Current pharmacological approaches to the treatment of tendinopathy.

INTRODUCTION: Tendinopathies are common in elite and recreational athletes: traditionally considered overuse injuries, they involve excessive tensile loading and subsequent breakdown of the loaded tendon. Many pharmacological treatments have been proposed for the management of tendinopathy, with no agreement regarding the overall best option available both for Achilles and patellar tendinopathy. AREAS COVERED: The present article reports the best scientific evidence regarding the efficacy and safety of different pharmacological treatments in different types of tendinopathy, focusing on Achilles and patellar tendinopathy, the conditions on which more studies have been published. EXPERT OPINION: No univocal evidence exists regarding the best non-operative management, which includes non-steroidal anti-inflammatory drugs, platelet-rich plasma, high volume image-guided injections, hyaluronic acid, and prolotherapy, for tendinopathy (in particular Achilles and patellar tendinopathies) as a suitable alternative to the commonly used eccentric loading rehabilitation regimen. It is unclear whether the combination of pharmacological substances with physical therapy would produce better results than physical therapy alone. There is an overall lack of published well-performed randomized controlled trials comparing the various options available for the management of tendinopathy, studying large cohorts of patients for adequately long follow-up periods and with well-validated standardized scores and scales.

Deep Friction Massage in the Management of Patellar Tendinopathy in Athletes: Short-Term Clinical Outcomes.

CONTEXT: Deep friction massage (DFM) is often used in the treatment of tendinopathies; however, the pressure applied may vary and interfere with the obtained results. OBJECTIVE: To assess whether the immediate effects of DFM on pain (pain intensity and time to onset of analgesia) and muscle strength are dependent on the pressure applied during the DFM application in athletes with patellar tendinopathy. DESIGN: Randomized, controlled, cross-over trial. SETTING: University research laboratory (institutional). PARTICIPANTS: Ten athletes with diagnosis of unilateral patellar tendinopathy (age 27.90 [5.24] y). INTERVENTIONS: All participants attended 4 sessions, 3 treatment sessions with DFM applied with different pressures (the mean pressure-previously determined for each participant-and the mean pressure ± 25%) and a control session, each of which was separated by 48 hours. MAIN OUTCOME MEASURES: Pain (intensity upon palpation and time to onset of analgesia), and muscle strength of knee extensors were assessed before and immediately after each session. RESULTS: Pain intensity changed significantly over time (F1,9 = 52.364; P < .001; ηp2=.853) and among sessions (F3,27 = 82.588; P < .001; ηp2=.902), with a significant interaction for group × time (F3,27 = 19.841; P < .001; ηp2=.688). The knee extensors strength did not change significantly over time (F1,9 = 2.240; P = .17; ηp2=.199), nor a significant interaction for session × time was observed (F3,27 = 3.276; P = .07; ηp2=.267). Regardless of the pressure applied, the time to onset of analgesia was not significantly different (F2,18 = 1.026; P > .05; ηp2=.102). CONCLUSION: It was shown that DFM induces an immediate reduction in pain intensity upon palpation, regardless of the pressure performed. Notwithstanding, the reader should take into account the small sample size and the caution needed in the results' interpretation.

The Jumper's Knee - a New Look at Non-surgical Treatment. Pilot Study.

BACKGROUND: There are many opinions and views regarding the methods of treatment of patellar ligament enthesopathy. No gold standard of treatment exists. This paper presents our approach involving conservative treatment and an appropriate rehabilitation regime. Our aim was to assess the effectiveness of a combination of various conservative treatment techniques and the time needed to return to sport. MATERIAL AND METHODS: The study enrolled 14 patients treated in 2019 and 2020. Knee joint evaluation was based on clinical and radiological examination (sonography and MR). All patients were treated conservatively according to a specially prepared treatment protocol. Patients were evaluated at two-week intervals until the symptoms subsided completely. The KOOS, Kujala and SF36 questionnaires were used to evaluate the results. RESULTS: All of the patients returned to painless physical activity within 3-4 weeks from the start of treatment. In the group of professional athletes, 100% returned to sport. The return to sport took slightly longer for pa-tients with bilateral (5-6 weeks) in comparison to unilateral jumper's knee (3-4 weeks). The longest period of return to sport, in a patient who had severe pain at rest before starting treatment, was 7 weeks. Statistically significant improvement was noted in all of the questionnaires used and in all subdomains at 6 months after the beginning of the treatment. CONCLUSIONS: 1. The conservative approach proposed by us generated promising results in the treatment of the jumper's knee. 2. A 100% rate of return to sport was recorded among our patients.

