Novel Treatments for Muscle-Tendon Injury€¦ · Applications for MSK US Shoulder Rotator cuff...
Transcript of Novel Treatments for Muscle-Tendon Injury€¦ · Applications for MSK US Shoulder Rotator cuff...
Novel Treatments for Tendon Injury
Peter Gonzalez, MD Assistant Professor
Department of Physical Medicine & Rehabilitation Eastern Virginia Medical School Director, EVMS Sports Medicine
Nothing to disclose
Define tendon injury
Review traditional treatments
Discuss emergence of MSK US for muscle-tendon pathology
Discuss novel procedures for treatment of tendon disorders
Conclusions
Tendon Pathology
Tendinitis: acute tendon injury ◦ Presumed inflammatory
mediators ◦ Limited evidence
Tendinosis: chronic tendon pain (?injury) ◦ Result of cumulative trauma ◦ Absence (minimal)true
inflammation ◦ Weakening of collagen
cross-linking ◦ Poor vascularity-
neovascularization of tendon
Tendinopathy: Clinical term
Normal Tendon
Injury
Degeneration
Inflammatory Phase
1. 2.
Theory of Tendinosis
Mechanical ◦ Repeated loading within physiological stress range of the
tendon ◦ Chronic repetitive injury or cumulative trauma
Vascular ◦ Hypovascularity to tendons ◦ Proximal to tendon-bone interface ◦ Blood flow decreased w overuse
Neural ◦ Uncertain hypothesis ◦ Chronic overuse leads to increased neural stimulation
and mast cell degranulation
Susceptible Tendons
Area Tendons
Shoulder Rotator cuff (SupS), biceps
Forearm Forearm extensors/flexors
Knee Patella, quadriceps tendon
Leg/foot Achilles, post. tibialis
Traditional treatments
RICE
NSAIDs
Bracing or splinting
Physical therapy ◦ Modalities-ICE,heat, US, electrical stimulation, iontophoresis, phonophoresis
◦ Eccentric strengthening
◦ Flexibility program
Corticosteroid injections
,
Coombes et al (JAMA,2013) ◦ PT/corticosteroid/placebo injection for lateral
epicondylagia ◦ 165 patients w unilateral LE for >6m ◦ At 4weeks:
◦ Corticosteroid effect w/wo PT ◦ CS>placebo injection
◦ At 1 yr: ◦ Corticosteroid (CS) group showed lower recovery rates and
greater recurrence compared to placebo injection ◦ No difference in PT or no-PT groups
◦ Conclusion: CS injections for LE may have short-term benefits but
poorer results in the long-term Physiotherapy did not provide LT benefit
MSK US
Growth of MSK Ultrasound for diagnosis
Percutaneous procedures with US-guidance
Applications for MSK US
Shoulder
Rotator cuff tear
Bursitis
Elbow
Tennis elbow
Golfers elbow
Cubital tunnel syndrome
Wrist
Arthritis
Carpal tunnel syndrome
Hand Trigger finger
Cysts
Hip
Tendonitis/bursitis
Knee
Baker’s cyst
Tendon tear
Foot/Ankle
Achilles tendon injury
Nerves
Muscles
Etc, etc, etc, etc…..
