The Efficacy of Intratissue Percutaneous Electrolysis (EPI®) and Nutritional Factors for the Treatment of Induced Tendinopathy in Wistar Rats: Hepatic Intermediary Metabolism Effects.

Achilles tendinopathy (TP) is characterized as the third most common disease of the musculoskeletal system, and occurs in three phases. There is currently no evidence of effective treatment for this medical condition. In this study, the modulatory effects of the minimally invasive technique intratissue percutaneous electrolysis (EPI) and combinations of EPI with four nutritional factors included in the diet, hydroxytyrosol (HT), maslinic acid (MA), glycine, and aspartate (AA), on hepatic intermediary metabolism was examined in Wistar rats with induced tendinopathy at various stages of TP. Results obtained showed that induced tendinopathy produced alterations in the liver intermediary metabolisms of the rats. Regarding carbohydrate metabolism, a reduction in the activity of pro-inflammatory enzymes in the later stages of TP was observed following treatment with EPI alone. Among the combined treatments using nutritional factors with EPI, HT+EPI and AA+EPI had the greatest effect on reducing inflammation in the late stages of TP. In terms of lipid metabolism, the HT+EPI and AA+EPI groups showed a decrease in lipogenesis. In protein metabolism, the HT+EPI group more effectively reduced the inflammatory effects of induced TP. Treatment with EPI combined with nutritional factors might help regulate intermediary metabolism in TP disease and reduce the inflammation process.

Iliotibial Band Origin Tendinopathy Is an Underrecognized Cause of Anterolateral Hip Pain: A Narrative Review and Clinical Commentary.

ABSTRACT: Hip pain is a common concern among athletes. With gluteal tendinopathy, femoroacetabular impingement, and osteoarthritis predominating sports medicine and musculoskeletal practices, less common etiologies may be overlooked. Complex pelvic anatomy and variable pain referral patterns may make identifying an accurate diagnosis challenging. Employing a systematic approach to evaluation and having a thorough understanding of hip region anatomy are essential. A potentially overlooked cause of anterolateral hip pain is iliotibial band origin tendinopathy. Patients often present with pain around the anterolateral hip and tenderness to palpation at the anterolateral iliac crest. While patients with iliotibial band origin tendinopathy usually respond to nonsurgical intervention, there is little literature to guide evaluation and treatment, highlighting a gap in the recognition of this condition. The purpose of this narrative review is to describe the anatomy of the proximal iliotibial band origin, outline the clinical diagnosis and imaging findings of ITBOT, and summarize current treatment options.

Association of calcific rotator cuff tendinopathy with nephrolithiasis and/or cholelithiasis: A case-control study.

This study aimed to examine the association between calcific rotator cuff tendinopathy (RCT) and nephrolithiasis and/or cholelithiasis. A case-control study was conducted on patients diagnosed with RCT between June 2016 and June 2022. RCT was confirmed by ultrasound, and patients were divided into 2 groups: calcific RCT (case) and non-calcific RCT (control). Data were collected retrospectively from electronic medical records and completed by phone calls, looking for a history of nephrolithiasis and/or cholelithiasis; based on clinical features or incidental findings on abdominal and pelvic imaging. A total of 210 patients with RCT were included. Among the 95 cases of calcific RCT, 43 had a history of lithiasis (45.3%) against 23 (20%) from the non-calcific RCT group (P < .001); 21 patients suffered from nephrolithiasis (22.1%) and 26 had cholelithiasis (27.4%) versus 10 (8.7%) (P = .006) and 16 (13.9%) (P = .015) in the non-calcific RCT group, respectively. Logistic regression showed that the independent predictors of calcific RCT included a history of nephrolithiasis (OR, 4.38; 95% CI: 1.61-11.92, P = .004) and a history of cholelithiasis (OR, 3.83; 95% CI: 1.64-8.94, P = .002). In patients with calcific RCT, the occurrence of lithiasis was significantly associated in the bivariate analysis with higher age, body mass index, fasting blood sugar, and HbA1c (all with P < .05), but only with the presence of another site of calcific tendinopathy than the shoulder (OR, 3.11; 95% CI: 1.12-8.65, P = .03) in the multivariate analysis. Nephrolithiasis and/or cholelithiasis are associated with calcific RCT, and their presence predicts calcific RCT at least 3 times. Further research is required to determine the common risk factors and preventive measures against lithogenesis in patients with calcific RCT, nephrolithiasis, and cholelithiasis.