Double-Blind Randomized Controlled Trial: Injection of Autologous Blood in the Treatment of Chronic Patella Tendinopathy-A Pilot Study.

OBJECTIVE: To assess the efficacy of autologous blood injections (ABIs) against saline in patients with chronic recalcitrant patella tendinopathy (PT). DESIGN: Double-blind randomized controlled study. SETTING: Homerton Hospital Sports Medicine department. PATIENTS: Those with a diagnosis of refractory patellar tendinopathy were recruited between March 2010 and March 2012. INTERVENTIONS: Using 2 practitioners, patients were randomized to either receive ABIs or saline injections. MAIN OUTCOME MEASURES: All patients completed the Short-Form McGill Pain Questionnaire (MPQ), a visual analog scale (VAS), and a Victoria Institute of Sport Assessment for Patella Tendinopathy scale over a 12-month period. RESULTS: Twenty-two patients completed the final review at 12 months and were included in the study. Subjects ranged in age from 22 and 61 years and were randomized to 11 in each ABI and saline groups. Autologous blood injection group had a mean duration of symptoms of 16.7 months, whereas that of the saline group was 19.2 months. The saline group mean VAS score was reduced from 7.9 to 4.5 at 1 month (P = 0.003) and 3.3 (P = 0.005) at 1 year. With ABI, the score was reduced from 7.5 to 4.5 (P = 0.005) at 1 month and 3.1 (P = 0.003) at 1 year. Victoria Institute of Sport Assessment for Patella Tendinopathy, MPQ, and VAS scores improved significantly in both groups. CONCLUSIONS: This study demonstrated that both the ABI and saline groups experienced a significant improvement in symptoms. However, when the results were compared, there was no statistical difference between the 2 groups. CLINICAL RELEVANCE: This research showed that tendon fenestration is an alternative cost-effective treatment for recalcitrant PT.

Platelet-rich plasma: evidence for the treatment of patellar and Achilles tendinopathy--a systematic review.

Platelet-rich plasma (PRP) has been introduced in the clinical practice to treat a growing number of different musculoskeletal pathologies. It is currently applied in the treatment of Achilles and patellar tendinopathies, which are common sport-related injuries very challenging to manage. Aim of the present paper was to review systematically the available clinical evidence concerning the application of PRP in the treatment of patellar and Achilles tendinopathy. A systematic review of the literature was performed according to the following inclusion criteria for relevant articles: (1) clinical reports of any level of evidence, (2) written in the English language, (3) with no time limitation and (4) on the use of PRP to treat conservatively Achilles and patellar tendinopathy. Twenty-two studies were included and analyzed. Two studies on patellar tendinopathy were randomized controlled trials (RCTs), whereas just one RCT was published on Achilles tendon. All the papers concerning patellar tendon reported positive outcome for PRP, which proved to be superior to other traditional approaches such as shock-wave therapy and dry needling. In the case of Achilles tendon, despite the encouraging findings reported by case series, the only RCT available showed no significant clinical difference between PRP and saline solution. The main finding of this study was the paucity of high-level literature regarding the application of PRP in the management of patellar and Achilles tendinopathy. However, the clinical data currently available, although not univocal, suggest considering PRP as a therapeutic option for recalcitrant patellar and Achilles tendinopathies.

Combined magnetic fields accelerate bone-tendon junction injury healing through osteogenesis.

The objective of this study was to explore the effect of combined magnetic fields (CMFs) on osteogenesis and the remodeling of newly formed bone at bone-tendon (BT) junction. Forty-eight mature rabbits in whom partial patellectomy was performed were used to establish a BT junction injury model at the patella-patellar tendon (PPT) complex and were then allocated to CMF treatment group (CMF group) or placebo treatment group (control group). Daily CMF therapy was delivered continuously from post-operative day 3 to weeks 4, 8, and 16. At each time point, the animals were sacrificed, and the PPT complexes were harvested for radiographic, histological, peripheral quantitative computed tomography, and micro-computed tomography (micro-CT) evaluation. The area, length, and bone mineral density of the newly formed bone in the CMF group were significantly greater than the control group at post-operative weeks 8 and 16. The micro-CT results showed that the newly formed bone in the CMF group contained more and thicker trabeculae than the control group at weeks 8 and 16. Histologically, the CMF group showed better remodeling of the BT junction. In conclusion, CMF treatment was able to accelerate osteogenesis during BT junction repair, thus facilitating the healing of BT junction injury.

