Michael Messmer DO, CAQSM

Beacon Medical Group Sports Medicine

I have no disclosures to reveal for this lecture.

Differs from tendinitis which is a more acute inflammatory disease state of the tendon.

Chronic tendinopathy is described as an overuse syndrome manifested with pain and tenderness due to mucoid and chondroid degeneration and formation of plump tenocytes and increased myofibroblastic and fibroblastic cells with absent inflammatory cells (1). It is reported that chronic painful tendinopathy exhibits increased occurrence of sprouting nonvascular sensory, substance P-positive nerve fibers, and altered sensory-sympathetic innervation which may play a role in the pathogenesis of it (2).

1) Reactive tendinopathy – occurs in response to acute overload. Non-inflammatory proliferative response. Shifting to larger modular proteoglycans. Tendons increase in size/thickness.

2) Tendon disrepair – Or failed healing. Resembles reactive tendinopathy but with greater matrix disorganization. Neovascularity and neuronal growth representing attempted but failed repair. Evidence exists here that in this stage with inclusive load modulation and eccentric exercise stimulus, the tendon can recover.

3) Degenerative tendinopathy – True tendinosis. Final stage of this continuum. Vast areas of hypocellularity, pooling of PG’s, and severely disorganized collagen. This stage is irreversible with Physical therapy and/or oral NSAIDs etc. Usually at this point intervention with regenerative medicine or surgery is necessary at this point.

Examples:◦ Lateral epicondylitis – effect 1-2% of the general

population. 2-3 times higher rate in patients over 40 years.

◦ Patellar tendinopathy – 6% of athletes (active people) effected, higher rates in jumping and sprinting sports or activities (e.g. plyometrics, cross fit, P90x etc.).

◦ Achilles tendinopathy – In a study by Kvist M. (19), 698 patients with achilles pain showed 66% with paratenonitis, 23% with achilles insertional problems. 89% were men, 53% were casual to competitive runners.

Define tendinopathy

Discuss various treatments of tendinopathy of the upper extremities

Discuss various treatments of tendinopathy of the lower extremities.

Discuss treatments that are falling out of favor in certain areas.

Learn new methods of treatments for chronic tendon pain.

Confluence of tendons including supraspinatous, infraspinatous, and teresminor at the greater tuberosity of the humerus. Also has the subscapularis tendon attaching on the lesser tuberosity.

Occurs most often at the insertion of the supraspinatous. Less likely to occur at the insertion of the teres minor.

Image courtesy of Physiopedia. http://www.physio-pedia.com/File:Schema_rotator_cuff_tendinopathy.png

RICE: Rest, Ice, Compression, Elevation◦ Rest should be relative. Use of pendulum exercises is warranted to

prevent frozen shoulder. Avoid sling if at all possible. If too painful, can go in sling for 1-2 weeks, but come out once an hour for pendulum exercises.

◦ Ice should be 10-20 minutes at the area of maximal pain. Can do this as much as possible. Make sure to let skin warm up completely before re-applying to avoid frost bite

◦ Compression is tough to do on the shoulder◦ Elevation only necessary if significant swelling. Resting forearm on head

for 1-5 minutes can help in this case

NSAIDS◦ Make sure no previous issues with bleeding or stomach ulcerations. ◦ Ibuprofen or Aleve in most cases works better then tylenol for it’s anti-

inflammatory effects. But make sure not to overuse. Some of the inflammatory cascade is important, and we don’t want to prevent it altogether. Recent research suggests there may be detrimental effects to use of NSAIDs in acute injuries (3).