Current research trends on the effect of diabetes mellitus on rotator cuff tendon healing/tendinopathy.

Rotator cuff tendon tears are a leading cause of shoulder pain. They are challenging to treat, and tendon-bone healing has a high failure rate despite successful surgery. Tendons connect the muscles and bones, which make them important for the body's overall mobility and stability. Metabolic diseases, including diabetes or high blood pressure, can affect the healing process after repair of a damaged tendon. With a global incidence of 9.3%, diabetes is considered as a significant risk factor for rotator cuff tendon healing because it causes structural, inflammatory, and vascular changes in the tendon. However, the mechanisms of how diabetes affects tendon healing remain unknown. Several factors have been suggested, including glycation product accumulation, adipokine dysregulation, increased levels of reactive oxygen species, apoptosis, inflammatory cytokines, imbalanced matrix-metalloproteinase-to-tissue-inhibitor ratio, and impaired angiogenesis and differentiation of the tendon sheath. Despite the effects of diabetes on tendon function and healing, few treatments are available to improve recovery in these patients. This review summarizes the current literature on the pathophysiological changes of the tendon in diabetes and hyperlipidemia. Preclinical and clinical evidence regarding the association between diabetes and tendon healing is presented. Moreover, current approaches to improve tendon healing in patients with diabetes are reviewed.

Physical and psychosocial work-related exposures and the occurrence of disorders of the shoulder: A systematic review update.

This review is an update of a previous systematic review and assesses the evidence for the association of work-related physical and psychosocial risk factors and specific disorders of the shoulders. Medline, Embase, Web of Science Core Collection, Cochrane Central and PsycINFO were searched and study eligibility and risk of bias assessment was performed by two independent reviewers. A total of 14 new articles were added with the majority focusing on rotator cuff syndrome (RCS) with seven studies. Nine articles reported psychosocial exposures in addition to physical exposures. The strongest evidence was found for the association between elevation, repetition, force and vibration and the occurrence of SIS and tendinosis/tendonitis. Evidence also suggests that psychosocial exposures are associated with the occurrence of RCS and tendinosis/tendonitis. Other findings were inconsistent which prevents drawing strong conclusions.

Determination of preoperative risk factors for iliopsoas tendonitis after total hip arthroplasty: A simulation study.

This study aims to identify preoperative risk factors for iliopsoas tendonitis after total hip arthroplasty, a complication typically attributed to acetabular cup position and orientation, using a validated iliopsoas impingement detection simulation. Analyzing CT scans and X-rays of 448 patients using a validated preoperative planning protocol, patients were simulated for iliopsoas impingement and categorized into at-risk and not at-risk groups based on a prior validation study, with a 23% at-risk incidence. Implementing a propensity score matching algorithm to reduce covariate imbalance, we identified factors that may exacerbate risk of iliopsoas tendonitis. Parameters that were investigated included standing pelvic tilt, functional femoral rotation, and the difference between the planned acetabular cup diameter and native femoral head diameter (ΔC-NFH). Comparing pelvic tilt, we found a significant difference between the groups (at-risk: -6.0°, not at-risk: -0.7°; p << 0.01). A similar trend was noted for ΔC-NFH (at-risk: +5.7 mm, not at-risk: +5.1 mm; p = 0.01). Additional simulations of at-risk patients indicated increased anteversion of the acetabular cup reduces impingement risk more effectively than medialisation. These findings suggest that spinopelvic parameters may exacerbate iliopsoas irritation risk, underscoring their importance in preoperative planning and patient expectation management. Similar findings of a greater than 6 mm difference between cup size and native femoral head diameter being a significant risk for iliopsoas tendonitis have been observed before, underscoring its potential veracity. These results may provide surgeons with a simple threshold that can be used in determining a cup size to reduce the risk of iliopsoas tendonitis.