Enhanced patella-patellar tendon healing using combined magnetic fields in a rabbit model.

BACKGROUND: A combined magnetic field (CMF) is a composite of a dynamic sinusoidal magnetic field and a magnetostatic field. Stimuli from CMFs has proved to be an effective tool for healing problem fractures and spinal fusion procedures. HYPOTHESIS: Combined magnetic field technology will enhance healing of bone-tendon junction repair via endochondral ossification for regeneration of the fibrocartilage zone. STUDY DESIGN: Controlled laboratory study. METHODS: Forty-eight mature rabbits were randomly divided into CMF-treated and placebo-treated (control) groups. A partial patellectomy model was created. The CMF-treated group was subjected to CMF stimulation from the third postoperative day for 30 minutes per day up to weeks 8 or 16. At each time point, tissue samples were harvested and evaluated biomechanically and histomorphologically. The area of newly formed bone and the thickness of fibrocartilage were measured in hematoxylin and eosin-stained sections and toluidine blue-stained sections, respectively, while the density of fibrocartilage cells and the amount of proteoglycans were calculated using safranin O-stained sections. A biomechanical analysis was carried out to ascertain tensile strength. RESULTS: Quantitative histological measurements showed that the newly formed bone and regenerated fibrocartilage zone in the CMF-treated group increased by a respective 99.2% and 41.9% compared with the control group at week 8 and a respective 97.8% and 22.8% at week 16. In the CMF-treated group at postoperative week 16, the amount of proteoglycans was 36.9% more than that of the control group, but the density of fibrocartilage cells was just 71.4% of the control group; there were no significant differences at week 8. Mechanical test results showed that energy to failure was not significantly different between the 2 groups at week 8. Yet, at week 16, load to failure, ultimate strength, and energy to failure in the CMF-treated group (311.0 ± 59.4 N, 8.46 ± 1.41 MPa, and 0.87 ± 0.17 J, respectively) were significantly higher than those in the control group (247.1 ± 65.6 N, 6.84 ± 1.12 MPa, and 0.52 ± 0.15 J, respectively). CONCLUSION: Biophysical stimulation with CMFs enhances healing after bone-tendon junction injuries in a rabbit model. CLINICAL RELEVANCE: These results demonstrate the feasibility of using CMFs for stimulating bone-tendon healing after repair.

Management of chronic tendon injuries.

Chronic tendon injuries present unique management challenges. The assumption that these injuries result from ongoing inflammation has caused physicians to rely on treatments demonstrated to be ineffective in the long term. Nonsteroidal anti-inflammatory drugs should be limited in the treatment of these injuries. Corticosteroid injections should be considered for temporizing pain relief only for rotator cuff tendinopathy. For chronic Achilles tendinopathy (symptoms lasting longer than six weeks), an intense eccentric strengthening program of the gastrocnemius/ soleus complex improved pain and function between 60 and 90 percent in randomized trials. Evidence also supports eccentric exercise as a first-line option for chronic patellar tendon injuries. Other modalities such as prolotherapy, topical nitroglycerin, iontophoresis, phonophoresis, therapeutic ultrasound, extracorporeal shock wave therapy, and low-level laser therapy have less evidence of effectiveness but are reasonable second-line alternatives to surgery for patients who have persistent pain despite appropriate rehabilitative exercise.

Effect of androgenic-anabolic steroids and heavy strength training on patellar tendon morphological and mechanical properties.

Combined androgenic-anabolic steroids (AAS) and overloading affects tendon collagen metabolism and ultrastructure and is often associated with a higher risk of injury. The aim of this prospective study was to investigate whether such effects would be reflected in the patellar tendon properties of individuals with a history of long-term resistance training and AAS abuse (RTS group), compared with trained (RT) and untrained (CTRL) nonsteroids users. Tendon cross-sectional area (CSA), stiffness, Young's modulus, and toe limit strain were measured in vivo, from synchronized ultrasonography and dynamometry data. The patellar tendon of RT and RTS subjects was much stiffer and larger than in the CTRL group. However, stiffness and modulus were higher in the RTS group (26%, P < 0.05 and 30%, P < 0.01, respectively) than in the RT group. Conversely, tendon CSA was 15% (P < 0.05) larger in the RT group than in RTS, although differences disappeared when this variable was normalized to quadriceps maximal isometric torque. Yet maximal tendon stress was higher in RTS than in RT (15%, P < 0.05), without any statistical difference in maximal strain and toe limit strain between groups. The present lack of difference in toe limit strain does not substantiate the hypothesis of changes in collagen crimp pattern associated with AAS abuse. However, these findings indicate that tendon adaptations from years of heavy resistance training are different in AAS users, suggesting differences in collagen remodeling. Some of these adaptations (e.g., higher stress) could be linked to a higher risk of tendon injury.