Physical therapy

Specific modalities and exercises include:◦ Astym directed at the insertion

and scapular muscles◦ Cross friction massage directed at

the insertion◦ Spencer’s techniques◦ Rhomboid muscle stretch◦ Scapular stabilization exercises for

dyskinesia◦ Controlled ER and IR exercises

with the theraband◦ BOSU ball exercises◦ Wall walking◦ Core strengthening for throwers

with education on use of core when throwing

◦ Game ready ice therapy

Steroid injection (Kenalog, Depo Medrol, Celestone)

In most cases this is subacromial due to impingement and needle should be directed at the bursa. Use of Ultrasound is recommended to guarantee proper placement of the substrate

Sometimes GH injections of steroid are helpful to decrease capsular inflammation and help with proprioception of the rotator cuff muscles. This has a gold standard of Ultrasound use for guidance due to depth of the joint.

Coombes and colleagues conducted a meta-analysis on the effect of corticosteroids in various tendons in comparison with other nonsurgical interventions. Short-term effectiveness for rotator cuff tendon was inconclusive, and no significant difference was noted regarding intermediate and long-term results (4).

Healing and repair of a tendon occurs in 3 stages. The inflammatory phase in the first few days is characterized by inflammation and migration of erythrocytes and polymorphonuclear leukocytes. Monocytes and macrophages are also present for phagocytosis of necrotic tissue. Chemokines are released, leading to chemotaxis of tenocytes, which lay down collagen III.

This process is followed by the proliferative phase, which is characterized by more collagen III and increased ground substance,lasting several weeks.

From week 6 up to 1 year, remodeling takes place. Collagen I is synthesized along the path of stress (which is why physical therapy is so important), followed by scar formation. Ligament and muscle injuries undergo basic stages of healing similar to those of tendons. (4)

Based on the current literature, it is my opinion that although corticosteroids may offer short-term relief of symptoms, it is likely more harmful in the long term due to its interference in the cascade outlined above.

What I do: If I can, with good confidence, say that clinically, or with imaging there is a bursitis in the shoulder, and I am confident in my injection skills, a steroid injection into the bursa can be done. If I think there may be a tear of some kind in the rotator cuff (in particular an acute or subacute tear), then a steroid injection is not warranted.

Physical Therapy

Alternative injections:◦ Prolotherapy

◦ Platelet rich plasma

◦ Stem Cell injections

ROM To help capsular motion – I will encompass Spencer’s techniques in if I am confident in the capsular integrity

Strengthening of the rotator cuff tendons with proper eccentric and concentric loads given at the right time of remodeling to encourage proper tendon fiber deposition

Scapular motion control –essential to prevent furtehrinjury to the tendon

Prolotherapy: introduces an irritating agent to pathologic tissue to obtain a healing response (5). It is a homeopathic remedy intended not to “cure” an injury, but to stimulate the body to heal itself.

Chemical irritants - such as phenol, guaiacol or tannic acid, trigger the healing process. These substances attach themselves to the walls of the cells wherever they are injected, causing irritation that stimulates the body’s reactive healing process

Chemotactic agents – Primarily sodium morrhuate are thought to be proliferants used to attract immune cells to the area.

Osmotic Shock agents - simple compounds like dextrose and glycerine. The most commonly used prolotherapy agents, work by causing cells to dehydrate slightly which stimulates the immune response.

Particulates – Pumice flour is most commonly used. microscopic particles that attract macrophages, tiny organisms which gobble them up, in turn secreting polypetidegrowth factors that result in collagen production. Collagen production is an essential event in phase 3 of the healing response.

Platelet Rich Plasma Therapy

Defined as an ultrafiltrate of deposited autologous whole blood with a platelet count above baseline values (6). Platelet concentrations will vary from 2.5-8 times the normal concentration depending on the commercial centrifuge used.

When these platelets release their contents, there is a 3- to 5-fold increase in the number of growth factors, including platelet-derived growth factor (PDGF), transforming growth factor b (TGF-b), vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), epidermal growth factor (EGF), and insulin-like growth factor (IGF). These growth factors act as powerful chemoattractants, are involved in cell proliferation and immune cell regulation, and can stimulate endothelial growth and angiogenesis (6),(7).

Numerous studies have demonstrated the ability of PRP to heal damaged tissue. These included medial collateral ligament injuries of the knee,(8) chronic elbow tendinitis, (9) Achilles tendon tears, (10) (11) bone healing, (12) muscle strains, (13) patellar tendinopathy,(14) (15) and rotator cuff repair (16) (17).

