Overuse tendinopathy is problematic to manage clinically. People of different ages with tendons under diverse loads present with varying degrees of pain, irritability, and capacity to function. Recovery is similarly variable; some tendons recover with simple interventions, some remain resistant to all treatments. The pathology of tendinopathy has been described as degenerative or failed healing. Neither of these descriptions fully explains the heterogeneity of presentation. This review proposes, and provides evidence for, a continuum of pathology. This model of pathology allows rational placement of treatments along the continuum. A new model of tendinopathy and thoughtful treatment implementation may improve outcomes for those with tendinopathy. This model is presented for evaluation by clinicians and researchers.

https://bjsm.bmj.com/content/bjsports/43/6/409.full.pdf

Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy

Introduction: Several biomaterials are available to bridge large tendon defects or reinforce tenuous tendon repairs. Methods: We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL, and Embase databases using various combinations of the commercial names of each scaffold and the keywords ‘tendon’, ‘rotator cuff’, ‘supraspinatus tendon’, ‘Achilles tendon’, ‘scaffold’, ‘biomaterials’, ‘extracellular matrix’, ‘substitute’, and ‘devices’ over the years 1966–2009. All articles relevant to the subject were retrieved, and their bibliographies hand searched for further references in the context to biomaterials for tendon repair. Results: Many biomaterials are available for tendon augmentation. Scanty evidence is available for the use of these scaffolds. Discussion: The emerging field of tissue engineering holds the promise to use biomaterials for tendon augmentation. Preliminary studies support the idea that these biomaterials have the ability to provide an alternative for tendon augmentation. However, available data are lacking to allow definitive conclusion on the use of biomaterials for tendon augmentation. Additionally, the prevalence of postoperative complications encountered with their use varies within the different studies. Conclusion: Rather than providing strong evidence for or against the use of these materials for tendon augmentation, this study instead generates potential areas for additional prospective investigation.

/pdf/tendon-augmentation-grafts-a-systematic-review-2xdzh3rxdo.pdf

Tendon augmentation grafts: a systematic review.

Tendinopathy is characterized by pain in the tendon and impaired performance sometimes associated with swelling of the tendon. Its diagnosis is usually clinical but ultrasonography and magnetic resonance imaging can refine the diagnosis. Tendinopathy is highly prevalent and is one of the most frequently self reported musculoskeletal diseases in physical workers and sports people. Nevertheless, it is very difficult to carry out general epidemiologic studies on tendinopathy because of the varying sports cultures and sports habits in different countries. The aetiology of tendinopathy seems to be multi-factorial, involving intrinsic and extrinsic factors. The role of inflammation is still debated but the absence of inflammatory cells does not mean that inflammatory mediators are not implicated. Different theories have been advanced to explain pain and chronicity mechanisms, but these mechanisms remain largely unknown. "Conventional "treatments are generally employed empirically to fight pain and inflammation but they do not modify the histological structure of the tendon. However, these treatments are not completely satisfactory and the recurrence of symptoms is common. Currently, eccentric training remains the treatment of choice for tendinopathy, even though some studies are contradictory. Moreover, many interesting new treatments are now being developed to treat tendinopathy, but there is little evidence to support their use in clinical practice. Key pointsThe word "tendinopathy "is the correct term for the clinical diagnosis of pain accompanied by impaired performance, and sometimes swelling in the tendon.The aetiology of tendinopathy seems to be a multi-factorial process, involving promoting factors that are intrinsic or extrinsic, working either alone or in combination.US (with color Doppler) and MRI are usually prescribed when tendinopathy is unresponsive to treatment and entails lingering symptoms.Eccentric training is currently considered to be the most efficient treatment for tendinopathy; nevertheless, in order to be effective, this treatment needs specific modalities: slow speed, low intensity and gradual intensification, with minimum 20 to 30 sessions of exercises often being needed.Many interesting new treatments are now being developed to treat tendinopathy, but currently there is little evidence to support their use in clinical practice.

Current Opinions on Tendinopathy

Injuries can counter the beneficial aspects related to sports activities if an athlete is unable to continue to participate because of residual effects of injury. We provide an updated synthesis of existing clinical evidence of long-term follow-up outcome of sports injuries. A systematic computerized literature search was conducted on following databases were accessed: PubMed, Medline, Cochrane, CINAHL and Embase databases. At a young age, injury to the physis can result in limb deformities and leg-length discrepancy. Weight-bearing joints including the hip, knee and ankle are at risk of developing osteoarthritis (OA) in former athletes, after injury or in the presence of malalignment, especially in association with high impact sport. Knee injury is a risk factor for OA. Ankle ligament injuries in athletes result in incomplete recovery (up to 40% at 6 months), and OA in the long term (latency period more than 25 years). Spine pathologies are associated more commonly with certain sports (e.g. wrestling, heavy-weight lifting, gymnastics, tennis, soccer). Evolution in arthroscopy allows more accurate assessment of hip, ankle, shoulder, elbow and wrist intra-articular post-traumatic pathologies, and possibly more successful management. Few well-conducted studies are available to establish the long-term follow-up of former athletes. To assess whether benefits from sports participation outweigh the risks, future research should involve questionnaires regarding the health-related quality of life in former athletes, to be compared with the general population.