A Passive Ankle Dorsiflexion Testing System for an In Vivo Model of Overuse-induced Tendinopathy.

Tendinopathy is a chronic tendon condition that results in pain and loss of function and is caused by repeated overload of the tendon and limited recovery time. This protocol describes a testing system that cyclically applies mechanical loads via passive dorsiflexion to the rat Achilles tendon. The custom-written code consists of pre- and post-cyclic loading measurements to assess the effects of the loading protocol along with the feedback control-based cyclic fatigue loading regimen. We used 25 Sprague-Dawley rats for this study, with 5 rats per group receiving either 500, 1,000, 2,000, 3,600, or 7,200 cycles of fatigue loads. The percentage differences between the pre- and post-cyclic loading measurements of the hysteresis, peak stress, and loading and unloading moduli were calculated. The results demonstrate that the system can induce varying degrees of damage to the Achilles tendon based on the number of loads applied. This system offers an innovative approach to apply quantified and physiological varying degrees of cyclic loads to the Achilles tendon for an in vivo model of fatigue-induced overuse tendon injury.

Satisfactory mid-term clinical outcomes of endoscopic tenotomy for iliopsoas tendinopathy following total hip arthroplasty.

PURPOSE: To report 5-year outcomes of endoscopic iliopsoas tenotomy in patients with iliopsoas tendinopathy following total hip arthroplasty (THA) and determine whether clinical scores are associated with cup position. METHODS: Patients who underwent endoscopic iliopsoas tenotomy for iliopsoas tendinopathy following THA (2014-2017) were contacted. Indications for endoscopic iliopsoas tenotomy after THA were groin pain during active hip flexion, exclusion of other causes of groin pain, and no pain relief after 6 months of conservative treatment. Pretenotomy cup inclination and anteversion were measured on radiographs; axial and sagittal cup overhang were measured on computed tomography (CT) scans. Oxford hip score (OHS), modified Harris hip score (mHHS), and groin pain were assessed. RESULTS: The initial cohort comprised 16 men (17 hips) and 31 women (32 hips), aged 60.7 ± 10.6 years. Cup inclination and anteversion were, respectively, 46.2 ± 6.2° and 14.6 ± 8.4°, while axial and sagittal cup overhang were, respectively, 4.4 ± 4.0 mm and 6.9 ± 4.5 mm. At ≥5 years follow-up, four hips underwent cup and stem revision, two underwent isolated cup revision and one underwent secondary iliopsoas tenotomy. OHS improved by 23 ± 10 and mHHS improved by 31 ± 16. Posttenotomy groin pain was slight in 20.0%, mild in 17.5% and moderate in 12.5%. Regression analyses revealed that net change in mHHS decreased with sagittal cup overhang (ß = -3.1; 95% confidence interval [CI] = -4.6 to -1.7; p < 0.001), but that there were no associations between cup position and net change in OHS. CONCLUSIONS: Endoscopic iliopsoas tenotomy provides good mid-term clinical outcomes in patients with iliopsoas tendinopathy following THA. Furthermore, improvements in mHHS were found to decrease with increasing sagittal cup overhang, in cases for which adequate preoperative imaging was available. LEVEL OF EVIDENCE: Level IV.

Comparison of iliopsoas tendonitis after hip resurfacing arthroplasty and total hip arthroplasty: A case-controlled investigation using a validated simulation.