Platelet count?

Leukocyte count? New literature suggests leukocyte poor (specifically neutrophils) may be more effective for tendons and even joints.

RBC count? – less worrisome, seems to contribute more to pain response.

Ultrasound guidance vs. Landmark guided injections?

Most effective at which areas? Tendon, joint, ligament?

Acute vs. Chronic injuries?

Percutaneous needle tenotomy: Otherwise known (inaccurately) as “dry needling”. It involves introduction of a needle at an area of damage in a tendon or ligament using ultrasound for precise placement of the needle and performing multiple passes through 50% of the tendon thickness to induce inflammatory (and therefore healing) response.

A recent study by Dong-wook et al. Showed effectiveness in range of motion, pain, and disability (18).

Stem Cell injections: There are various sources of stem cells that have been used for a variety of medical

conditions, ranging from embryonic stem cells to human adult stem cells.

Embryonic stem cell therapy is subject to significant regulatory and religious issues with potential adverse effects, with no studies supporting its use for orthopedic conditions.

Human adult stem cells are available from various tissues including blood, adipose, bone marrow, and synovial tissue. The literature would support bone marrow as the main source and having most published research for orthopedic conditions. (20)

Harvesting mesenchymal stem cells (MSCs) from bone marrow is also associated with a lower complication rate in comparison with adipose-derived stem cell extraction.

The multipotent nature of MSCs allows them to differentiate into various cells in the mesenchymal lineage, including bone, cartilage, adipose, and other soft tissues.

Centeno and colleagues showed that stem cells were effective for severe OA in one patient they injected for a case report. The investigators found that after BMAC containing MSCs were injected into hips and knees, MRI’s confirmed thickening of cartilage within the joint space after 4 weeks in the hip as well as thickening of meniscus and cartilage in the knees after 24 weeks. Patient reported increased movement and decreased pain. (21)(22)

Most literature on stem cells is limited to case reports and animal studies. Therefore, this is still in the experimental phase as many physicians around the country are currently undergoing many studies to help further this therapy

Inflammation and irritation with possible partial tear of the common extensor tendon at the lateral epicondyle

Commonly seen in patients who do many repetitive low impact activities (i.e. typing) or short burst aggressive movements involving wrist extension (i.e. throwing boxes, or swinging a tennis racquet).

1st step: NSAIDs with icing and resting

2nd step: Home exercises for stretching the extensors and increasing grip strength

3rd step: Gradual return to work

This conservative management works fairly well in most patients. 80% of patients will improve with this strategy (23)

Physical therapy: (24) Progressive Exercise Program,

Steps 1 to 4

Step Exercises:

1 Clenching fist strongly

Resisted wrist extension

Resisted wrist flexion

Wrist rotation with a stick

Toward the little finger

Toward the thumb

End: stretching at least 30 seconds to flexion and

Extension

2 Exercises against an elastic band for:

Wrist extension

Wrist flexion

Wrist radial deviation

Wrist ulnar deviation

End: stretching as in step 1, 10 × 3 series, several repetitions daily

3 Combined wrist rotary movements using, for example, a table top as a support

Upward resisted from below

Toward the little finger

Toward the thumb

Downward resisted from above

Toward the little finger

Toward the thumb

Pressing hand against a wall

End: stretching as in step 2

4 An occupational training program including:

Softball compressing exercises

Transferring buttons from 1 cup into another

Twisting a towel into a roll

Rotating hand on a table in bo

Percutaneous needle tenotomy

Very effective in pain control and healing.

Not very well tolerated by patient.

PRP injections

Highly effective to illicit healing response

Well tolerated by patient

Not covered by insurance

Steroid injection:◦ Is effective for pain control and to decrease

inflammation, but recent literature questions the efficacy and whether long term damage can occur doing these. Especially with improper placement (25).

◦ In some cases has led to worse outcomes after a year (26).

