenzo Denaro, MD
Department of Orthopaedic and Trauma Surgery,
Campus Biomedico University,
Via Alvaro del Portillo,
200, 00128 Rome, Italy.
E-mail address for U.G. Longo:
E-mail address for V. Denaro:
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... 26,27 Discussion Therapeutic exercises and non-steroidal anti-inflammatory drugs represent the first-line treatment of CST. 28,29 However, if CST becomes chronic ESWT (including radial, low-energy/high-energy focused ESWT), ultrasoundguided needling, TENS, and T-US are considered in the treatment. 30 In a systematic literature review and metaanalysis on the efficacy of conservative treatment of for ESWT, such as severe coagulopathy, and side effects of high-energy-focused ESWT like hematoma, or as in patients with a reduced pain threshold. ...
... 26,27 Nevertheless, both therapeutic exercises combined with T-US, as well as therapeutic exercises alone increase shoulder ROM and therefore are rightly considered the basis of chronic cst therapy. 24,29 As far as we know, our study is the first in which hand grip strength was analyzed in patients with chronic CST after US therapy. Our findings showed a significant difference in hand grip strength improvement in the treatment group after the therapy, as shown in Table VI. ...
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Background: Calcific shoulder tendinitis (CST) is characterized by hydroxyapatite crystals deposition in the rotator cuff tendons. Therapeutic exercises have been the mainstay of CST treatment, and evidence for therapeutic ultrasound (T-US) utilization and efficacy is lacking. Aim: This study aimed to determine whether 4500 J T-US combined with therapeutic exercises is superior to therapeutic exercises alone regarding calcification size reduction and symptom improvement in chronic symptomatic CST. Design: This is a double-blind, placebo-controlled study. Setting: This study was conducted at a University Department for Rheumatic Diseases and Rehabilitation of a University Hospital. Population: Patients with chronic CST were analyzed. Methods: After eligibility allocation, 46 patients with sonographically confirmed CST were divided into two groups (56 shoulders, 26 per group). Both groups performed the same therapeutic exercises for half an hour under physiotherapist supervision. In the treatment group T-US (4500 J, 10 minutes per session at a frequency of 1 MHz and an intensity of 1.5 W/cm2), and in the placebo group, sham T-US was applied for 4 weeks. Patients were assessed for: calcification size, shoulder pain, global health (GH), shoulder mobility (ROM), handgrip strength, Health Assessment Questionnaire Disability Index (HAQ-DI), Shoulder Pain and Disability Index (SPADI), and overall rehabilitation satisfaction. Results: All assessed variables improved in both groups. A significantly greater reduction in calcification size was recorded in the treatment group compared to placebo: -10.92% (IQR 4.61% to 19.38%) versus -5.04% (2.30% to 7.22%), P=0.008. There was a significantly greater decrease in HAQ-DI, reduction of VAS GH, and an increase in hand grip strength in the treatment group, while no significant differences were observed for other parameters between the groups. Conclusions: Our results showed that adding the 4500 J T-US to therapeutic exercises in chronic symptomatic CST therapy resulted in greater calcification size reduction immediately following the treatment, as well as hand grip strength, HAQ-DI, and VAS GH improvement. Clinical rehabilitation impact: 4500 J T-US combined with therapeutic exercises is more effective in reducing calcification size than therapeutic exercises alone in the treatment of chronic symptomatic CST.
... Although dogs with mineralized supraspinatus tendinopathy had higher body weight, no other differences were identified among groups, suggesting that mineralized and nonmineralized supraspinatus tendinopathy are similar entities [7]. Medical treatment includes the restriction of physical activity, anti-inflammatory medication, physiotherapy and rehabilitation, ultrasound therapy, extracorporeal shock wave therapy and regenerative medicine, especially a combination of mesenchymal stem cells (MSCs) and platelet rich plasma (PRP) [10][11][12][13][14][15]. Surgical treatment is recommended when conservative treatment fails and consists of removal of the mineralized foci, longitudinal incisions or splitting of the tendon of insertion of the supraspinatus muscle, and decompression of the biceps tendon, which is frequently impinged by the enlarged supraspinatus tendon [4,[16][17][18]. ...
