The value of local dexmedetomidine as an adjuvant to ultrasound-guided wide awake local anesthesia no tourniquet (WALANT) in flexor tendon repair surgeries: a randomized controlled trial.

BACKGROUND: The Wide-Awake Local Anesthesia No Tourniquet (WALANT) technique allows intraoperative motor assessment of tendon repair integrity of the hand compared with general anesthesia or brachial plexus block. No studies have tested the effect of adding dexmedetomidine to lidocaine on the analgesic properties of the WALANT technique, which is the aim of our study. METHODS: A total of 128 patients aged more than 18 years were scheduled for surgical flexor tendon injury repair using WALANT technique. Patients were divided into two equal groups. Ultrasound-guided subcutaneous injection of lidocaine 1% with dexmedetomidine (1 µg/kg), Group D, or without dexmedetomidine, Group C, was performed at four points: proximal to the wrist joint, the distal forearm, palm region, and proximal phalanges. The primary outcome was total morphine consumption throughout the first postoperative day. Secondary outcomes included number of patients requiring rescue analgesia, time to first analgesic request, and pain score. RESULTS: Total morphine consumption was significantly (P < 0.001) lower in group D (2.66 ± 0.998) than in group C (3.66 ± 1.144) mg. Number of patients requiring rescue analgesia was significantly (P < 0.001) lower in group D (54.7% (35)) than group C (100.0% (64)). The time for first request for analgesia was significantly (P < 0.001) longer in group D (11.31 ± 6.944) than in group C (5.91 ± 4.839) h. Pain score was significantly higher in group C than D at three (P < 0.001), and six (P = 0.001) hours (P = 0.001) postoperatively. CONCLUSION: Dexmedetomidine significantly improves the analgesic quality of WALANT when added to lidocaine with less opioid consumption. TRIAL REGISTRATION: (ID: PACTR202203906027106; Date: 31/07/2023).

Correlation between jingjin injury and wulao and the relevant prevention and treatment strategies. / 经筋损伤与"五劳"çš„ç›¸å ³æ€§åŠé˜²æ²»ç­–ç•¥.

The paper explores the correlation between jingjin (muscle regions of meridians, sinews/fascia) injury and wulao (five types of exhaustion) and the relevant prevention and treatment strategies, and determines the internal mechanism of the disease so as to provide the ideas for prevention and treatment of jingjin injury. Wulao may result in jingjin injury not only through the damages of blood, qi, muscles, bones and tendons indirectly, but also through the damage of soft tissues directly. The great attention should be paid to preventing from jingjin injury, especially wulao, due to which, the appropriate combination of the static and the dynamic skills is emphasized in the way of physical exercise. When the injury occurred, the conditions of the whole body should be analyzed comprehensively and the local affected regions be concentrated simultaneously in treatment. For the indirect injury, the holistic idea should be the basis of regulating five zang organs and restoring the physiological functions of blood, qi, muscles, bones and sinews so as to adjust jingjin. Regarding the direct injury, the staging regimen for the local treatment is considered to harmonize qi and blood and balance sinews and bones. When the injury has been cured, the physical exercise is recommended to strengthen sinews and bones according to individual conditions to prevent from recurrence.

Effects of adipose-derived cell supplementation on tendon-bone healing in a rat model of chronic rotator cuff tear with suprascapular nerve injury.

OBJECTIVE: To investigate the effect of adipose-derived cells (ADCs) on tendon-bone healing in a rat model of chronic rotator cuff tear (RCT) with suprascapular nerve (SN) injury. METHODS: Adult rats underwent right shoulder surgery whereby the supraspinatus was detached, and SN injury was induced. ADCs were cultured from the animals' abdominal fat. At 6 weeks post-surgery, the animals underwent surgical tendon repair; the ADC (+ve) group (n = 18) received an ADC injection, and the ADC (-ve) group (n = 18) received a saline injection. Shoulders were harvested at 10, 14, and 18 weeks and underwent histological, fluorescent, and biomechanical analyses. RESULTS: In the ADC (+ve) group, a firm enthesis, including dense mature fibrocartilage and well-aligned cells, were observed in the bone-tendon junction and fatty infiltration was less than in the ADC (-ve) group. Mean maximum stress and linear stiffness was greater in the ADC (+ve) compared with the ADC (-ve) group at 18 weeks. CONCLUSION: ADC supplementation showed a positive effect on tendon-bone healing in a rat model of chronic RCT with accompanying SN injury. Therefore, ADC injection may possibly accelerate recovery in massive RCT injuries.

