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

Background: Platelet-rich plasma (PRP) has been shown to be a general stimulation for repair and 1-year results showed promising success percentages. Purpose: This trial was undertaken to determine the effectiveness of PRP compared with corticosteroid injections in patients with chronic lateral epicondylitis with a 2-year follow-up. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: The trial was conducted in 2 Dutch teaching hospitals. One hundred patients with chronic lateral epicondylitis were randomly assigned to a leukocyte-enriched PRP group (n = 51) or the corticosteroid group (n = 49). Randomization and allocation to the trial group were carried out by a central computer system. Patients received either a corticosteroid injection or an autologous platelet concentrate injection through a peppering needling technique. The primary analysis included visual analog scale (VAS) pain scores and Disabilities of the Arm, Shoulder and Hand (DASH) outcome scores. Results: The PRP group was more often successfully treated than the corticosteroid group (P\.0001). Success was defined as a reduction of 25% on VAS or DASH scores without a reintervention after 2 years. When baseline VAS and DASH scores were compared with the scores at 2-year follow-up, both groups significantly improved across time (intention-to-treat principle). However, the DASH scores of the corticosteroid group returned to baseline levels, while those of the PRP group significantly improved (as-treated principle). There were no complications related to the use of PRP. Conclusion: Treatment of patients with chronic lateral epicondylitis with PRP reduces pain and increases function significantly, exceeding the effect of corticosteroid injection even after a follow-up of 2 years. Future decisions for application of PRP for lateral epicondylitis should be confirmed by further follow-up from this trial and should take into account possible costs and harms as well as benefits.

/pdf/ongoing-positive-effect-of-platelet-rich-plasma-versus-212qfavttw.pdf

Ongoing Positive Effect of Platelet-Rich Plasma Versus Corticosteroid Injection in Lateral Epicondylitis: A Double-Blind Randomized Controlled Trial With 2-year Follow-up

Clinical practice. Plantar fasciitis.

A systematic review of the literature on the effectiveness of physical interventions for lateral epicondylalgia (tennis elbow) was carried out. Seventy six randomised controlled trials were identified, 28 of which satisfied the minimum criteria for meta-analysis. The evidence suggests that extracorporeal shock wave therapy is not beneficial in the treatment of tennis elbow. There is a lack of evidence for the long term benefit of physical interventions in general. However, further research with long term follow up into manipulation and exercise as treatments is indicated.

https://bjsm.bmj.com/content/bjsports/39/7/411.full.pdf

A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia

Background:Plantar fasciitis is a relatively common disorder of the foot, yet little is known about its prevalence, what types of physicians see patients with the disorder, or how, on a national sc...

Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors.

ContextExtracorporeal shock wave therapy (ESWT) is increasingly used for plantar
fasciitis, but limited evidence supports its use.ObjectiveTo determine whether ultrasound-guided ESWT reduces pain and improves
function in patients with plantar fasciitis.DesignDouble-blind, randomized, placebo-controlled trial conducted between
April 1999 and June 2001.SettingParticipants were recruited from the community-based referring physicians
(primary care physicians, rheumatologists, orthopedic surgeons, and sports
physicians) of a radiology group in Melbourne, Australia.ParticipantsWe screened 178 patients and enrolled 166; 160 completed the 15-week
protocol. Entry criteria included age at least 18 years with plantar fasciitis,
defined as heel pain maximal over the plantar aspect of the foot of at least
6 weeks' duration, and an ultrasound-confirmed lesion, defined as thickening
of the origin of the plantar fascia of at least 4 mm, hypoechogenicity, and
alterations in the normal fibrillary pattern.InterventionsPatients were randomly assigned to receive either ultrasound-guided
ESWT given weekly for 3 weeks to a total dose of at least 1000 mJ/mm2 (n = 81), or identical placebo to a total dose of 6.0 mJ/mm2 (n = 85).Main Outcome MeasuresOverall, morning, and activity pain, measured on a visual analog scale;
Maryland Foot Score; walking ability; Short-Form–36 Health Survey (SF-36)
score; and Problem Elicitation Technique score, measured at 6 and 12 weeks
after treatment completion.ResultsAt 6 and 12 weeks, there were significant improvements in overall pain
in both the active group and placebo group (mean [SD] improvement, 18.1 [30.6]
and 19.8 [33.7] at 6 weeks [P = .74 for between-group
difference], and 26.3 [34.8] and 25.7 [34.9] at 12 weeks [P = .99], respectively). Similar improvements in both groups were also
observed for morning and activity pain, walking ability, Maryland Foot Score,
Problem Elicitation Technique, and SF-36. There were no statistically significant
differences in the degree of improvement between treatment groups for any
measured outcomes.ConclusionWe found no evidence to support a beneficial effect on pain, function,
and quality of life of ultrasound-guided ESWT over placebo in patients with
ultrasound-proven plantar fasciitis 6 and 12 weeks following treatment.

/pdf/ultrasound-guided-extracorporeal-shock-wave-therapy-for-4wadcwqr0b.pdf

Ultrasound-guided extracorporeal shock wave therapy for plantar fasciitis: a randomized controlled trial.