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(1) Background: two forms of supraspinatus tendinopathy (ST) have been reported in dogs: mineralized and non-mineralized. Surgical treatment consists of longitudinal incisions (splitting) in the tendon of insertion of the supraspinatus muscle. The purpose of this retrospective study is to describe the diagnostic workout, the surgical procedure and the short and long term follow up of dogs treated for non-mineralized ST. (2) Methods: medical records (2010–2017) of dogs diagnosed with non-mineralized ST that underwent surgical treatment were reviewed. Data retrieved were: signalment, history, clinical signs, orthopaedic examination findings, diagnostic imaging findings, surgical treatment, histopathologic diagnosis and clinical outcome. (3) Results: A total of 27 dogs met the inclusion criteria. The most consistent clinical findings were intermittent lameness accompanied by pain on palpation of the insertion of the supraspinatus. Magnetic resonance imaging (MRI) of 27 shoulders distended sheaths of the biceps tendon (10/27), compression of the biceps brachii tendon sheaths (5/27) and enlargement of the supraspinatus tendon (3/27) were observed. The most prominent histologic finding was severe myxomatous degeneration in all 27 samples. Resolution of lameness was achieved in 80% of the cases surgically treated without any further lameness episodes in the long-term follow-up. (4) Conclusions: the surgical splitting of the non-mineralized supraspinatus tendon is an effective procedure with no intra-operative complications and a low incidence of minor (18%) and major (4%) complications.
... Platelets and growth factors are integral to the normal wound healing process [7] . Studies suggest that a platelet-rich plasma (PRP), can be used to treat chronic injuries [8] . PRP is thought to improve healing in chronic degenerative tendon injuries [9] . ...
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Introduction: De Quervains disease is a chronic inflammation of tendons of abductor pollicis longus (APL) and the extensor pollicis brevis (EPB) as they pass through 1 st dorsal extensor compartment of wrist. Aim of the study is to compare the functional outcome between PRP (Platelet rich plasma) vs Steroid injections in the management of this pathology. Methods: This was a prospective study of 30 patients with de quervains tenosynovitis and study conducted between September 2021 to November 2021 for a period of 3 months follow up done. The present study included 30 patients of both sexes, different age groups associated with co-morbidities divided into two groups. Group I received CS injection, and group II received PRP injection. Results: The average age of patients in Category I was 37 years and in category II was 37 years. A statistical difference was seen in VAS on comparing the baseline evaluation with the results after 1 month of injection administration. It was found that there was more depletion in VAS score in Category I (2.33%) after one month of injection whereas Category II showed an initial low depletion rate after one month (2.86%) followed by a steady decline rate after 3 months. A similar difference was reflected on using the Quick DASH score in which Category I projected a greater improvement after one month of injection use whereas Category II projected a steady improvement rate after 3 months of injection use. Conclusion: PRP for De Quervains tenosynovitis can be used as a 2nd line of management instead of steroid as PRP has better functional outcome and lesser complications as compared to steroid therapy. Introduction De Quervains disease is characterised by inflammation of 1 st compartment tendons as they lie over the styloid process of the radius. When they pass through relatively a narrow canal which causes swelling and associated with formation of a fibrotic tendon nodule, which contributes to improper gliding of extensor tendons [1]. The edema in surrounding area is caused due to inflammatory changes and incarceration of the tendon blocking in its gliding in both directions. With disease progression, the retinaculum thickens prominently and there is fibrocartilaginous metaplasia [2, 3]. With further advancement of the disease there are signs of tendinous erosion, and an overall increase in the sheath's thickness. Incidence is more common in pregnant women, postpartum, Lactating women, malunited radius fracture, rheumatoid arthritis, recent trauma [4]. Treatment protocol starts immobilisation with thumb spica, NSAID's, UST therapy and steroid injection followed by surgical release of tendon sheath [5]. Steroid injection has been used as treatment for long time and proved effective and it has its own advantages like faster pain relief, and recovery from symptoms then disadvantages like skin hypopigmentation, and tendon rupture on repeated steroid injection [6]. Platelets and growth factors are integral to the normal wound healing process [7]. Studies suggest that a platelet-rich plasma (PRP), can be used to treat chronic injuries [8]. PRP is thought to improve healing in chronic degenerative tendon injuries [9]. As wound healing improves, pain and function can improve. PRP has shown greater efficacy in managing recurrent tendonitis and tendinosis than in managing other conditions.
... Platelets and growth factors are integral to the normal wound healing process [7] . Studies suggest that a platelet-rich plasma (PRP), can be used to treat chronic injuries [8] . PRP is thought to improve healing in chronic degenerative tendon injuries [9] . ...