Editorial Commentary: Postoperative Zoledronic Acid Improves Tendon Healing but Does Not Affect Outcomes in Rotator Cuff Repair Patients With Postmenopausal Osteoporosis.

Understanding the preoperative risk factors for successful rotator cuff repair (RCR) and ways to optimize these factors is an evolving area of study. The Rotator Cuff Healing Index and other proxy risk factors for failed rotator cuff healing have implicated significant fatty infiltration, muscular atrophy, advanced chronological age, tear size and retraction, and ultimately, osteoporosis. Although structural (or biological) augmentation and tendon transfer have been proposed as solutions for the alarmingly high rate of failure after primary RCR, other options may preferentially focus on the enthesis and underlying osseous footprint. Currently, bisphosphonates are frequently used in the treatment of osteoporosis and prevention of fragility fractures. However, burgeoning evidence suggests that postoperative zoledronic acid may have clinical utility after rotator cuff and other tendon repairs. In the cost-conscious world of evidence-based medicine, the added economic burden of additional medications and office visits may or may not improve patient outcomes-much less confer added value. Our advice to fellow shoulder surgeons: Wait for further information, but continue to holistically consider and optimize risk factors for poor soft-tissue healing. Although the addition of postoperative bisphosphonates may improve suture anchor fixation and promote a better foundation for healing, it will not immediately transform your RCR success rates.

Physical therapy interventions used to treat individuals with biceps tendinopathy: a scoping review.

BACKGROUND: Shoulder pain related to pathology of the long head of the biceps tendon (LHBT) can be debilitating. Chronic LHBT tendinopathy is a common condition that is difficult to treat. Little consensus exists regarding the optimal approach to treating individuals with LHBT tendinopathy. OBJECTIVE: To systematically scope the literature to identify and present the available information regarding physical therapist interventions used for the management of individuals with LHBT tendinopathy including types of interventions used or recommended. METHODS: A scoping review of physical therapist interventions used to treat LHBT was conducted of the CINAHL, Embase, Medline, and SportDiscus databases. Full text records reporting physical therapist-based interventions in individuals with proximal LHBT pathology were included. Articles not written in English were excluded. RESULTS: Of the 4059 records identified, 14 articles met the inclusion criteria. Interventions used to treat LHBT tendinopathy identified in quantitative studies included: extracorporeal shock wave therapy, polarized light, ultrasound, low-level laser, iontophoresis, general exercise, eccentric training, stretching, dry needling, and joint mobilization. Interventions described in literature reviews, clinical commentaries, and a Delphi study included: therapeutic modalities, manual therapy, exercise, dry needling, and patient education. CONCLUSION: This scoping review reported interventions primarily based on therapeutic modalities in quantitative studies while literature reviews, clinical commentaries, and a Delphi study described the addition of manual therapy, patient education, exercise, and dry needling. Overall, there is a dearth of evidence detailing the conservative management of LHBT tendinopathy.

Estrogen and testosterone supplementation improves tendon healing and functional recovery after rotator cuff repair.