Iliopsoas tendonitis, typically caused by impingement with the acetabular cup, occurs in up to 18% of patients after total hip arthroplasty (THA) and up to 30% of patients after hip resurfacing arthroplasty (HRA). We have developed a simulation for detecting iliopsoas impingement and validated it in a previous study of THA patients. However, due to the difference in incidence between HRA and THA, this study had two aims. First, to validate the simulation in a cohort of HRA patients and, second, to comparethe results of the HRA and THA patients to understand any differences in their etiology. We conducted a retrospective search in an experienced surgeon's database for HRA patients with iliopsoas tendonitisand control patients without iliopsoas tendonitis, resulting in two cohorts of 12 patients. Using CT scans, 3D models of the each patient's prosthetic and bony anatomy were generated, landmarked, and simulated. Regarding validation of the simulation for HRA patients, impingement significantly predicted the probability of iliopsoas tendonitis in logistic regression models and the simulation had a sensitivity of 83%, specificity of 100%, and an AUC ROC curve of 0.95. Unexpectedly, the HRA cohort exhibited less impingement than the THA cohort. Our novel simulation has now been demonstrated to detect iliopsoas impingement and differentiate between the symptomatic and asymptomatic cohorts in investigations of THA and HRA patients. This tool has the potential to be used preoperatively, to guide decisions about optimal cup placement, and postoperatively, to assist in the diagnosis of iliopsoas tendonitis.

Gluteal Tendinopathy Is Associated With Lower Patient-Reported Outcome Measures in Total Hip Arthroplasty With a Posterior Approach: A Prospective Cohort Study of 1,538 Patients.

BACKGROUND: Gluteal tendinopathy (GT) is found in 20 to 25% of patients undergoing total hip arthroplasty (THA). Despite this, there is a scarcity of literature assessing the association between GT and THA outcomes. The aim of this study was to evaluate whether intraoperative diagnosis of GT negatively affected postoperative outcomes. METHODS: Consecutive patients undergoing primary THA for osteoarthritis via a posterior approach over 5 years were recruited in a prospective study. Gluteal tendinopathy was assessed and graded at the time of surgery, but not repaired. A total of 1,538 (93%) completed the patient-reported outcome measures (PROMs) at 1 year after surgery and were included in the analysis. The PROMs included the Oxford Hip Score (OHS), Hip Disability and Osteoarthritis Outcome Score Joint Replacement (HOOS JR), and EuroQol 5-Dimension, and were collected preoperatively and one year after THA. RESULTS: The gluteal tendons were graded as 4 distinct grades: normal (n = 1,023, 66%), tendinopathy but no tear (n = 337, 22%), partial thickness tear (n = 131, 9%), and full thickness tear (n = 47, 3%). The occurrence of GT was associated with age, body mass index, and sex. There was no significant difference in baseline OHS or HOOS JR scores according to GT grade. As GT grade increased, lower median 1-year OHS (P = .001) and HOOS JR (P = .016) were observed. This association was confirmed by linear regression analysis with 1-year OHS (B = 0.5, 95% CI = -0.9 to -0.1, P = .011) when controlled for age and sex. CONCLUSIONS: Gluteal tendinopathy was commonly observed and was associated with inferior 1-year PROMs in patients undergoing THA via posterior approach. Increasing degree of tendinopathy was a negative prognostic factor for outcomes and patient satisfaction. LEVEL OF EVIDENCE: Level 2 (High quality prospective cohort study).

Mechanical overload-induced release of extracellular mitochondrial particles from tendon cells leads to inflammation in tendinopathy.