... Furthermore, the mechanical irritation caused by a tight and thickened ITB is believed to induce inflammation in the greater trochanteric bursa, located between the ITB and the greater trochanter, and this relates to pain found in GTB [1,30,53,56,67]. However, pain and dysfunction do not always correlate with clinical findings [49], as some of the CSE patients describe the snapping without any reported discomfort or accompanying pain [30,56,65]. ...
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Background Current literature presents a variety of surgical interventions aimed at modifying the iliotibial band (ITB) at the hip to relieve lateral hip pain (LHP). However, a focus towards the hip abductors as a main driver in LHP has evolved in the last decade, which could influence the indications for isolated ITB surgery. No previous review has been undertaken to evaluate isolated ITB surgery in LHP cases. Purpose The purpose of this systematic review was to evaluate isolated ITB surgery in LHP patients in relation to pain, snapping, use of non-surgical treatments postoperatively, and repeated surgery. Methods The study was reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The study was registered in Prospero (CRD42021216707) prior to initiation. A systematic search of literature on PubMed and Embase as well as bibliography screening on adult patients undergoing isolated ITB surgery with or without additional bursectomies was performed. Due to the lack of reliable data, no meta-analysis was performed. Results A total of 21 studies (360 patients) were considered eligible for inclusion. The snapping and non-snapping group consisted of 150 and 210 patients, respectively. The mean follow-up time in the snapping group was 30 months and 19 months in the non-snapping group. Utilizing different surgical techniques, complete pain relief was not achieved in 12% of patients in the snapping group and 36% of the patients in the non-snapping group. In the snapping group, snapping was eliminated in 95% of patients, and five of 150 patients (3%) had repeated surgery. Eight of nine non-snapping studies reported information regarding repeated surgery, in which seven of 205 patients (3%) received repeated surgery. Conclusion ITB surgery at the hip remains widely adopted, although only level 4 studies are available, and little information exists on the long-term clinical, as well as patient reported outcomes. Based on the available data, we found indication of a positive short-term outcome in LHP with snapping regarding elimination of snapping, pain reduction, reuse of non-surgical treatment, and repeated surgery. In LHP with no snapping, we found limited evidence supporting ITB surgery based on current literature.
... Platelets and growth factors are integral to the normal wound healing process [7] . Studies suggest that a platelet-rich plasma (PRP), can be used to treat chronic injuries [8] . PRP is thought to improve healing in chronic degenerative tendon injuries [9] . ...
... 10 In addition, corticosteroids have adverse effects such as atrophy, systemic absorption, infection, subcutaneous tendon rupture, and tendon rupture on the skin. 11 The use of PRP as a biological solution for injuries to tendons of the rotator cuff has achieved popularity over the past several years. 12 PRP is blood plasma with a high platelet concentration that, once activated, releases various growth factors involved in the tissue repair process. ...
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Background: Shoulder impingement is a common diagnosis for patients with pain and dysfunction of shoulder joint. Due to its chronicity of clinical manifestation of the impingement syndrome, there is a need to find new therapies that collaborate to improve pain management. Methods: A hospital based descriptive, epidemiological study was conducted with 150 patients. The patients were divided in the following three groups of 50 patients each: Platelet-rich plasma (PRP) group: 50 patients received PRP, steroid group: 50 patients received steroid injection normal saline group: 50 patients received normal saline injection. Baseline visual analogue scale (VAS) score on overhead activities were recorded. After the 4th week, 12th week, and 24th week, patients were examined in the outpatient clinic. The main outcome measure was pain with overhead activities using a VAS. Results: The VAS score improved significantly in PRP group and Steroid group compared to normal saline group at the 4th week, 12th-week and 24th-week follow-up periods post injection, as per ANOVA test (p<0.05). Conclusions: PRP and steroids, both can be considered effective methods to treat pain in chronic shoulder impingement syndrome (SIS) and less invasive compared to surgical treatment. They improve the pain and hence shoulder function in chronic impingement syndrome.
... 6 Corticosteroid injections are also a widespread intervention to relieve pain and improve function quickly and inexpensively (although it may result in tendon rupture). 7 On the other hand, physiotherapeutic methods include the application of ultrasound, laser, transcutaneous electrical nerve stimulation, deep transverse massage, eccentric training, extracorporeal shock waves and percutaneous electrolysis. [8][9][10] The percutaneous electrolysis is a minimally invasive electrotherapy technique that involves the application of galvanic current through an echo-guided acupuncture needle. ...