Failure of healing after rotator cuff repair (RCR) is common. The purpose of the current study was to evaluate the effect of systemic estrogen or testosterone supplementation on tendon healing after RCR. Seventy-two adult male mice were utilized for all experiments. The supraspinatus tendon was transected and repaired with 6-0 Prolene suture on the left shoulder of 51 animals. Mice were segregated into three groups postoperative: (1) vehicle group (VG; n = 18), (2) estrogen group (EST; n = 17), and (3) testosterone group (TST; n = 16). An unrepaired control group (unrepaired, n = 21) did not have surgery. Utilizing these animals, histological analysis, activity testing, biomechanical testing and RNA sequencing (RNA-seq) was performed. At 8 weeks post-RCR, TST, and EST supplementation improved the overall histologic structure of the repaired enthesis site. No differences in ultimate failure loads or stiffness were detected between VG, EST, and TST groups after biomechanical testing. RCR caused a reduction in wheel activity compared to unrepaired controls and supplementation with TST restored wheel activity. RNA-seq analysis indicated that estrogen and testosterone regulated different pathways associated with enthesis healing, including a suppression of inflammatory signaling. Supplementation with sex hormones improved the structure of the repaired tendon enthesis and significantly regulated expression of diverse pathways regulating multiple biological processes. Testosterone administration following RCR restored wheel activity without having a detrimental impact on biomechanical strength. Future human studies of sex hormone supplementation after RCR are warranted as supplementation in an animal model may improve tendon enthesis healing.

Examining the Potential of Vitamin C Supplementation in Tissue-Engineered Equine Superficial Digital Flexor Tendon Constructs.

Because equine tendinopathies are slow to heal and often recur, therapeutic strategies are being considered that aid tendon repair. Given the success of utilizing vitamin C to promote tenogenesis in other species, we hypothesized that vitamin C supplementation would produce dose-dependent improvements in the tenogenic properties of tendon proper (TP) and peritenon (PERI) cells of the equine superficial digital flexor tendon (SDFT). Equine TP- and PERI-progenitor-cell-seeded fibrin three-dimensional constructs were supplemented with four concentrations of vitamin C. The gene expression profiles of the constructs were assessed with 3'-Tag-Seq and real-time quantitative polymerase chain reaction (RT-qPCR); collagen content and fibril ultrastructure were also analyzed. Moreover, cells were challenged with dexamethasone to determine the levels of cytoprotection afforded by vitamin C. Expression profiling demonstrated that vitamin C had an anti-inflammatory effect on TP and PERI cell constructs. Moreover, vitamin C supplementation mitigated the degenerative pathways seen in tendinopathy and increased collagen content in tendon constructs. When challenged with dexamethasone in two-dimensional culture, vitamin C had a cytoprotective effect for TP cells but not necessarily for PERI cells. Future studies will explore the effects of vitamin C on these cells during inflammation and within the tendon niche in vivo.

Myotendinous Thermoregulation in National Level Sprinters after a Unilateral Fatigue Acute Bout-A Descriptive Study.

In the last decade there has been a growing interest in infrared thermography in the field of sports medicine in order to elucidate the mechanisms of thermoregulation. The aim of this study was to describe bilateral variations in skin temperature of the anterior thigh and patellar tendon in healthy athletes and to provide a model of baseline tendon and muscle thermoregulation in healthy sprinters following a unilateral isokinetic fatigue protocol. Fifteen healthy national-level sprinters (eleven men and four women), with at least 3 years of athletic training experience of 10-12 h/week and competing in national-level competitions, underwent unilateral isokinetic force testing and electrostimulation in which their body temperature was measured before, during, and after the protocol using an infrared thermographic camera. ANOVA detected a significant difference in the time × side interaction for patellar temperature changes (p ≤ 0.001) and a significant difference in the time/side interaction for quadriceps temperature changes (p ≤ 0.001). The thermal challenge produces homogeneous changes evident in quadriceps areas, but not homogeneous in tendon areas. These data show that metabolic and blood flow changes may depend on the physical and mechanical properties of each tissue. Future research could be conducted to evaluate the predictive value of neuromuscular fatigue in the patellar tendon and quadriceps after exercise in order to optimize post-exercise recovery strategies.

Basic research of meridian-tendon based on fascia: review and prospects. / åŸºäºŽç­‹è†œçš„ç»ç­‹åŸºç¡€ç ”ç©¶ï¼šè¿°è¯„ä¸Žå±•æœ›.