Tendinopathy is one of the most common musculoskeletal diseases, and mechanical overload is considered its primary cause. However, the underlying mechanism through which mechanical overload induces tendinopathy has not been determined. In this study, we identified for the first time that tendon cells can release extracellular mitochondria (ExtraMito) particles, a subtype of medium extracellular particles (mEPs), into the environment through a process regulated by mechanical loading. RNA sequencing systematically revealed that oxygen-related reactions, extracellular particles, and inflammation were present in diseased human tendons, suggesting that these factors play a role in the pathogenesis of tendinopathy. We simulated the disease condition by imposing a 9% strain overload on three-dimensional mouse tendon constructs in our cyclic uniaxial stretching bioreactor. The three-dimensional mouse tendon constructs under normal loading with 6% strain exhibited an extended mitochondrial network, as observed through live-cell confocal laser scanning microscopy. In contrast, mechanical overload led to a fragmented mitochondrial network. Our microscopic and immunoblot results demonstrated that mechanical loading induced tendon cells to release ExtraMito particles. Furthermore, we showed that mEPs released from tendon cells overloaded with a 9% strain (mEP9%) induced macrophage chemotaxis and increased the production of proinflammatory cytokines, including IL-6, CXCL1, and IL-18, from macrophages compared to mEP0%, mEP3%, and mEP6%. Partial depletion of the ExtraMito particles from mEP9% by magnetic-activated cell sorting significantly reduced macrophage chemotaxis. N-acetyl-L-cysteine treatment preserved the mitochondrial network in overloaded tendon cells, diminishing overload-induced macrophage chemotaxis toward mEP9%. These findings revealed a novel mechanism of tendinopathy; in an overloaded environment, ExtraMito particles convey mechanical response signals from tendon cells to the immune microenvironment, culminating in tendinopathy.

Elbow calcific tendinosis initially detected by ultrasonography: a case report.

INTRODUCTION: Calcific tendinosis is a common condition caused by the deposition of hydroxyapatite crystals within the tendons that can impact any tendinous insertion. In this situation, ultrasound (US) may be a viable imaging modality in addition to radiography. CASE PRESENTATION: A 56-year-old Iranian male presented with left elbow pain. US evaluation at the lump site revealed a subcutaneous lipoma. Ultrasonography showed a thickened and diffusely heterogeneously hypoechoic pronator teres tendon. These characteristics were consistent with the diagnosis of calcific tendinosis. DISCUSSION AND CONCLUSION: Radiography is the most common and practical imaging modality for calcific tendinosis diagnosis. Despite this, the real-time nature of ultrasonography makes it both diagnostic and therapeutic in this condition. Other conditions, such as lipoma, may interfere with the proper diagnosis of calcific tendinosis.

A Novel Tendon Injury Model, Induced by Collagenase Administration Combined with a Thermo-Responsive Hydrogel in Rats, Reproduces the Pathogenesis of Human Degenerative Tendinopathy.

Patellar tendinopathy is a common clinical problem, but its underlying pathophysiology remains poorly understood, primarily due to the absence of a representative experimental model. The most widely used method to generate such a model is collagenase injection, although this method possesses limitations. We developed an optimized rat model of patellar tendinopathy via the ultrasound-guided injection of collagenase mixed with a thermo-responsive Pluronic hydrogel into the patellar tendon of sixty male Wistar rats. All analyses were carried out at 3, 7, 14, 30, and 60 days post-injury. We confirmed that our rat model reproduced the pathophysiology observed in human patients through analyses of ultrasonography, histology, immunofluorescence, and biomechanical parameters. Tendons that were injured by the injection of the collagenase-Pluronic mixture exhibited a significant increase in the cross-sectional area (p < 0.01), a high degree of tissue disorganization and hypercellularity, significantly strong neovascularization (p < 0.01), important changes in the levels of types I and III collagen expression, and the organization and presence of intra-tendinous calcifications. Decreases in the maximum rupture force and stiffness were also observed. These results demonstrate that our model replicates the key features observed in human patellar tendinopathy. Collagenase is evenly distributed, as the Pluronic hydrogel prevents its leakage and thus, damage to surrounding tissues. Therefore, this model is valuable for testing new treatments for patellar tendinopathy.