Objective To evaluate the efficacy of percutaneous electrolysis for the treatment of patients with tendinopathies. Data sources A systematic search of publications was conducted in Pubmed, Cinahl, Medline, Scopus and Web of Science. Methods The Oxford 2011 Levels of Evidence and the Jadad scale were used to assess the quality of studies. The mean and standard deviation were obtained for each study group and used to calculate the effect size. The DerSimonian and Laird method was used to develop a random-effects model. Results Of the 14 articles, four applied percutaneous electrolysis to the knee, three to the shoulder, three to the elbow, two to the hip and two to the ankle and foot. A meta-analysis on intensity of pain (evaluated with algometer and the Visual Analogue Scale) was performed on studies comparing percutaneous electrolysis with a control group, indicating that the groups treated with percutaneous electrolysis had better results ( p = 0.01). Although percutaneous electrolysis did not overcome the analgesic effect achieved by corticosteroid injections. Conclusions The percutaneous electrolysis is effective for the treatment of tendinopathies. The combination of this technique with eccentric training has proven to be one of the most effective treatments to date for improving pain. PROSPERO Registration: CRD42021230005.
Background: Peritendinous injection of local anesthetics, alone or in combination with corticosteroids, is widely used in the treatment of tendinopathies. Toxicity of local anesthetics has been demonstrated in many cells, including myocytes, chondrocytes, and neurons. Bupivacaine and lidocaine are known to have time- and dose-dependent cytotoxicity in these cells. The effects of these agents on the tendon remain unknown. Purpose: To show histological and biomechanical effects after the injection of different local anesthetics and steroids, both single and combined, at different concentrations into the peritendinous sheath of rat Achilles tendon. Study design: Controlled laboratory study. Methods: In the study, 100 rats were divided into 10 groups with equal body weights. Inflammation was induced in both Achilles tendons of each rat by means of the ball drop technique; 7 hours later, injections were made into the peritendinous sheaths of both Achilles tendons using lidocaine, bupivacaine, and dexamethasone as appropriate for the rat's group. At the end of the first week, the right Achilles tendons of the rats were removed for histological study. Left Achilles tendons were evaluated in terms of biomechanics. Results: Histological findings demonstrated that the group with the most toxicity to the tendon was the group that received injection of dexamethasone alone. The groups with the least toxicity were those receiving dexamethasone combined with low- or high-dose bupivacaine. Biomechanical findings showed that the experimental groups had similar results to each other with the exception of the groups receiving 0.25% bupivacaine alone and dexamethasone alone, in which tendons revealed higher tensile strength. Conclusion: Local anesthetic and steroid applications have different histological and biomechanical effects on the tendon. Although the dexamethasone-injected group was the most affected in terms of histology, these changes could not be demonstrated biomechanically. Clinical relevance: In future clinical studies, the effect of steroids on the tendon should be investigated more comprehensively. Whether biomechanical results overlap with histological results should be investigated further.
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Background Patellofemoral pain (PFP) is a common overuse injury among runners, affecting females at a higher rate than males. PFP can often become chronic, with evidence suggesting it may be linked to both peripheral and central sensitization of the nervous system. Sensitization of the nervous system can be identified through quantitative sensory testing (QST). Hypothesis/Purpose The primary objective of this pilot study was to quantify and compare pain sensitivity as identified through QST measures, in active female runners with and without PFP. Study Design Cohort Study Methods Twenty healthy female runners and 17 female runners with chronic PFP symptoms were enrolled. Subjects completed the Knee injury and Osteoarthritis Outcome Score for Patellofemoral Pain (KOOS-PF), University of Wisconsin Running Injury and Recovery Index (UWRI), and the Brief Pain Inventory (BPI). QST consisted of pressure pain threshold testing to three local and three distant sites to the knee, heat temporal summation, heat pain threshold, and conditioned pain modulation. Data was analyzed utilizing independent t-tests for comparison of between-group data, effect sizes for QST measures (Pearson’s r), and Pearson’s correlation coefficient between pressure pain threshold values at the knee and functional testing. Results The PFP group exhibited significantly lower scores on the KOOS-PF (p<0.001), BPI Pain Severity and Interference Scores (p<0.001), and UWRI (p<0.001). Primary hyperalgesia, identified through decreased pressure pain threshold at the knee, was detected in the PFP group at the central patella (p<0.001), lateral patellar retinaculum (p=0.003), and patellar tendon (p=0.006). Secondary hyperalgesia, a sign of central sensitization, was observed via differences in pressure pain threshold testing for the PFP group at the uninvolved knee (p=0.012 to p=0.042), involved extremity remote sites (p=0.001 to p=0.006), and uninvolved extremity remote sites (p=0.013 to p=0.021). Conclusion Compared to healthy controls, female runners with chronic PFP symptoms exhibit signs of both peripheral sensitization. Despite actively participating in running, nervous system sensitization may contribute to continued pain in these individuals. For female runners with chronic PFP, physical therapy management may need to include interventions which address signs of central and peripheral sensitization. Level of Evidence Level 3