Meridian-tendon is a central concept in meridian theory of TCM, and its basic research has been increasingly emphasized. While there is no unified understanding of the essence of meridian-tendon, the concept that function of fascia could partially reflect the functions of meridian-tendons has reached consensus in the academic community. This article suggests that under the guidance of meridian-tendon theory, based on previous research foundation of fascia, focusing on adopting fascia research methods, the mechanisms of tender point hyperalgesia and abnormal proliferation related to meridian lesions should be adopted to explain yitong weishu (taking the worst painful sites of muscle spasm as the points), and the mechanisms of meridian intervention efficacy should be adopted to explain yizhi weishu (feelings from patients and acupuncture operators). Furthermore, this article provides an analysis of the future trends in basic research of meridian tendons.

[Clinical efficacy of local injection of platelet-rich plasma combined with double-layer artificial dermis in treating wounds with exposed tendon on extremity].

Objective: To investigate the clinical efficacy of local injection of platelet-rich plasma (PRP) combined with double-layer artificial dermis in treating wounds with exposed tendon on extremity. Methods: A retrospective observational study was conducted. From December 2017 to October 2022, 16 patients were admitted to Department of Orthopaedic Trauma of the Second Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, and 32 patients were admitted to Department of Burns and Plastic Surgery of Guiyang Steel Factory Staff Hospital. All the patients had wounds with exposed tendon on extremity caused by various reasons and met the inclusion criteria. There were 39 males and 9 females, aged 26 to 58 years. The patients were divided into PRP alone group, artificial dermis alone group, and PRP+artificial dermis group, with 16 patients in each group. The wounds were treated with autologous PRP, double-layer artificial dermis, or thei combination of autologous PRP and double-layer artificial dermis, followed by autologous split-thickness scalp grafting after good growth of granulation tissue. On the 7th day after the secondary surgery, the autograft survival was observed, and the survival rate was calculated. The wound healing time and length of hospital stay of patients were recorded. At 3 and 6 months after wound healing, the Vancouver scar scale (VSS) was used to score the pigmentation, height, vascularity, and pliability of scars, and the total score was calculated. Adverse reactions during the entire treatment process were recorded. Data were statistically analyzed with chi-square test, Fisher's exact probability test, one-way analysis of variance, least significant difference test, Kruskal-Wallis H test, Nemenyi test, and Bonferroni correction. Results: On the 7th day after the secondary surgery, there was no statistically significant difference in the autograft survival rate of patients among PRP alone group, artificial dermis alone group, and PRP+artificial dermis group (P>0.05). The wound healing time and length of hospital stay of patients in PRP+artificial dermis group were (20.1±3.0) and (24±4) d, respectively, which were significantly shorter than (24.4±5.5) and (30±8) d in PRP alone group (P<0.05) and (24.8±4.9) and (32±8) d in artificial dermis alone group (P<0.05). At 3 and 6 months after wound healing, the pliability scores of patients in PRP+artificial dermis group were significantly lower than those in PRP alone group (with Z values of 12.91 and 15.69, respectively, P<0.05) and artificial dermis alone group (with Z values of 12.50 and 12.91, respectively, P<0.05). There were no statistically significant differences in pigmentation, vascularity, height scores, and total score of scar of patients among the three groups (P>0.05). In artificial dermis alone group, one patient experienced partial liquefaction and detachment of the double-layer artificial dermis due to local infection of Staphylococcus epidermidis, which received wound dressing change, second artificial dermis transplantation, and subsequent treatment as before. No adverse reactions occurred in the remaining patients during the whole treatment process. Conclusions: Local injection of PRP combined with double-layer artificial dermis is effective in treating wounds with exposed tendon on extremity, which can not only significantly shorten wound healing time and length of hospital stay, but also improve scar pliability after wound healing to some extent in the long term. It is a clinically valuable treatment technique that is worth promoting and applying.

Combination of Shengji ointment and bromelain in the treatment of exposed tendons in diabetic foot ulcers: study protocol for a non-blind, randomized, positive control clinical trial.

