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Dr James Brown MBChB MSc FFSEM(UK) Consultant Sports Physician Sports Doc British Triathlon Director Health Partners Europe Director Benchmark 54 Injury Analytics james.brown5@nhs.net
Interventional treatment for Tendons
When
Why
What
How
Overview
• Anatomy • What happens to tendons in tendinopathy • Histopathology – Clues for therapies ? • Science** - What science its mainly theoretical • When do you need an interventionist ? – not
often but If you do choose carefully we are not all the same !
Achilles Tendon Anatomy
Achilles tendon encased by paratenon –there is no synovial sheath. Functions as an elastic sleeve that permits free movement of tendon against surrounding tissue
The tendon comprised of an extra celluar matrix tenoblasts, fibroblasts and dry mass comprised largely of type 1 collagen
Endotenon septae
FAT
Crural Fascia
Nerve fibres form rich plexuses of the paratenon pierce the epitenon and lay on the tendon surface responsible for nocioceptors and mechanoreceptors
Paratenon highly vascularised provides part of tendons blood supply, however there is a hypovascular area 4cm from insertion on calcaneus
Endotenon: – thin network of
crisscross collagen fibrils
– envelopes the primary, secondary and tertiary fiber bundles together
– allows fiber bundles to glide with respect to each other
– carry blood vessels, nerves and lymphatics to tendon
(From “Human Tendons” by Józsa and Kannus)
collagen fibril (20-150 nm), collagen fiber (1-50 µm), tendon(2-12 mm) Vitamin C important in
collagen synthesis!
(From “Human Tendons” by Józsa and Kannus)
ECM GAG’s Different in different loading conditions WATER Gycoproteins
repair regenerate adhesive
Proteoglycans • water retention [hydrophllyic] • collagen fibrillogenesis • “gluing” of collagen fibrils
Fibroblasts / Tenocytes aligned along fibrils EC Matrix synth from tenoblasts
STRESS
The cellular deformation which occurs with ECM strain produces tension in the cytoskeleton which can be sensed by the cell nucleus through a mechano-sensory tensegrity system to elicit a metabolic response
Science
Science
Mechanical Strain
Change cellular activity of tenocytes
Increased rate of collagen turnover mainly Anabolic max at 11 weeks
Other factors Age / Genetic predisposition / fatigue / neuromuscular
control /smoking / vascularity ..
Flouroquinolone Antibiotics e.g. Ciprofloxacin
Single Event
Collagen fibrillar
damage
Smaller strains microscopic
trauma repetitive
No Clinical symptoms
Change cellular activity of tenocytes
Changes in activity of MMP’s Collagenases other enzymes Increase Collagen
cleaving à + denaturing
Increase immature collagen
Increase PG / Intra-fibrillar GAG
Increase Water Content
Matrix remodelling process abnormal due to failure of the regulatory process MMP-3 MMP-1 responsible
Collagen fibrillar
damage
Relaxation of surrounding ECM
Understress of ECM
Smaller strains microscopic
trauma repetitive overuse!!
Matrix disorganisation Increased immature collagen Increased water content due to increased amounts of ECM - PG’s GAG’s
Normal Tendon 0.6 cm
ACHILLES TENDON
The Art of treating Tendinopathy! • Tendinopathy can be cured in a clinical sense. • Overload is bad for tendons but so is drastic
underload (i.e. complete rest, plaster). • The ‘art’ of managing tendinopathy is being
able to teach the patient to moderately load the tendon and increase this load gradually as tendon function improves
• Eccentric only – no longer panacea. Add in concentric strengthening. Monitor load carefully everyone is different.
Non Responders
Continue Alfredson Program
Paratenon* distension
Focal * dry needling
Intratendinous* prolotherapy
Autologous Blood / PRP Stem Cells*
GTN Patches Imaging
Consider other diagnoses ASTM
*Level IV evidence only
*
*
*
Sero negative spondyloarthropathy
Intervention ?
Phase 1: pain after activity (immediate - 12 hours) which is
palpable at injury site
Phase 2: pain during & after activity - no significant impairment - eventually resolves
Phase 3: pain during & after activity - significant impairment - eventually
resolves
Phase 4: pain all the time accompanied by significant impairment – prognosis not great
High Volume Injection High Volume injection Total 50mls Large volume of saline Paratenon US guidance (With LA and small dose of Steroid) Results 80+% return to sport Numerous Premiership & Championship players Long term results may depend on continuing eccentric loading 200+ performed Submitted for publication in CJSM
Post procedure management 3 days rest Eccentric loading Return to running after 7-10 days under supervision Full training at 2 weeks depending on duration of symptoms Repeat only if still pain or recurs
Prolotherapy – dextrose / PRP
Mechanism
Proliferation of fibroblastic activity decrease in tendon repair time increased collagen fibre organisation increased cellular proliferation Increase in certain growth factors responsible for tissue healing Overall somewhat theoretical however there are a number of studies now showing some positive value
Research quality is still of low value and certainly more studies are needed one of the main issues in PRP is quantifying concentrations of platelets and the actual preparation of the sample
AJR:189, October 2007 1ml 2% lidocaine + 1ml 50% dextrose Ultrasound Guided 0.5ml per injection site max 4 – 5 injections 6 weeks apart Outcomes VAS Activity Changes on US
Intratendinous Prolotherapy
INTRATENDINOUS PROLO
Better outcome and lower cost than conventional care
Physio cost – 14 sessions over 6/12 £ 960
Injection cost inc staff and equip £ 234
Patient playing cricket again biking and happy
Ostenil Tendon – us guided injection of the paratenon possible use in fascio – crural disruption of the Achilles tendon
Lubricating the tendon could reduce pain, improve tendon function and reduce the potential for adhesions.
The lubricating and visco-elastic properties of OSTENIL® TENDON promote tendon gliding and the physiological repair process. In addition,
due to its macro-molecular structure
My Summary
Intervention should only be considered if it is justified Most athletic tendons can be rehabilitated Match the intervention with the structural problem found Often this is done by experience of using different modalities Don’t just stick to one you need experience in all to offer the best outcome Don’t be pushed into intervention in elite sport by the athlete or the “specialist” weigh up the pros and cons and the likelyhood of success in a given time frame
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