Objective The aims of this double-blind, randomized, placebo-controlled trial were to determine whether ultrasound-guided extracorporeal shock wave therapy (ESWT) reduced pain and improved function in patients with lateral epicondylitis (tennis elbow) in the short term and intermediate term. Methods Sixty-eight patients from community-based referring doctors were randomized to receive 3 ESWT treatments or 3 treatments at a subtherapeutic dose given at weekly intervals. Seven outcome measures relating to pain and function were collected at followup evaluations at 6 weeks, 3 months, and 6 months after completion of the treatment. The mean changes in outcome variables from baseline to 6 weeks, 3 months, and 6 months were compared for the 2 groups. Results The groups did not differ on demographic or clinical characteristics at baseline and there were significant improvements in almost all outcome measures for both groups over the 6-month followup period, but there were no differences between the groups even after adjusting for duration of symptoms. Conclusion Our study found little evidence to support the use of ESWT for the treatment of lateral epicondylitis and is in keeping with recent systematic reviews of ESWT for lateral epicondylitis that have drawn similar conclusions.

https://www.jrheum.org/content/jrheum/35/10/2038.full.pdf

A randomized controlled trial of extracorporeal shock wave therapy for lateral epicondylitis (tennis elbow).

Background: This study investigated changes in tendon vascularity in 102 (67 men and 35 women) volleyball players over a 6 month competitive season. 

Methods: Athletes were examined with both grey scale ultrasound and standardised colour Doppler settings. Vessel length and pain were measured each month on five separate occasions. Vascular tendons were divided into (i) those that were vascular on all occasions (persistent vascularity) and (ii) those that were vascular on more than two but less than five occasions (intermittent vascularity). 

Results: A total of 41 of the 133 abnormal tendons were vascular on two or more occasions. Of these, 16 had persistent vascularity and 25 had intermittent vascularity. There was no significant difference in the prevalence of vascularity between men and women. None of the tendons had a pattern of vascularity over the season that could be clearly interpreted as the onset or resolution of vascularity. Subjects with changes in both tendons were more likely to have persistent vascularity (p = 0.045). Vessels were longer in tendons with persistent vascularity (p<0.000) and pain was significantly greater (p = 0.043) than in tendons with intermittent vascularity. Tendons with intermittent vascularity had similar pain scores on all days, whether or not they had detectable blood flow. 

Conclusions: These data suggest that the presence of blood vessels is more likely to be the source of pain than the blood flow in them.

https://bjsm.bmj.com/content/bjsports/39/7/458.full.pdf

Vascularity and pain in the patellar tendon of adult jumping athletes: a 5 month longitudinal study

Objective: Patellar tendon injury, defined by tendon abnormality (TA) on imaging and by pain, is common among volleyball players, but little is known about change in this injury over a volleyball season. Increased activity in the season compared with the off season may result in the development of TA and/or pain. This study investigated the behaviour of TA and pain over a competitive volleyball season. Methods: Tendon abnormality and pain were measured in 101 volleyball players at the beginning and end of a season. Pain was measured with the single leg decline squat test, which loads the patellar tendon, and TA was detected with ultrasound imaging. Hours of weekly activity were measured and compared during the season and the off season. The proportion of tendons that underwent development and resolution in TA and/or pain over the season was investigated. Results: Hours of weekly activity was greater during the season than in the off season. Most of the tendons investigated (66.3%) did not undergo a change in TA or pain over the season. Tendon abnormality and/or pain developed in 16.6% of tendons and resolved in 11.2%. Conclusions: The tendons of volleyball players respond variably to the increased load over the season. Change in TA and pain does not appear to be entirely dependent upon load.

/pdf/prospective-study-of-change-in-patellar-tendon-abnormality-3gwnozgr9x.pdf

Prospective study of change in patellar tendon abnormality on imaging and pain over a volleyball season

Background
Ameloblastoma is a locally aggressive odontogenic neoplasm. With local recurrence rates reaching 90%, only completeness of excision can facilitate cure. Surgical clearance has widely been based on pre-operative imaging to guide operative excision margins, however use of intra-operative specimen x-ray or frozen-section has been sought to improve clearance rates, and advanced imaging technologies in this role have been proposed. This manuscript aims to quantify the evidence for evaluating intra-operative resection margins and present the current standard in this role.

/pdf/achieving-adequate-margins-in-ameloblastoma-resection-the-18ta0mdw7h.pdf

Ronnie Ptasznik

Papers

Ultrasound-guided extracorporeal shock wave therapy for plantar fasciitis: a randomized controlled trial.

A randomized controlled trial of extracorporeal shock wave therapy for lateral epicondylitis (tennis elbow).

Vascularity and pain in the patellar tendon of adult jumping athletes: a 5 month longitudinal study

Prospective study of change in patellar tendon abnormality on imaging and pain over a volleyball season

Achieving adequate margins in ameloblastoma resection: the role for intra-operative specimen imaging. Clinical report and systematic review.