Tendinosis
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| Tendinosis | |
| Classification and external resources | |
| MeSH | D052256 |
|---|---|
Tendinosis, sometimes called chronic tendinitis, tendinosus, chronic tendinopathy or chronic tendon injury, is damage to a tendon at a cellular level (the suffix "osis" implies a pathology of chronic degeneration without inflammation). It is thought to be caused by microtears in the connective tissue in and around the tendon, leading to an increase in tendon repair cells. This may lead to reduced tensile strength, thus increasing the chance of tendon rupture. Tendinosis is often misdiagnosed as tendinitis due to the limited understanding of tendinopathies by the medical community.[1]
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[edit]Diagnosis
Swelling in a region of micro damage or partial tear can be detected visually or by touch. Increased water content and disorganized collagen matrix in tendon lesions may be detected byultrasonography or magnetic resonance imaging.
Symptoms can vary from an ache or pain and stiffness to the local area of the tendon, or a burning that surrounds the whole joint around the inflamed tendon. With this condition, the pain is usually worse during and after activity, and the tendon and joint area can become stiffer the following day as swelling impinges on the movement of the tendon. Many patients report stressful situations in their life in correlation with the beginnings of pain which may contribute to the symptoms.
[edit]Treatment
Due to their highly specialised ultrastructure, low level of vascularization and slow collagen turnover, tendons and ligaments are very slow to heal if injured, and rarely regain their original strength. Partial tears heal by the rapid production of disorganized type-III collagen, which is weaker than normal tendon. Recurrence of injury in the damaged region of tendon is common.
Standard treatment of tendon injuries is largely palliative. Use of non-steroidal anti-inflammatory drugs combined with rest and gradual return to exercise is a common therapy, although there is evidence to suggest that tendinosis is not an inflammatory disorder, and that anti-inflammatory drugs are not an effective treatment[2] and that inflammation does not cause tendon dysfunction.[3] There are a variety of treatment options, but more research is necessary to determine their effectiveness. Initial recovery is usually within 2 to 3 months and full recovery is within 3 to 6 months. About 80% of patients will fully recover.[4]
[edit]On-going research
Both eccentric loading and extracorporeal shockwave therapy are currently being researched as possible treatments for tendinosis. One study found both modalities to be equally effective in treating tendinosis of the Achilles tendon and more effective than a 'wait and see' approach.[5] Other treatments for which research is on-going includes vitamin E, nitric oxide and stem cell injections.
[edit]Eccentric loading
Perhaps the most promising avenue of therapy is indicated in a line of research finding dramatic rates of recovery including complete remodeling of chronically damaged tendon tissue witheccentric loading.[6][7][8][9][10][11][12][13]
[edit]Inflatable brace
The use of an inflatable brace (AirHeel) was shown to be as effective as eccentric loading in the treatment of chronic Achilles tendinopathy. Both modalities produced significant reduction in pain scores, but their combination was no more effective than either treatment alone.[14]
[edit]Shock-wave therapy
Shock-wave therapy (SWT) may be effective in treating calcific tendinosis in both humans[15] and rats.[16] In rat subjects, SWT increased levels of healing hormones and proteins leading to increased cell proliferation and tissue regeneration in tendons. Another study found no evidence that SWT was useful in treating chronic pain in the Achilles tendon.[17]
[edit]Tendon Bioengineering
The future of non-surgical care for tendinosis is likely bioengineering. Fan has demonstrated that ligament reconstruction is possible using mesenchymal stem cells and a silk scaffold.[18]Long has also demonstrated that these same stem cells were capable of seeding repair of damaged animal tendons.[19]
[edit]Vitamin E
Vitamin E has been found to increase the activity of fibroblasts, leading to increased collagen fibrils and synthesis, which seems to speed up the regeneration and increase the regenerative capacity of tendons.[20][21]
[edit]Nitric oxide
Nitric oxide (NO) also appears to play a role in tendon healing[22] and inhibition of NO synthesis impairs tendon healing.[23] Supplementing with arginine, the amino acid that the body uses to form NO, may be useful in tendon healing.[24] The use of a NO delivery system (glyceryl trinitrate patches) applied over the area of maximal tenderness was tested in three clinical trials for the treatment of tendinopathies and was found to significantly reduce pain and increase range of motion and strength.[25]
[edit]References
- ^ "Understanding tendinopathies -- Murrell 36 (6): 392 -- British Journal of Sports Medicine". Retrieved on 2008-01-29.
- ^ Khan, K.M.; Cook, J.L., Kannus, P., Maffulli, N., Bonar, S.F. (2002-03-16). "Time to abandon the "tendinosis" myth: Painful, overuse tendon conditions have a non-inflammatory pathology". British Medical Journal324: 626–627. doi:. PMID 11895810. Retrieved on 2007-04-02.
- ^ Marsolais D, Duchesne E, Côté CH, Frenette J. (2007). "Inflammatory cells do not decrease the ultimate tensile strength of intact tendons in vivo and in vitro: protective role of mechanical loading". J Appl Physiol 102(1): 3–4. PMID 16916923.
- ^ Wilson, J.J.; Best, T.M. (2005). "Common overuse tendon problems: A review and recommendations for treatment" (PDF). American Family Physician (American Academy of Family Physicians.) 72 (5): 811–818. Retrieved on 2007-04-02.
- ^ Rompe JD, Nafe B, Furia JP, Maffulli N (2007). "Eccentric loading, shock-wave treatment, or a wait-and-see policy for tendinopathy of the main body of tendo Achillis: a randomized controlled trial". Am J Sports Med 3 (35): 374–83. PMID 17244902. Retrieved on 2007-06-06.
