Novel Treatments for Tendon Injury

Peter Gonzalez, MD Assistant Professor

Department of Physical Medicine & Rehabilitation Eastern Virginia Medical School Director, EVMS Sports Medicine

Nothing to disclose

Define tendon injury

Review traditional treatments

Discuss emergence of MSK US for muscle-tendon pathology

Discuss novel procedures for treatment of tendon disorders

Conclusions

Tendon Pathology

Tendinitis: acute tendon injury ◦ Presumed inflammatory

mediators ◦ Limited evidence

Tendinosis: chronic tendon pain (?injury) ◦ Result of cumulative trauma ◦ Absence (minimal)true

inflammation ◦ Weakening of collagen

cross-linking ◦ Poor vascularity-

neovascularization of tendon

Tendinopathy: Clinical term

Normal Tendon

Injury

Degeneration

Inflammatory Phase

1. 2.

Theory of Tendinosis

Mechanical ◦ Repeated loading within physiological stress range of the

tendon ◦ Chronic repetitive injury or cumulative trauma

Vascular ◦ Hypovascularity to tendons ◦ Proximal to tendon-bone interface ◦ Blood flow decreased w overuse

Neural ◦ Uncertain hypothesis ◦ Chronic overuse leads to increased neural stimulation

and mast cell degranulation

Susceptible Tendons

Area Tendons

Shoulder Rotator cuff (SupS), biceps

Forearm Forearm extensors/flexors

Knee Patella, quadriceps tendon

Leg/foot Achilles, post. tibialis

Traditional treatments

RICE

NSAIDs

Bracing or splinting

Physical therapy ◦ Modalities-ICE,heat, US, electrical stimulation, iontophoresis, phonophoresis

◦ Eccentric strengthening

◦ Flexibility program

Corticosteroid injections

,

Coombes et al (JAMA,2013) ◦ PT/corticosteroid/placebo injection for lateral

epicondylagia ◦ 165 patients w unilateral LE for >6m ◦ At 4weeks:

◦ Corticosteroid effect w/wo PT ◦ CS>placebo injection

◦ At 1 yr: ◦ Corticosteroid (CS) group showed lower recovery rates and

greater recurrence compared to placebo injection ◦ No difference in PT or no-PT groups

◦ Conclusion: CS injections for LE may have short-term benefits but

poorer results in the long-term Physiotherapy did not provide LT benefit

MSK US

Growth of MSK Ultrasound for diagnosis

Percutaneous procedures with US-guidance

Applications for MSK US

Shoulder

Rotator cuff tear

Bursitis

Elbow

Tennis elbow

Golfers elbow

Cubital tunnel syndrome

Wrist

Arthritis

Carpal tunnel syndrome

Hand Trigger finger

Cysts

Hip

Tendonitis/bursitis

Knee

Baker’s cyst

Tendon tear

Foot/Ankle

Achilles tendon injury

Nerves

Muscles

Etc, etc, etc, etc…..

Tendons

In long axis (LA), fibrillar pattern of hyperechoic parallel patterns

In short axis (SA), appears as round/oval hyperechoic structures

Tendinosis

Normal

Abnormal

Tenotomy

Needle insertions into tendon

◦ Break up scar tissue

◦ Promote bleeding

◦ Prompt body’s own healing response

Tenotomy

LE C

Needle

Tenotomy

Does evidence exist for tenotomy? ◦ McShane et al (J Ultra Med, 2008)

◦ Housner et al (J Ultra Med, 2009)

Tenotomy

McShane et al (J Ultrasound Med,2008) ◦ US guided percutaneous tenotomy for refractory common extensor tendinosis (Lateral epicondylagia)

◦ 57 consecutive patients ◦ Phone interview follow-up at average 22 months (7-34m)

