Tendinopathy

Tendinopathy refers to a disease of a tendon. The clinical presentation includes tenderness on palpation and pain, often when exercising or with movement.[1]

Three terms have evolved in the medical terminology to refer to injuries that cause tendon pain:

Tendon injuries arise from a combination of intrinsic and extrinsic factors; acute tendon injuries may be predominantly caused by extrinsic factors, whereas in overuse syndromes as in the case of tendinopathy it may be caused by multifactorial combinations of both intrinsic and extrinsic factors. An example of an intrinsic factor for tendinopathies are: poor biomechanics such as limb malalignments and hyperpronation that may cause increased traction loads acting on the foot and ankle that may increase the incidence of Achilles, flexor hallucis longus muscle, and tibialis posterior muscle tendinopathies.

Epidemiology

Tendon injury and resulting tendinopathy are responsible for up to 30% of consultations to sports doctors and other musculoskeletal health providers.[2] Tendinopathy is most often seen in tendons of athletes either before or after an injury but is becoming more common in non-athletes and sedentary populations. For example, the majority of patients with Achilles tendinopathy in a general population-based study did not associate their condition with a sporting activity.[3] In another study the population incidence of Achilles tendinopathy increased sixfold from 1979-1986 to 1987-1994.[4]

Etiology

The exact etiology of tendinopathy has not been fully elucidated and different stresses may induce varying responses in different tendons. There are multifactorial theories that could include: tensile overload, tenocyte related collagen synthesis disruption, load-induced ischemia, neural sprouting, thermal damage, and adaptive compressive responses. The intratendinous sliding motion of fascicles and shear force at interfaces of fascicles could be an important mechanical factor for the development of tendinopathy and predispose tendons to rupture.[5] Obesity, or more specifically, adiposity or fatness, has also been linked to an increasing incidence of tendinopathy.[6]

The most commonly accepted cause for this condition however is seen to be an overuse syndrome in combination with intrinsic and extrinsic factors leading to what may be seen as a progressive interference or the failing of the innate healing response.

Tendinopathy can be induced in animal models by a surgical injury to the tendon. In both sheep shoulder (infraspinatus)[7] and horse forelimb (superficial digitor flexor)[8] tendons, a mid-tendon transection caused pathology in the entire tendon after four and six weeks respectively.

Treatment

Steroid injections are helpful in the short term (first approximately 4 weeks) however, their long term effectiveness is not known, and quality of evidence for its use remains poor and controversial.[9] Other, more conservative and non-surgical, treatment options available for the management and treatment of tendinopathy include: rest, ice, massage therapy, eccentric exercise, NSAIDs, ultrasound therapy, LIPUS, electrotherapy, taping, sclerosing injections, blood injection, glyceryl trinitrate patches, and (ESWT) extracorporeal shockwave therapy. Studies with a rat model of fatigue-damaged tendons suggested that delaying exercise until after the initial inflammatory stage of repair could promote remodelling more rapidly.[10]

Nutraceuticals

Recent study of a newly developed proprietary nutraceutical formulation that includes mucopolysaccharides, collagen and vitamin C (Tendoactive), in an in vitro model of tendon inflammation shows that it reversed the IL-1β-induced down-regulation of collagen type I and β1-integrin receptor expression. [11] Tendoactive may therefore be used on prophylaxis and treatment of tendinopathies to stimulate tendon healing, regeneration and repair. [12] Recent clinical studies shows the efficacy and safety of a nutritional supplement containing mucopolysaccharides, type I collagen and vitamin C on the clinical and structural evolution of tendinopathies of the Achilles tendon, patellar tendon and lateral epicondyle tendon in the elbow. A significant reduction in pain both at rest and when active was observed between the first control visit for all three types of tendinopathy. Nutraceutical formulation Tendoactive decreased the thickness of Achilles tendon, patellar tendon and lateral epicondyle tendon. Tendoactive found to be safe and effective for improving the clinical symptoms and structural evolution of tendinopathies of the Achilles, patella and lateral epicondyle tendons. [13] Tendoactive significantly reduced pain and improved the biomechamical properties of the joint and found to be effective for the management of various tendinopathies and plantar fasciitis. [14]