- ^ Alfredson Tom , MD, Håkan; Pietilä, T., Jonsson, P. & Lorentzon, R. (1998). "Heavy-Load Eccentric Calf Muscle Training For the Treatment of Chronic Achilles Tendinosis". The American Journal of Sports Medicine(American Orthopaedic Society for Sports Medicine) 26: 360–366. PMID 9617396. Retrieved on 2007-04-02.
- ^ Mafi, N.; Lorentzon R. & Alfredson H. (2001). "Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis". Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA (Springer International) 9 (1): 42–47. doi:. 11269583. Retrieved on 2007-04-02.
- ^ Fahlstrom ., M.; Jonsson P., Lorentzon R. & Alfredson H. (2003). "Chronic Achilles tendon pain treated with eccentric calf-muscle training". Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA (Springer International) 11 (5): 327–333. doi:. 12942235. Retrieved on 2007-04-02.
- ^ Roos, E.M.; Engstrom M., Lagerquist A. & Soderberg B. (2004). "Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathy -- a randomized trial with 1-year follow-up". Scandinavian Journal of Medicine & Science in Sports (Munksgaard International Publishers) 14 (5): 286–295. doi:. 15387802. Retrieved on 2007-04-02.
- ^ Öhberg, L.; Lorentzon R. & Alfredson H. (2004). "Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up". British Journal of Sports Medicine(BMJ Publishing Group Ltd.) 38: 8–11. doi:. PMID 14751936.
- ^ >Jonsson, P.; Alfredson H. (2005). "Superior results with eccentric compared to concentric quadriceps training in patients with jumper's knee: a prospective randomised study". British journal of sports medicine(BMJ Publishing Group) 39 (11): 847–850. doi:. 16244196. PMID 16244196. Retrieved on 2007-04-02.
- ^ Wilson, J.J.; Best, T.M. (2005). "Common overuse tendon problems: A review and recommendations for treatment" (PDF). American Family Physician (American Academy of Family Physicians.) 72 (5): 811–818. Retrieved on 2007-04-02.
- ^ Rees, J.D.; Wilson A.M. & Wolman R.L. (2006). "Current concepts in the management of tendon disorders". Rheumatology (Oxford University Press) 45 (5): 508–521. doi:. 16490749.PMID 16490749. Retrieved on 2007-04-02.cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17062655 | accessdate = 2007-06-06 |doi=10.1136/bjsm.2006.029769 }}
- ^ Petersen W, Welp R, Rosenbaum D (June 14, 2007). "Chronic Achilles Tendinopathy: A Prospective Randomized Study Comparing the Therapeutic Effect of Eccentric Training, the AirHeel Brace, and a Combination of Both". Am J Sports Med. PMID 17569792.
- ^ Cacchio A, Paoloni M, Barile A, Don R, de Paulis F, Calvisi V, Ranavolo A, Frascarelli M, Santilli V, Spacca G (2006). "Effectiveness of radial shock-wave therapy for calcific tendinosis of the shoulder: single-blind, randomized clinical study". Phys Ther 5 (86): 672–82. PMID 16649891. Retrieved on 2007-06-06.
- ^ Chen YJ, Wang CJ, Yang KD, Kuo YR, Huang HC, Huang YT, Sun YC, Wang FS (2004). "Extracorporeal shock waves promote healing of collagenase-induced Achilles tendinosis and increase TGF-beta1 and IGF-I expression". J Orthop Res 22 (4): 854–61. doi:. PMID 15183445. Retrieved on 2007-06-06.
- ^ Costa ML, Shepstone L, Donell ST, Thomas TL (2005). "Shock wave therapy for chronic Achilles tendon pain: a randomized placebo-controlled trial". Clin Orthop Relat Res 440 (440): 199–204.doi:. PMID 16239807. Retrieved on 2007-06-06.
- ^ Fan H, Liu H, Wong EJ, Toh SL, Goh JC.. "In vivo study of anterior cruciate ligament regeneration using mesenchymal stem cells and silk scaffold". PubMed.
- ^ Long et al.. "Repair of rabbit tendon by autologous bone marrow mesenchymal stem cells". PubMed.
- ^ Gonzalez, Santander R; Plasencia Arriba MA, Martinez Cuadrado G, Gonzalez-Santander Martinez M & Monteagudo de la Rosa M. (1996). "Effects of "in situ" vitamin E on fibroblast differentiation and on collagen fibril development in the regenerating tendon". The International Journal of Developmental Biology (University Of The Basque Country Press) 1 (Supplemental): 181–182. PMID 9087752.
- ^ Plasencia., M.A.; Ortiz C., Vazquez B., San Roman J., Lopez-Bravo A., Lopez-Alonso A. (1999). "Resorbable polyacrylic hydrogels derived from vitamin E and their application in the healing of tendons". Journal of Materials Science. Materials in Medicine (Kluwer Academic Publishers) 10 (10/11): 641–648. doi:. PMID 15347979.
- ^ Xia, W.; Szomor Z., Wang Y. & Murrell G.A. (2006). "Nitric oxide enhances collagen synthesis in cultured human tendon cells". Journal of Orthopaedic Research : Official Publication of the Orthopaedic Research Society (Wiley) 24 (2): 159–172. doi:. 16435353. Retrieved on 2007-04-02.
- ^ Darmani, H.; Crossan J.C. & Curtis A. (2004). "Single dose of inducible nitric oxide synthase inhibitor induces prolonged inflammatory cell accumulation and fibrosis around injured tendon and synovium". Mediators of Inflammation (Hindawi Pub. Corp.) 13 (3): 157–164. doi:. 15223606.
- ^ Erickson, Laurie (2002-07-01). "Future Treatments". Retrieved on 2007-04-02.
- ^ Murrell GA. (2007). "Using nitric oxide to treat tendinopathy". Br J Sports Med 41 (4): 227–31. doi:. PMID 17289859.
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