Tendons
In long axis (LA), fibrillar pattern of hyperechoic parallel patterns
In short axis (SA), appears as round/oval hyperechoic structures
Tendinosis
Normal
Abnormal
Tenotomy
Needle insertions into tendon
◦ Break up scar tissue
◦ Promote bleeding
◦ Prompt body’s own healing response
Tenotomy
LE C
Needle
Tenotomy
Does evidence exist for tenotomy? ◦ McShane et al (J Ultra Med, 2008)
◦ Housner et al (J Ultra Med, 2009)
Tenotomy
McShane et al (J Ultrasound Med,2008) ◦ US guided percutaneous tenotomy for refractory common extensor tendinosis (Lateral epicondylagia)
◦ 57 consecutive patients ◦ Phone interview follow-up at average 22 months (7-34m)
◦ Procedure: Fenestrate tendinotic tissue, break up calcifications, abrade bone
◦ 58% (excellent), 35% (good), 2% fair, 5.8% poor
Tenotomy
Housner et al (J Ultrasound Med,2009) ◦ Effectiveness of tenotomy for various tendons in
body ◦ Treated 14 tendons in 13 patients
Patellar tendon (5) Achilles (4) Proximal gluteus medius (1) Proximal ITB (1) Proximal hamstring (1) CET (1) Proximal rectus femoris (1)
◦ Failed phys therapy and >6 month history of pain ◦ Outcomes: VAS prior, at 4 weeks, at 12 weeks
Tenotomy
◦ Procedure:
US-guided percutaneous needle tenotomy
◦ Results:
Baseline VAS: 5.8 +/- 0.6
Significant pain reduction at 4 weeks (2.4 +/- 0.7) and 12 weeks (2.2 +/- 0.7)
◦ Conclusion:
Effective in improving symptoms without complications
Tenotomy Pat tendinosis
Housner, 2009
Tenotomy GMed
Housner, 2009
PRP
Blood plasma with high concentration of platelets
Drawn from patient and placed to centrifuge
Injected into region of interest
PRP Process
Sampson, 2008
Platelet-poor Platelet-rich plasma
PRP
Selected growth factors: ◦ Platelet-derived GF
Mesenchymal stem cells
◦ Transforming GF-B Enhances extracellular
matrix production
◦ Vascular endothelial GF Stimulates
angiogenesis
Other factors/cytokines: ◦ Adenosine
Prevents tissue injury through inflammatory cascade
◦ Serotonin Increases capillary
permeability
Effects on fibroblasts
◦ Histamine Increases capillary
permeability
◦ Calcium
PRP
Does clinical evidence exist for PRP?
◦ Mishra et al (Am J Sports Med, 2006)
◦ Filardo et al (Int Ortho, 2009)
◦ deVos et al (JAMA, 2010)
◦ Gosens et al (Am J Sports Med, 2011)
◦ Finnoff et al (PMR, 2011)
PRP
Mishra, et al (AJSM,2006) ◦ 15 PRP, 5 controls for ‘chronic elbow tendinosis’
Autologous PRP vs bupivacaine inj
◦ Reduction in pain seen in PRP-cohort
At 8 weeks, 60% improvement in VAS (vs 16%)
At 6 months, 81% improvement in VAS
At average of 25m, 93% improvement in VAS
PRP
Filardo et al (Int Ortho, 2009) ◦ Patellar tendinosis (‘jumper’s knee’)
◦ Prospective case control PRP + PT (n=15)
PT-only (n=16)
◦ At 6m: Improved function and pain in both groups Greater improvement in sports
activity in PRP
PRP
deVos et al (JAMA, 2010) ◦ RCT of PRP vs saline injections for Achilles tendinopathy
N=54
Chronic mid-portion Achilles injury
◦ Both groups treated w eccentric ex
◦ Both groups improved after 24 wks
No sign. benefit in PRP group for pain, function, or patient satisfaction
PRP
Gosens et al (Am J Sports Med,2011) ◦ DB-RCT w 100 subjects
Compared PRP-corticosteroid injection for lat epi
◦ At 2 yrs, both groups improved in pain and function
Improvement w CS declined over time
Improvement w PRP was maintained
PRP group showed better functional outcomes
PRP
Finnoff et al (PMR,2011) ◦ Case series (n=34) w
tendinopathy
◦ Patients received tenotomy & PRP
◦ Pre and post MSK US examination
◦ 83% ‘satisfied’ with the results
◦ Sign. improvements in pain and functional scores
◦ MSK US remained ‘abnormal’ improvements noted
Conclusions
Tendinosis, not tendinitis
Traditional treatments remain traditional ◦ RICE, eccentric exercises
MSK US for diagnostic and therapeutic purposes
Corticosteroids: Use with caution
Novel treatments are emerging ◦ Needle tenotomy/autologous PRP
Peter G. Gonzalez, MD Assistant Professor
Eastern Virginia Medical School
Department of Physical Medicine and Rehabilitation
Director, EVMS Sports Medicine
Team Physician, Hampton University
Team Physician, Norfolk Public Schools