Traumatic patellar dislocation: nonoperative treatment compared with MPFL reconstruction using patellar tendon.

BACKGROUND: Over the long term, acute patellar dislocations can result in patellar instability, with high recurrence rates after nonoperative treatment. PURPOSE: To compare the results of operative (reconstruction of the medial patellofemoral ligament [MPFL]) versus nonoperative treatment of primary patellar dislocation. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Thirty-nine patients (41 knees) (mean age, 24.2 years; range, 12-38 years) with acute patellar dislocation were randomized into 2 groups. One group was treated nonoperatively with immobilization and physiotherapy, the other was treated surgically with MPFL reconstruction; both groups were evaluated with minimum follow-up of 2 years. The Kujala questionnaire was applied to assess pain and quality of life, and recurrence was evaluated. Pearson χ(2) or Fisher exact test was used in the statistical evaluation. RESULTS: The statistical analysis showed that the mean Kujala score was significantly lower in the nonoperative group (70.8), when compared with the mean value of the surgical group (88.9; P = .001). The surgical group presented a higher percentage of "good/excellent" results (71.43%) on the Kujala score when compared with the nonoperative group (25.0%; P = .003). The nonoperative group presented a large number of recurrences and subluxations (7 patients; 35% of cases), whereas there were no reports of recurrences or subluxations in the surgical group. CONCLUSION: Treatment with MPFL reconstruction using the patellar tendon produced better results, based on the analyses of posttreatment recurrences and the better final results of the Kujala questionnaire after a minimum follow-up period of 2 years.

Re-revision of a patellar tendon rupture in a young professional martial arts athlete.

A 27-year-old professional martial arts athlete experienced recurrent right knee patellar tendon rupture on three occasions. He underwent two operations for complete patellar tendon rupture: an end-to-end tenorrhaphy the first time, and revision with a bone-patellar-tendon (BPT) allograft. After the third episode, he was referred to our department, where we performed a surgical reconstruction with the use of hamstring pro-patellar tendon, in a figure-of-eight configuration, followed by a careful rehabilitation protocol. Clinical and radiological follow-ups were realized at 1, 3, and 6 months and 1 and 2 years postop, with an accurate physical examination, the use of recognized international outcome scores, and radiograph and MRI studies. As far as we know, this is the first paper to report a re-revision of a patellar tendon rupture.

Patient guided Piezo-electric Extracorporeal Shockwave Therapy as treatment for chronic severe patellar tendinopathy: A pilot study.

BACKGROUND AND PURPOSE: Patellar tendinopathy is a common overuse injury for which no evidence-based treatment guidelines exist. Extracorporeal Shock Wave Therapy (ESWT) seems to be an effective treatment for patellar tendinopathy but the most beneficial treatment strategies still need to be ascertained. Aim of this pilot study was to investigate if patient guided Piezo-electric, focused ESWT, without local anesthesia is a safe and well tolerated treatment which improves pain and function in patients with patellar tendinopathy. METHODS: Nineteen male athletes with severe chronic patellar tendinopathy received 3 patient guided focused medium to high energy ESWT treatments at a weekly interval. Before and after 3 months VISA-P and VAS (pain) scores were recorded. Data on side effects and complications of treatment were also collected. RESULTS: No serious complications were reported and patients tolerated the treatment well. Mean VISA-P score improved from 36.1 to 50.1 (p < 0.05), VAS decreased from to 7.2 to 3.7 (p < 0.05). CONCLUSION: Patient guided Piezo-electric ESWT without local anesthesia is a safe and well tolerated treatment which should be considered as a treatment for patients with patellar tendinopathy.

Radix Dipsaci does not improve tendon healing in a rat model of patellar tendon donor site injury.