◦ At this point if a tear is not identified, and there is known inflammation that is a direct reason for the pain, then steroid injection can be considered. If this is a chronic pain, steroid should be avoided.

One of the more common tendinopathies - as many as 20% of jumping athletes

Jumper’s Knee

Inflammation of the tendon that connects the patella to the tendon-the inferior patellar pole

Mechanism of injury: ◦ no exact mechanism, subtle onset

progressive pain

Due to repetitive jumping, kicking or cutting

Risk factors: ◦ Training frequency and intensity

muscular imbalance

◦ Poor quadriceps and hamstring flexibility

Eccentric muscle action during landing may exert the tensile loads that lead to injury

Anterior knee pain - aching quality

Symptom onset is insidious

Physical Exam:

Point tenderness -inferior patellar pole, superior patellar pole, or tibial tuberosity

Hamstring and quadriceps tightness

Swelling may be present

Intra-articular effusion of the knee - rare

Grading System:

I. Pain only after exercise

II. Discomfort during exercise with pain after exercise ceases

III. Pain during and after exercise

IV. Rupture of Tendon

Treatment:

Rest, Ice, NSAIDs

Activity Modification

PT – Stretching (quads and hip flexors) Strengthening - closed kinetic chain and eccentric exercise

Sport-specific proprioceptive training and plyometrics

Counterforce Strap (Grade I)

Injections: Steroid, Sclerosing Agents, PRP

Steroid- Ultrasound imaging shows that steroids can reduce inflammation and edema in a tendon, but cannot repair degenerative changes (Fredberg et al, 1998)

-Steroid injections demonstrated improvements in pain scores in the short term (3/12), however improvements deteriorated in the long term (6/12) and in some cases even relapsed to their initial pain scores after 4wks (Fredberg et al (2004), Kongsgaard et al (2009) and Capasso et al (1997) )

-adverse effects including slowing and weakening of collagen synthesis leading to a higher risk of tendon rupture has been shown with the use of repeated steroid injections

Sclerosing injections

Sclerosis, the act of injecting a chemical irritant

(e.g. polidocanol) into the tendon, is thought to

destroy the neovessles and accompanying

nerves, thus ridding the patient of pain.

Alfredson and Ohberg (2005): significant reductions in pain during activity, and increases in knee function up to 4/12 post treatment

PRP Platelet rich plasma (PRP) is blood plasma

enriched with platelets containing growth factors, and is utilized to stimulate soft tissue healing with low healing potential.

Volpi et al (2007), Kon et al (2009) and Filardo et al (2010) investigated the use of PRP injections combined with varying exercise and stretching programs they showed significant reductions in pain and, in some cases, an improvement in regeneration of the tendon tissue

inflammation of the tendon or paratendon

resulting from overuse, or hyperextension injury

change in playing surface, footwear, or intensity of an activity

Risk Factors:

Achilles tightness

Excessive pronation

Compensatory posturing up and down the kinetic chain such as hip external rotation

Functional genurecurvatum

Midtarsal rotation

Associated Sports:

Runners

Gymnasts

Cyclists

Volleyball

Tendon subjected to 8-10x

a person's body weight

during strenuous exercise

Presentation:

Paratenonitis: Localized/burning pain during or following activity occurs; as the disease progresses, onset of pain may occur earlier during activity, with decreased activity level, or even at rest.

Tendinosis: Usually, this injury is an asymptomatic, noninflammatory, degenerative disease process (mucoid degeneration); the patient may complain of a sensation of fullness or a nodule in the back of the leg

Paratenonitis with tendinosis: Activity-related pain and diffuse swelling of the tendon sheath with nodularity is present

Exam:

Tendinosis: is often pain free; may be palpable intratendinous nodule that accompanies the tendon

Paratenonitis: typically present with warmth, swelling, and diffuse tenderness localized 2-6 cm proximal to the tendon's insertion; crepitation may be present

Paratenonitis with tendinosis: patients with activity-related pain, as well as swelling of the tendon sheath and tendon nodularity.