/pdf/sport-injuries-a-review-of-outcomes-7f5sp50h6h.pdf

Sport injuries: a review of outcomes.

Tendinopathy is a failed healing response of the tendon. Despite 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. Eccentric 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. The 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. The 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. New 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 tendinopathy. Randomized controlled trials are necessary to better clarify the best therapeutic options for the management of tendinopathy.

Novel Approaches for the Management of Tendinopathy

BackgroundAchilles tendinopathy is commonly reported by athletes involved in activities that include running and jumping. Despite the prevalence of the problem, causative factors in Achilles tendinopathy remain poorly understood.HypothesisIn Masters track and field athletes, there is no influence of age, gender, weight, height, and impact profile in developing Achilles tendinopathy.Study DesignCross-sectional study; Level of evidence, 3.MethodsDuring the European Veterans Athletics Championships in Poznan, Poland, in July 2006, 178 athletes (110 men and 68 women; mean age, 54.1 years; range, 35-94 years) were evaluated with the Victorian Institute of Sport Assessment—Achilles (VISA-A) questionnaire. A fully trained orthopaedic surgeon made a diagnosis of Achilles tendinopathy according to clinical criteria.ResultsThere was no effect of gender on the presence of Achilles tendinopathy (P = .14). No significant track and field specialty effect upon the frequency of Achilles tendinopathy was found on the VISA...

No influence of age, gender, weight, height, and impact profile in achilles tendinopathy in masters track and field athletes.

We compared a minimally invasive surgical technique to the conventional (open approach) surgical technique used in fixation of hip fractures with the dynamic hip screw (DHS) device. Using a case-control design (44 cases and 44 controls), we tested the null hypothesis that there is no difference between the two techniques in the following outcome measures: duration of surgery, time to mobilisation and weight bearing postoperatively, length of hospital stay, mean difference of pre- and postoperative haemoglobin levels, position of the lag screw of the DHS device in the femoral head, and the tip–apex distance. The minimally invasive DHS technique had significantly shorter duration of surgery and length of hospital stay. There was also less blood loss in the minimally invasive DHS technique. The minimally invasive DHS technique produces better outcome measures in the operating time, length of hospital stay, and blood loss compared to the conventional approach while maintaining equal fixation stability.

Minimally invasive dynamic hip screw for fixation of hip fractures.

Background:Tendon Doppler flow may be associated with tendon pain in symptomatic patients, but the relationship between Doppler flow and pain among athletes who are still competing is unclear.Hypothesis:Among active athletes, Doppler flow may partly reflect tendon adaptation to increased mechanical load and/or asymptomatic tendinopathy.Study Design:Cross-sectional study; Level of evidence, 3.Methods:The Achilles tendons of 61 badminton players (24 elite, 37 recreational) were examined with gray-scale and color Doppler ultrasound. Achilles tendon pain and activity level (badminton training, badminton playing, badminton years) were measured.Results:Doppler flow was not associated with current Achilles tendon pain but was associated with an increased anteroposterior tendon diameter (an indicator of tendinopathy) (P = .02). Athletes who had been playing badminton for longer were more likely to have Doppler flow (P< .01), and there was a trend toward an association between a greater number of badminton playing...

Achilles Tendon Doppler Flow May Be Associated with Mechanical Loading among Active Athletes

Background. Eccentric training has shown promising results in the management of Achilles and patellar tendinopathy. Recently, studies have investigated eccentric training in the treatment of lateral elbow tendinopathy.Purpose. The purpose of this review was to describe eccentric training programs used to treat LET in order to inform clinicians and identify areas requiring further study.Method. An electronic search of publications indexed in the MEDLINE database was performed in May 2007. Studies comparing eccentric training with at least one other intervention were included.Results. Four studies investigating a total of 248 participants were identified. Three of the four studies reported superior results for eccentric training compared with other interventions, although this included one pilot study and another study that did not include an extended follow-up. There were several differences between the studies, including whether eccentric training was painful or pain-free, the duration of eccentric traini...

Eccentric training programmes in the management of lateral elbow tendinopathy

Purpose. In patellar tendinopathy, there is anterior knee pain with tenderness of the attachment of the patellar tendon over the lower pole of the patella. The condition is commonly associated with athletic overuse, but we have encountered it in some patients following direct blunt trauma to the anterior aspect of the knee. We describe the history and management of patients with traumatic patellar tendinopathy.Method. Between April 2000 and August 2006, we managed eight otherwise healthy well trained athletes who developed signs and symptoms compatible with classical patellar tendinopathy after a direct trauma to the anterior aspect of the patellar tendon during sport activity.Results. The clinical diagnosis of patellar tendinopathy was confirmed clinically and at imaging by MRI and ultrasound scans. Patients responded to conservative or surgical management, in the same way as patellar tendinopathy secondary to overuse.Conclusion. A single direct traumatic event can lead to chronic tendon problems. Hence,...

Giorgio Garau

Papers

No influence of age, gender, weight, height, and impact profile in achilles tendinopathy in masters track and field athletes.

Minimally invasive dynamic hip screw for fixation of hip fractures.

Achilles Tendon Doppler Flow May Be Associated with Mechanical Loading among Active Athletes

Eccentric training programmes in the management of lateral elbow tendinopathy

Traumatic patellar tendinopathy.