BACKGROUND: Diabetic foot ulcers often affect tendon tissue. Consequently, the infection may spread proximally along the tendon, leading to amputation or even the death of patients. Exposed, degenerated, and necrotic tendons are key factors affecting the healing of diabetic foot ulcers. The effective treatment of the tendon involvement may positively affect the prognosis. In clinical practice, treatment with Shengji ointment and bromelain induces islands of granulation tissue on the denatured tendon surface, which gradually grows and merges. Ideally, the exposed tendon is covered entirely by granulation tissue. This trial aims to assess the effect of a combined treatment regime of Shengji ointment, which has been shown to regenerate muscle tissue and pineapple protease in preventing the loss of function and amputation caused by tendon necrosis. This trial will provide high-quality evidence for the effectiveness of this combination in healing diabetic ulcers with tendon necrosis. METHODS: The sample size will be 180 patients who will be randomly assigned 1:1 to a treatment group (90 patients) using Shengji ointment combined with bromelain and a control group (90 patients) using hydrocolloid dressing. Both groups will continue their conventional treatments, such as blood glucose and blood pressure medication, lipid regulation, antiplatelets, and others. The primary outcome will be the wound coverage with granulation tissue. Secondary outcomes will be the wound healing rate, amputation extent (where needed), time to granulation, and the Maryland Foot Score. Other efficacy outcomes will be the time to debridement of necrotic tendon tissue and granulation tissue score. DISCUSSION: This study will treat patients with diabetic foot ulcers with exposed, degenerated, and necrotic tendons with Shengji ointment and bromelain. The trial aims to promote regeneration and healing, to preserve the limb and its function, and to develop a comprehensive and effective protocol that can be applied to promote the healing of exposed tendons in diabetic foot wounds. TRIAL REGISTRATION: ChiCTR2000039327 ; date of registration: 2020-10-23.

WAFER trial: a study protocol for a feasibility randomised controlled trial comparing wide-awake local anaesthesia no tourniquet (WALANT) to general and regional anaesthesia with tourniquet for flexor tendon repair.

INTRODUCTION: Flexor tendons are traditionally repaired under either general anaesthesia (GA) or regional anaesthesia (RA), allowing for the use of an arm tourniquet to minimise blood loss and establish a bloodless surgical field. However, the use of tourniquets exposes the patient to certain risks, including skin, muscle and nerve injuries. A recent advancement in anaesthesia delivery involves the use of a wide-awake approach where no sedation nor tourniquets are used (wide-awake local anaesthesia no tourniquet (WALANT)). WALANT uses local anaesthetic with epinephrine to provide pain relief and vasoconstriction, reducing operative bleeding. Several studies revealed potential benefits for WALANT compared with GA or RA. However, there remains a paucity of high-quality evidence to support the use of WALANT. As a result of this uncertainty, the clinical practice varies considerably. We aim to evaluate the feasibility of WALANT as an alternative to GA and RA in patients undergoing surgical repair of flexor tendon injuries. This involves addressing factors such as clinician and patient support for a trial, clinical equipoise, trial recruitment and dropout and the most relevant outcomes measures for a future definitive trial. METHODS AND ANALYSIS: WAFER is a multicentre, single-blinded, parallel group, randomised controlled trial (RCT) to assess the feasibility of WALANT versus RA and GA. The target population is patients with acute traumatic flexor tendon injuries, across 3 major hand surgery units in England involving a total of 60 participants. Outcome assessors will be blinded. The primary outcome will be the ability to recruit patients into the trial, while secondary outcomes include difference in functional outcome, patient-reported outcome measures, health-related quality of life, cost-effectiveness and complication rates. ETHICS AND DISSEMINATION: Ethical approval was obtained from the London-City and East Research Ethics Committee (22/PR/1197). Findings will be disseminated through peer-reviewed publication, conferences, patient information websites and social media networks. TRIAL REGISTRATION NUMBER: ISRCTN identifier: 15052559.