Treatment:

- Relative rest, Icing, NSAIDs, cross training ok

- Runners reducing mileage and eliminating hills for a while

- Crutches, walking cast or boot may be needed for a short time

- Physical Therapy eccentric exercises, with most patients achieving 60-80% pain relief

- Night splint (Strassburg sock) - ankle at 5°dorsiflexion

Glyceryl Trinitrate Patches

Theory: dilates blood vessels leading to increased blood flow; increases levels of NO which may stimulate healing

Regiment: off-label use of an FDA-approved medication ¼ patch 0.2mg/hr for 18-24hrs,6mth duration

Side Affects: HA

Achilles tendinopathy - showed 78% of the treatment group asymptomatic with activities of daily living at 6 months versus 49% of the control group (Paolini 2003)

At 3 years, 88% of the treatment group was completely asymptomatic compared to 67% of the control group (Paolini 2007)

Injections:

Several cases of Achilles tendon rupture have beenreported after corticosteroid injections to this

region(Bedi SS, Ellis W.; Kleinman M)

Gill et al. described a series of 83 injections to theAchilles region without serious complicationinjected the steroid under fluoroscopic guidance around the tendon but not within the substance of the tendon.

Platelet rich plasma – Can be effective in the treatment for chronic recalcitrant Achilles tendinosis. This was seen in a recent study by Monto (2012) showing 27 out of 29 patients getting clinical resolution in the 6 month follow up.

1 million visits per year in the US

most cases are from overuse stresses

degenerative irritation at the insertion of the plantar fascia on the medial process of the calcaneal tuberosity

Heel spur partial association

…however asymptomatic individuals have bony heel spurs, whereas many patients with plantar fasciitis do not have a spur

3 distinct parts: medialcentrallateral

development of microtrauma damage at the calcaneal-fascial interface secondary to repetitive stressing of the arch with weight bearing

Risks:multifactorialTraining errors, pes planus, overpronation, pes cavus,tightness in the hamstrings, gastrocnemius, soleus,overweight, DM, etc…

Key Findings:

- worse pain with 1st step in the AM

- pain with barefoot walking

- no symptoms & signs of neurologic involvement

- pain and tenderness over plantar fascia origin; tight achilles

Treatment:- Rest, Ice, Stretching, NSAIDs

- Night Splints

- Proper foot support – orthotics, arch support

- Injections

- ESWT

Injections: majority of studies show short term effect for steroid injections

- Crawford et al 106 patients, decrease in pain levels steroid after 1 month; however, after 3 months there was no statistical significant difference concluded that steroid injections can provide short-term relief

ESWT (Extracorporeal shockwave therapy

FDA-approved for plantar fasciitis

Entails delivering a series of low-energy shock waves directly over the painful area of the tendon.

The mechanism by which ESWT would provide pain relief or enhance tendon healing is not clear

About 34 clinical trials and systematic reviews investigating ESWT- half favorable and half neutral

Most convincing data are seen in the treatment of calcific tendonitis

Twenty patients had ESWT and 75% of patients were completely satisfied at six month post treatment with an ESWT device that required local anesthesia (Othman et al)

Haake et al. Assessed the efficacy of extracorporeal shockwave therapy (ESWT) in 272 subjects; Consequently, they showed that ESWT was ‘ineffective in the treatment of chronic plantar fasciitis’

Percutaneous tenotomy – microtiptenotomy/fasciotomy

What is it?

New technology delivers optimized ultrasonic energy to end of Microtip that precisely cuts diseased tendon tissue while sparing healthy tissue

Cutting of tissue achieved through longitudinal movement of needle at speed of sound (ultrasonic) – cut tissue at tip only via “jack-hammer effect”

Continuous saline irrigation cools Microtip to control unwanted heat and coupled to simultaneous removal of target tissue

Effectively, diseased or ineffective tissue is removed in a percutaneous fashion with minimal side effects.