◦ Procedure: Fenestrate tendinotic tissue, break up calcifications, abrade bone

◦ 58% (excellent), 35% (good), 2% fair, 5.8% poor

Tenotomy

Housner et al (J Ultrasound Med,2009) ◦ Effectiveness of tenotomy for various tendons in

body ◦ Treated 14 tendons in 13 patients

Patellar tendon (5) Achilles (4) Proximal gluteus medius (1) Proximal ITB (1) Proximal hamstring (1) CET (1) Proximal rectus femoris (1)

◦ Failed phys therapy and >6 month history of pain ◦ Outcomes: VAS prior, at 4 weeks, at 12 weeks

Tenotomy

◦ Procedure:

US-guided percutaneous needle tenotomy

◦ Results:

Baseline VAS: 5.8 +/- 0.6

Significant pain reduction at 4 weeks (2.4 +/- 0.7) and 12 weeks (2.2 +/- 0.7)

◦ Conclusion:

Effective in improving symptoms without complications

Tenotomy Pat tendinosis

Housner, 2009

Tenotomy GMed

Housner, 2009

PRP

Blood plasma with high concentration of platelets

Drawn from patient and placed to centrifuge

Injected into region of interest

PRP Process

Sampson, 2008

Platelet-poor Platelet-rich plasma

PRP

Selected growth factors: ◦ Platelet-derived GF

Mesenchymal stem cells

◦ Transforming GF-B Enhances extracellular

matrix production

◦ Vascular endothelial GF Stimulates

angiogenesis

Other factors/cytokines: ◦ Adenosine

Prevents tissue injury through inflammatory cascade

◦ Serotonin Increases capillary

permeability

Effects on fibroblasts

◦ Histamine Increases capillary

permeability

◦ Calcium

PRP

Does clinical evidence exist for PRP?

◦ Mishra et al (Am J Sports Med, 2006)

◦ Filardo et al (Int Ortho, 2009)

◦ deVos et al (JAMA, 2010)

◦ Gosens et al (Am J Sports Med, 2011)

◦ Finnoff et al (PMR, 2011)

PRP

Mishra, et al (AJSM,2006) ◦ 15 PRP, 5 controls for ‘chronic elbow tendinosis’

Autologous PRP vs bupivacaine inj

◦ Reduction in pain seen in PRP-cohort

At 8 weeks, 60% improvement in VAS (vs 16%)

At 6 months, 81% improvement in VAS

At average of 25m, 93% improvement in VAS

PRP

Filardo et al (Int Ortho, 2009) ◦ Patellar tendinosis (‘jumper’s knee’)

◦ Prospective case control PRP + PT (n=15)

PT-only (n=16)

◦ At 6m: Improved function and pain in both groups Greater improvement in sports

activity in PRP

PRP

deVos et al (JAMA, 2010) ◦ RCT of PRP vs saline injections for Achilles tendinopathy

N=54

Chronic mid-portion Achilles injury

◦ Both groups treated w eccentric ex

◦ Both groups improved after 24 wks

No sign. benefit in PRP group for pain, function, or patient satisfaction

PRP

Gosens et al (Am J Sports Med,2011) ◦ DB-RCT w 100 subjects

Compared PRP-corticosteroid injection for lat epi

◦ At 2 yrs, both groups improved in pain and function

Improvement w CS declined over time

Improvement w PRP was maintained

PRP group showed better functional outcomes

PRP

Finnoff et al (PMR,2011) ◦ Case series (n=34) w

tendinopathy

◦ Patients received tenotomy & PRP

◦ Pre and post MSK US examination

◦ 83% ‘satisfied’ with the results

◦ Sign. improvements in pain and functional scores

◦ MSK US remained ‘abnormal’ improvements noted

Conclusions

Tendinosis, not tendinitis

Traditional treatments remain traditional ◦ RICE, eccentric exercises

MSK US for diagnostic and therapeutic purposes

Corticosteroids: Use with caution

Novel treatments are emerging ◦ Needle tenotomy/autologous PRP

Peter G. Gonzalez, MD Assistant Professor

Eastern Virginia Medical School

Department of Physical Medicine and Rehabilitation

Director, EVMS Sports Medicine

Team Physician, Hampton University

Team Physician, Norfolk Public Schools