We have performed a double-blind placebo-controlled trial of moderate doses of extracorporeal shock-wave therapy (ESWT) for non-calcific tendonitis of the rotator cuff. Adults (74) with chronic tendonitis of the rotator cuff were randomised to receive either active (1500 pulses ESWT at 0.12 mJ/mm ² ) or sham treatment, monthly for three months. All were assessed before each treatment, and at one and three months after the completion of treatment. The outcome was measured with regard to pain in the shoulder, including a visual analogue score for night pain, and a disability index. There were no significant differences between the two groups before treatment. The mean duration of symptoms in both groups was 23.3 months. Both showed significant and sustained improvements from two months onwards. There was no significant difference between them with respect to change in the Shoulder Pain and Disability Index (SPADI) scores or night pain over the six-month period. A mean (±sd; range) change in SPADI of 16.1 ± 27.2 (0 to 82) in the treatment group and 24.3 ± 24.8 (−11 to 83) in the sham group was noted at three months. At six months the mean changes were 28.4 ± 25.9 (−24 to 69) and 30.4 ± 31.2 (−12 to 88), respectively. Similar results were noted for night pain. We conclude that there is a significant and sustained placebo effect after moderate doses of ESWT in patients with non-calcific tendonitis of the rotator cuff, but there is no evidence of added benefit when compared with sham treatment.
We have performed a controlled, randomised study to analyse the effects of low-energy shock-wave therapy (ESWT) on function and pain in tendinitis of the supraspinatus without calcification. There were 20 patients in the treatment group and 20 in the control group. The former group received 6000 impulses (energy flux density, 0.11 mJ/mm ² ) in three sessions after local anaesthesia. The control group had 6000 impulses of sham ESWT after local anaesthesia. The patients were examined at six and 12 weeks after treatment by an independent observer who evaluated the Constant score and level of pain. We found an increase in function and a reduction of pain in both groups (p ≤ 0.001). Statistical analysis showed no difference between the groups for the Constant score and for pain. We therefore do not recommend ESWT for the treatment of tendinitis of supraspinatus.
One hundred fifteen patients, all army personnel, with either tendinitis, periostitis, or sprains of less than 48 hours' duration were treated with tenoxicam 20 mg/day or placebo for ten days in a double-blind trial. While we could demonstrate no effect on periostitis and sprains, the effect on tendinitis was both statistically and clinically highly significant, with 71% of patients treated with tenoxicam reporting a good or excellent result as opposed to 31% in the placebo group. Side effects were slight and transient in both groups and no difference could be demonstrated between groups.
The clinical efficacy and safety of percutaneous niflumic acid gel were investigated in adult patients with Achilles heel tendinitis. A double-blind three-week study was conducted in 243 patients in eight centers in France, Belgium, and the Federal Republic of Germany. Patients were randomly allocated to 2.5% percutaneous niflumic acid gel or placebo. The efficacy criteria stuidied were pain on palpation of the Achilles tendon, resumption of sporting activity, and the investigators' and patients' evaluations of the effectiveness of the treatment. The active treatment was shown to be superior to placebo for all major parameters studied. Niflumic acid gel was shown to be equally well tolerated as the placebo. The findings indicate that treatment with topical niflumic acid gel is effective in the treatment of Achilles heel tendinitis, resulting in improvement in the clinical signs at the end of seven days, with more patients in the active treatment group being able to return to their previous levels of sporting activity.
To assess the efficacy and tolerability of paratendinous injections of aprotinin, a polyvalent inhibitor of inflammatory proteolytic enzymes, in patellar tendinopathy, we conducted a prospective, randomized trial in 116 athletes practising a variety of sports. Athletes were randomly assigned to one of three groups, and received injections of either aprotinin, methylprednisolone acetate, or 0.9% NaCl. Patients were followed up in a special clinic 12 months after the last patient in the trial had been injected. At this stage, there were 72% excellent and good results in the aprotinin group, 59% in the methylprednisolone acetate, and 28% in the 0.9% NaCl group, with, respectively, 7%, 12% and 25% of patients with poor results. This study suggests that paratendinous injections of aprotinin may have a lasting beneficial effect in patients suffering from patellar tendinopathy.