[Application of "Sancai principle" for needle-knife treatment of bi syndrome of neck region].

Under the guidance of the "Sancai principle", based on the understanding of the etiology and pathogenesis of the imbalance of muscles and bones in bi syndrome of neck region, holistic treatment should be used. The needle-knife release therapy is applied at corresponding acupoints in the three parts i.e. head, neck and back including Tiancai points (Naohu [GV 17] and Naokong [GB 19]), Rencai points (neck Jiaji [EX-B 2]), and Dicai points (Dazhui [GV 14], Quyuan [SI 13] and Tianzong [SI 11]). According to the layers of the lesion's meridians and muscles, the needle-knife is inserted into skin, muscle and bone to relax the tendons and treat bone disorders, and restore the normal mechanical balance of neck.

[The fenrou zhijian theory in The Inner Canon of Huangdi and the stratified treatment of painful bi syndrome of meridian tendons].

The fenrou zhijian is defined as potential gap between different layers in the three-dimensional network structure formed by the twelve meridian tendons. Various pathological changes of the meridian tendons lead to the adhesion and closure of fenrou zhijian, causing abnormal mechanical conduction of the meridian tendon system, which in turn leads to painful bi syndrome of meridian tendons. As such, restarting the fenrou zhijian is the key to acupuncture treatment for painful bi syndrome of meridian tendons. Under the guidance of musculoskeletal ultrasound, the level and the angle of needle insertion of acupuncture at fenrou zhijian could be accurately controlled, the efficacy of acupuncture is improved.

Exercise Plus Acupuncture on Consensus Acupoints Versus Acupoints Selected by the Theory of Equal Impact on Tendons, Bones, and Muscles for Knee Osteoarthritis.

Context: Knee osteoarthritis (KOA) is a degenerative disorder that significantly affects patients' quality of life. Acupuncture and exercise are the most popular treatments currently. The outcomes for acupuncture for KOA, however, are controversial, with some researchers finding that the addition of acupuncture to exercise therapy provided no additional improvement in pain scores. Objective: The study intended to evaluate the therapeutic effects for KOA of exercise in combination with acupuncture on acupoints selected using the Traditional Chinse Medicine (TCM) theory of Equal Impact on Tendons, Bones, and Muscles (EITBM) in comparison with that of acupoints selected using classical consensus for the treatment. Design: The research team performed a randomized controlled trial. Setting: The study took place in the Department of Acupuncture and Moxibustion at the First Affiliated Hospital of Hebei University of Chinese Medicine in Shijiazhuang, Hebei, China. Participants: Participants were 70 patients with KOA who visited the hospital between December 2020 and February 2021. Intervention: Participants in both group received acupuncture plus exercise therapy. The research team randomly assigned participants to one of two groups: (1) 35 to the intervention group, which received acupuncture using acupoints selected using EITBM, and (2) 35 to the control group, which received acupuncture using the classical consensus acupoints. Both groups performed a 25-min session of acupuncture three times weekly for 4 weeks, with the exercise therapy following the acupuncture each time. Outcome Measures: The research team assessed clinical efficacy at baseline and postintervention. The primary outcome measures included assessments: (1) of knee joint pain using a visual analog scale (VAS), (2) of knee joint pain, flexibility, and function using the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) pain subscale; and (3) joint range of motion (ROM). The secondary outcome measures included measurement of serum levels of interleukin-1 beta (IL-1ß), tumor necrosis factor alpha (TNF-α), and matrix metalloproteinase-13 (MMP-13) using enzyme-linked immunosorbent assays (ELISA). Results: The VAS and WOMAC scores significantly decreased for both groups between baseline and postintervention, and the intervention group's decrease was significantly greater than that of the control group. The ROM of knee flexion was significantly higher in both groups postintervention than at baseline, and the intervention group's increase was significantly higher than that of the control group. The serum IL-1ß, TNF-α, and MMP-13 also significantly decreased postintervention in both groups, and the intervention group's levels were significantly lower than those of the control group. The total effective rate was 94.1% in the intervention group, 32 out of 34 participants, and 75.8% in the control group, 25 out of 33 participants, which was significantly different. Conclusions: Acupuncture, in combination with exercise, can relieve symptoms, improve joint function, and reduce pro-inflammatory cytokines (IL-1ß and TNF-a) as well as MMP-13 for patients with KOA. The outcomes for acupuncture using EITBM acupoints were significantly better than those of the acupoints selected using classical consensus.