References

  1. ↑ "Management of tendinopathy". Am J Sports Med. 37: 1855–67. Sep 2009. doi:10.1177/0363546508324283. PMID 19188560.
  2. ↑ "Assessing health needs in primary care. Morbidity study from general practice provides another source of information". BMJ. 310: 1534. Jun 1995. doi:10.1136/bmj.310.6993.1534d. PMID 7787617.
  3. ↑ de Jonge S; et al. (2011). "Incidence of midportion Achilles tendinopathy in the general population". Br J Sports Med. 45: 1026–8. doi:10.1136/bjsports-2011-090342. PMID 21926076.
  4. ↑ Leppilahti J, Puranen J, Orava S. Incidence of Achilles tendon rupture. Acta Orthop Scand. 1996;67:277-9
  5. ↑ Sun, Y-L; et al. (2015). "Lubricin in Human Achilles Tendon: The Evidence of Intratendinous Sliding Motion and Shear Force in Achilles Tendon". J Orthop Res. 33: 932–7. doi:10.1002/jor.22897.
  6. ↑ Gaida JE, Ashe MC, Bass SL, Cook JL (2009). "Is adiposity an under-recognized risk factor for tendinopathy? A systematic review". Arthritis Rheum. 61: 840–9. doi:10.1002/art.24518. PMID 19479698.
  7. ↑ Smith MM; et al. (2008). "Modulation of aggrecan and ADAMTS expression in ovine tendinopathy induced by altered strain". Arthritis Rheum. 58: 1055–66. doi:10.1002/art.23388. PMID 18383380.
  8. ↑ Jacobsen E; et al. (2015). "Focal experimental injury leads to widespread gene expression and histologic changes in equine flexor tendons". PLOS ONE. 10 (4): e0122220. doi:10.1371/journal.pone.0122220. PMC 4383631Freely accessible. PMID 25837713.
  9. ↑ "Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials : The Lancet". 2010.
  10. ↑ Bell R, Boniello MR, Gendron NR, Flatow EL, Andarawis-Puri N (2015). "Delayed exercise promotes remodeling in sub-rupture fatigue damaged tendons.". J Orthop Res. 33 (6): 919–25. doi:10.1002/jor.22856. PMID 25732052.
  11. ↑ Shakibaei, M; Buhrmann, C; Mobasheri, A (2011). "Anti-inflammatory and anti-catabolic effects of TENDOACTIVE® on human tenocytes in vitro". HISTOLOGY AND HISTOPATHOLOGY Cellular and Molecular Biology. 26 (9): 1173-85. doi:10.14670/HH-26.1173. PMID 21751149.
  12. ↑ Torrent, A; Ruhí, R; Cid, M; Csaki, C; Shakibaei, M (2009). "472 USING A CULTURE MODEL OF HUMAN TENOCYTES TO INVESTIGATE THE EFFECTIVENESS OF TENDOACTIVE® FOR THE PROPHYLAXIS AND TREATMENT OF TENDINOPATHIES". Osteoarthritis and Cartilage. 17 (Supplement 1): S252–S253. doi:10.1016/S1063-4584(09)60493-3.
  13. ↑ Arquer, A; García, M; Laucirica, JA; Rius, M (2014). "The efficacy and safety of oral mucopolysaccharide, type I collagen and vitamin C treatment in tendinopathy patients". Apunts Med Esport. 49 (182): 31-36.
  14. ↑ Nadal, F; Bove, T; Sanchís, D; Martinez-Puig, D (2009). "473 EFFECTIVENESS OF TREATMENT OF TENDINITIS AND PLANTAR FASCIITIS BY TENDOACTIVE™". Osteoarthritis and Cartilage. 17 (Supplement 1): S253. doi:10.1016/S1063-4584(09)60494-5.

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