OBJECTIVE: To explore whether Radix Dipsaci (RD) exhibits beneficial effects on tendon healing. METHODS: An attempt was made to explore the in vitro effects of a hot water extract of RD on gene expression of procollagen Type I (COL1A1), procollagen Type III (COL3A1) and decorin in cultured tendon fibroblasts, and its in vivo effects in a well-established rat model of patellar tendon donor site injury. RESULTS: It was found that gene expression of COL3A1 and decorin in cultured tendon fibroblasts was significantly increased by RD, but that COL1A1 was not affected. In vivo studies showed that RD increased blood vessels in the wound but did not significantly affect the expression of COL1A1, COL3A1 and decorin at day 14 post-injury. The ultimate tensile stress of the healing tendon was not significantly improved by either local injection or oral administration of hot water extract of RD (P > 0.05). CONCLUSION: The present findings imply that RD per se does not significantly improve tendon healing. Further investigation of RD in a herbal formula may be necessary to test its efficacy in tendon injuries.

Thermal damage prediction for collagenous tissues part I: a clinically relevant numerical simulation incorporating heating rate dependent denaturation.

Subablative thermotherapy is frequently used for the treatment of joint instability related diseases. In this therapy, mechanically deformed collagenous tissues are thermally shrunk and the stability of the tissue is re-established. In this research, the thermal damage fields generated by three different clinical heating modalities (monopolar and bipolar radio frequency and Ho:YAG laser) are compared numerically using finite element analysis. The heating rate dependent denaturation characteristics of collagenous tissues are incorporated into the model using experimental data from in vitro experimentation with rabbit patellar tendons. It is shown that there are significant differences among the thermal damage profiles created by these modalities, explaining the main reason for the discrepancies reported in the literature in terms of the efficacy and safety of each modality. In the complementary paper, the accuracy of the model presented here is verified by in vitro experimentation with a model collagenous tissue and by quantifying the denaturation-induced birefringence change using Optical Coherence Tomography and Magnetic Resonance Imaging.

Hyperthermia at 434 MHz in the treatment of overuse sport tendinopathies: a randomised controlled clinical trial.

The objective of this randomized study was to compare a thermotherapy system, hyperthermia at 434 MHz and conventional ultrasound in the treatment of overuse sports tendinopathies. The study group consisted of 44 athletes, 33 males and 11 females (age 26 +/- 4.56 years) affected by tendinopathies at lower extremities (patellar or achilles tendons). After elucidation of the kind of trial, 22 patients were randomly assigned to hyperthermia and 22 to ultrasound. The patients received after a pain measurement and ultrasound scanning 12 treatments, 3 times a week for 4 weeks. The same standardized examination was done at the end of treatment and 1 month after the end of treatment. The assessor physician was unaware of the treatment allocation. The patients were asked to rate the ultimate outcome on the base of pain resolution and return to sports activity. Both groups had a significant decrease of symptoms (P<0.001). Hyperthermia, however, demonstrated better effects on the reduction of VAS score and on the subjective overall satisfaction (77 %) of excellent and good results in comparison to the 33 % of ultrasound. In patients with chronic overuse tendinopathies hyperthermia at 434 MHz showed encouraging results, with short-term clinical improvement, safety and no side effects.

[Rupture of the patellar ligament one month after treatment with fluoroquinolone]. / Rupture du ligament patellaire un mois après traitement par fluoroquinolone.

Musculoskeletal disorders including arthralgia and myalgia are adverse effect common to all fluoroquinolones. We report a case of spontaneous rupture of the patellar ligament in a 37-year-old man participating in leisure sports which occurred one month after a three-week course of Ciprofloxacine(R). Several cases of tendon ruptures have been reported in the literature, including the patellar tendon. Unusual features in our case were the one-month delay before tendon rupture and the absence of inaugural signs. We reviewed the pathophysiological mechanisms leading to fluoroquinolone-related tendon rupture as well as the risk factors and discussed proper management. Care must be taken when prescribing fluoroquinolones for patients at risk. Close follow-up is most important.

Bilateral simultaneous infrapatellar tendon ruptures: a case study.

This case study reports on a patient with a diagnosis of bilateral patellar tendon ruptures. Bilateral ruptures of the infrapatellar tendons are rare occurrences; approximately 20 cases have been reported in the medical literature. Much of the medical literature concentrates on surgical repair, immediate postoperative follow-up, and final outcome. There is a void in the literature concerning the rehabilitative process of these patients. The subject of this study is a 26-year-old male former collegiate athlete who suffered simultaneous bilateral patellar tendon ruptures while jumping. A rehabilitation model is provided that may assist others treating patients with similar conditions.