Conservative management of distal bicipital tendinopathy with lateral antebrachial nerve entrapment: A case report.

INTRODUCTION: Kettlebell snatches are an efficient and effective exercise. If the kettlebell being utilized is too heavy or too many repetitions are executed, this can lead to an overuse injury such as a tendinopathy. Multiple orthopedic tests exist to evaluate for a distal biceps tendon rupture. At present, there are no publications utilizing shockwave and active rehabilitation to treat distal bicipital tendinopathy with Lateral Antebrachial Cutaneous Nerve (LABCN) entrapment. Currently, no published manuscripts are reporting distal bicipital tendinopathy with LABCN nerve entrapment being treated successfully with shockwave and active rehabilitation over the course of 5 weeks. METHODS: The objective of this case report is to examine the conservative management of a 37-year-old male with a diagnosis of distal bicipital tendinopathy and LABCN entrapment. The patient presents with discomfort originated weeks prior after an intense block of kettlebell training. The patient was diagnosed with brachioradialis tendinopathy due to the specifics of his injury. Following the initial evaluation, the patient was unable to supinate the forearm past 45° actively, yet he can passively achieve 90°, although this is done with minor discomfort. DISCUSSION: The patient's rehab began with the execution of wrist, elbow, and shoulder controlled articular rotation (CARS). The concept of CARs is to train the joint and soft tissues to respond to full range activity. A progressive approach utilizing isometric to eccentric exercise with extracorporeal shockwave was used. The authors studied forty-eight patients with chronic distal biceps tendinopathy. After five shockwave therapy treatments over three months, there was a significant decrease in symptomology without complications (Furia et al., 2017). CONCLUSION: This case report demonstrates that active rehabilitation and shockwave therapy effectively resolved the patient's symptoms with no adverse reactions. Additionally, the case report can be a suggested management protocol for successful conservative management for patients with suspected distal bicipital tendinopathy with LABCN entrapment going forward.

Emerging Treatment Options for Chronic Tendinopathy of the Foot: A Clinical Vignette.

ABSTRACT: The patient is a 65-year-old female recreational skier and avid walker who presented with a several-month history of right ankle and foot pain. The patient's pain began without inciting event and was described as a constant aching pain aggravated by downhill walking and alleviated with rest. She was diagnosed with right distal tibialis anterior tendinopathy with partial thickness tear noted on magnetic resonance imaging and musculoskeletal ultrasound. Given symptoms recalcitrant to conservative measures, the patient opted to pursue an ultrasound-guided prolotherapy injection and a course of physical therapy; unfortunately, she did not have any improvement in symptoms. The patient subsequently underwent ultrasound-guided percutaneous ultrasonic tenotomy and debridement of the distal tibialis anterior tendon, followed by a postprocedure rehabilitation protocol of physical therapy with transition to home exercise program with complete resolution of her pain. Prolotherapy, and percutaneous ultrasonic tenotomy and debridement are two treatment modalities that show promise in the treatment of painful, chronic tendinopathy.

Tendon Cells Root Into (Instead of Attach to) Humeral Bone Head via Fibrocartilage-Enthesis.