Shoulder –rotator cuff tendinosis or calcific tendinosis

Elbow – lateral epicondylosis

Knee – patellar tendinosis

Foot – plantar fasciosis

Ankle – achillestendinosis

Proximal hamstring tendinosis

Gluteus mediustendinosis

Ultrasound imaging used to identify diseased tissue and guide Microtip during procedure Diseased tendon tissue

TX1 MicroTip placed intohypoechoic region

Removal of hypoechoic region

1. Visualize damaged tendon (dark region) via ultrasound

3. Foot-pedal activation of MicroTip preciselycuts and debrides target damaged tissue

2. Guide Microtip to damaged tissue with ultrasound guidance

Extent of incision – 1cm

Chronic pain (> 3 months) at the affected joint and not responsive to conservative medical treatment (rest, ice, brace, physical therapy)

Point tenderness – point of maximum pain typically corresponds to the location of the damaged tissue and can be identified one finger by the patient

Ultrasound confirmation – placement of ultrasound transducer on the site of maximum tenderness should identify a region of degenerated tendon tissue visualized as a hypoechoic region due to irregular/disorganized fibers and thickened tendon tissue.

No restrictions before procedure

Total procedure time from cleaning of skin to placing band-aid is less than 20 min.

No pain or discomfort during procedure

Permitted to go home afterwards - no PT

Post-procedure …• Over-the-counter pain meds and ice as

needed• Refrain from heavy lifting or in boot for 2

weeks• Return to full activity in 4 to 6 weeks (if

some comorbidities can be 8-12 weeks in my experience)

Published/Accepted Koh et al – Am. Journal of Sports Medicine,2013 (elbow)

Hackel – Orthopedics Today 2013 (procedure overview / mixed tendons)

Morrey – Techniques in Elbow and Hand Surgery 2013 (elbow)

ElAttrache – Operative Techniques in Sports Medicine 2013 (knee)

Barnes – Operative Techniques in Sports Medicine 2013 (procedure overview/mixed tendons)

Khanna et al – Am Academy of Physical Med & Rehab Poster 2013 (mixed tendons)

Traister et al – Am Med Society for Sports Medicine Presentation 2014 (mixed tendons)

Barnes et al – Journal of Shoulder and Elbow Surgery 2014 (elbow)

Patel – in print, American Journal of Orthopedics 2014 (plantar fascia)

Mayo Clinic Epidemiology study – in print, American Journal of Sports Medicine 2014 (elbow)

Stowers – accepted, Orthopedics (knee)

Submitted/In Preparation Kamineni (Univ. of KY) – Controlled animal model study

Koh et al (Singapore/Mayo) – Two year clinical efficacy and safety follow-up in elbow tendonosis

Yanish (Des Moines, IA) – Cost effectiveness study: Tenex vs Surgery (elbow)

Vanderwoude (Lincoln, NE) – Plantar fascia study

Ellis et al (Phoenix, AZ) – Achilles tendon study

Patel (Indianapolis) – Plantar fibroma study

Elbow: Prospective studies (2) revealed > 90% patients pain free – 12 & 24 month follow-upStatistical significant improvement in quality of life (QOL) measurement vs baseline

Knee/Patellar: Clinical evaluations (2) revealed 93 % patient pain free – 6 month follow-upStatistical significant improvement in QOL measurement vs baseline

Achilles: Prospective study revealed 91% patients pain free – 12 month follow-upStatistical significant improvement in QOL measurement vs baseline

Plantar Fascia: Case evaluation revealed 92% patients pain free – 6 month follow-upStatistical significant improvement in QOL measurement vs baseline

Animal Model: Precise removal of damaged tendon tissue leaving healthy tissue intactRemodeled tendon has physical and biochemical make-up of healthy tissue

Economic Analysis: Efficacy (6 month follow-up): Tenex = 91% vs Open = 74 % Average work weeks missed: Tenex = 1.1 vs Open = 8.2

Total cost savings/patient: Tenex was $ 11,753 less than Surgery

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