Large joints are composed of two closely linked cartilages: articular cartilage (AC; rich in type II collagen, a well-studied tissue) and fibrocartilaginous enthesis (FE; rich in type I collagen, common disorder sites of enthesopathy and sporting injuries, although receiving little attention). For many years, both cartilages were thought to be formed by chondrocytes, whereas tendon, which attaches to the humeral bone head, is primarily considered as a completely different connective tissue. In this study, we raised an unconventional hypothesis: tendon cells directly form FE via cell transdifferentiation. To test this hypothesis, we first qualitatively and quantitatively demonstrated distinct differences between AC and FE in cell morphology and cell distribution, mineralization status, extracellular matrix (ECM) contents, and critical ECM protein expression profiles using comprehensive approaches. Next, we traced the cell fate of tendon cells using ScxLin (a tendon specific Cre ScxCreERT2; R26R-tdTomato line) with one-time tamoxifen induction at early (P3) or young adult (P28) stages and harvested mice at different development ages, respectively. Our early tracing data revealed different growth events in tendon and FE: an initial increase but gradual decrease in the ScxLin tendon cells and a continuous expansion in the ScxLin FE cells. The young adult tracing data demonstrated continuous recruitment of ScxLin cells into FE expansion during P28 and P56. A separate tracing line, 3.2 Col 1Lin (a so-called "bone-specific" line), further confirmed the direct contribution of tendon cells for FE cell formation, which occurred in days but FE ECM maturation (including high levels of SOST, a potent Wnt signaling inhibitor) took weeks. Finally, loss of function data using diphtheria toxin fragment A (DTA) in ScxLin cells demonstrated a significant reduction of ScxLin cells in both tendons and FE cells, whereas the gain of function study (by stabilizing ß-catenin in ScxLin tendon cells via one-time injection of tamoxifen at P3 and harvesting at P60) displayed great expansion of both ScxLin tendon and FE mass. Together, our studies demonstrated that fibrocartilage is an invaded enthesis likely originating from the tendon via a quick cell transdifferentiation mechanism with a lengthy ECM maturation process. The postnatally formed fibrocartilage roots into existing cartilage and firmly connects tendon and bone instead of acting as a simple attachment site as widely believed. We believe that this study will stimulate more intense exploring in this understudied area, especially for patients with enthesopathy and sporting injuries.

Is Curcumine Useful in the Treatment and Prevention of the Tendinopathy and Myotendinous Junction Injury? A Scoping Review.

Physical activity in general and sports in particular, is a mechanism that produces stress and generates great force in the tendon and in the muscle-tendon unit, which increases the risk of injury (tendinopathies). Eccentric and repetitive contraction of the muscle precipitates persistent microtraumatism in the tendon unit. In the development of tendinopathies, the cellular process includes inflammation, apoptosis, vascular, and neuronal changes. Currently, treatments with oral supplements are frequently used. Curcumin seems to preserve, and even repair, damaged tendons. In this systematic review, we focus more especially on the benefits of curcumin. The biological actions of curcumin are diverse, but act around three systems: (a) inflammatory, (b) nuclear factor B (NF-κB) related apoptosis pathways, and (c) oxidative stress systems. A bibliographic search is conducted under the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) as a basis for reporting reliable systematic reviews to perform a Scoping review. After analysing the manuscripts, we can conclude that curcumin is a product that demonstrates a significant biological antialgic, anti-inflammatory, and antioxidant power. Therefore, supplementation has a positive effect on the inflammatory and regenerative response in tendinopathies. In addition, curcumin decreases and modulates the cell infiltration, activation, and maturation of leukocytes, as well as the production of pro-inflammatory mediators at the site of inflammation.

Clinical Rationale and Rehabilitation Guidelines for Post Biologic Therapy.

The use of orthobiologic modalities such as platelet-rich plasma in orthopedics and sports medicine to deliver high concentrations of naturally occurring biologically active growth factors and proteins to the site of injury is very promising and continues to evolve. Early protection and tissue-specific progressive loading are critical components to successful outcomes following orthobiologic intervention. Each tissue heals and responds differently. Ligament, tendon, muscle, and articular cartilage each have unique healing properties that require tissue-specific loading. The authors have found using a criteria-based loading and exercise progression guided by dynamic imaging when appropriate to further advance the goal-oriented rehabilitation program. Each patient and injured tissue are unique and require specific intervention and rehabilitation.