Effect of Nutraceutical Factors on Hepatic Intermediary Metabolism in Wistar Rats with Induced Tendinopathy.

Tendinopathy (TP) is a complex clinical syndrome characterized by local inflammation, pain in the affected area, and loss of performance, preceded by tendon injury. The disease develops in three phases: Inflammatory phase, proliferative phase, and remodeling phase. There are currently no proven treatments for early reversal of this type of injury. However, the metabolic pathways of the transition metabolism, which are necessary for the proper functioning of the organism, are known. These metabolic pathways can be modified by a number of external factors, such as nutritional supplements. In this study, the modulatory effect of four dietary supplements, maslinic acid (MA), hydroxytyrosol (HT), glycine, and aspartate (AA), on hepatic intermediary metabolism was observed in Wistar rats with induced tendinopathy at different stages of the disease. Induced tendinopathy in rats produces alterations in the liver intermediary metabolism. Nutraceutical treatments modify the intermediary metabolism in the different phases of tendinopathy, so AA treatment produced a decrease in carbohydrate metabolism. In lipid metabolism, MA and AA caused a decrease in lipogenesis at the tendinopathy and increased fatty acid oxidation. In protein metabolism, MA treatment increased GDH and AST activity; HT decreased ALT activity; and the AA treatment does not cause any alteration. Use of nutritional supplements of diet could help to regulate the intermediary metabolism in the TP.

Clinical Impairments and Rotator Cuff Tendon Pathology in Primary and Intrinsic Secondary Adhesive Capsulitis.

OBJECTIVE: This study was conducted to compare the differences in clinical impairments between patients with primary and intrinsic secondary adhesive capsulitis and confirm rotator cuff tendon pathology in intrinsic secondary adhesive capsulitis. DESIGN: This study included 130 patients with unilateral adhesive capsulitis in freezing or frozen stages. Clinical impairment was evaluated using visual analog scale score, shoulder passive range of motion, Cyriax stage, and Constant-Murley score. Plain radiography, ultrasonography, single-contrast arthrography, and intravenous gadolinium-enhanced magnetic resonance imaging were performed in all patients. RESULTS: Among 130 patients, 77 patients were diagnosed as primary adhesive capsulitis and 53 patients as intrinsic secondary adhesive capsulitis. Among intrinsic secondary adhesive capsulitis patients, 44 rotator cuff tendon tears, 6 calcific tendinitis, and 3 rotator cuff tendon tears with calcific tendinitis were observed. No significant intergroup difference was observed in all clinical parameters, including shoulder passive range of motion, visual analog scale, Cyriax stage, and Constant-Murley score. The prevalence of subacromial subdeltoid bursitis was significantly higher in intrinsic secondary adhesive capsulitis compared with primary adhesive capsulitis. CONCLUSIONS: There was no significant difference in all clinical parameters investigated between patients with primary and intrinsic secondary adhesive capsulitis caused by rotator cuff tendon pathology.

Achilles Tendinopathy Pathogenesis and Management: A Narrative Review.

The Achilles tendon is the thickest and strongest tendon of the human body, and it is frequently injured during sports activity. The incidence of Achilles tendon pathologies has increased over recent decades, especially in the last few years, because of increased sports participation among the general population and due to the diffusion of competitive sports at a high level. Tendinopathies are common in athletes and in middle-aged overweight patients. The term "tendinopathy" refers to a condition characterised clinically by pain and swelling, with functional limitations of tendon and nearby structures, and consequently to chronic failure of healing response process. Tendinopathies can produce marked morbidity, and at present, scientifically validated management modalities are limited. Despite the constantly increasing interest and number of studies about Achilles tendinopathy (AT), there is still not a consensual point of view on which is the best treatment, and its management is still controversial. AT can be treated conservatively primarily, with acceptable results and clinical outcomes. When this approach fails, surgery should be considered. Several surgical procedures have been described for both conditions with a relatively high rate of success with few complications and the decision for treatment in patients with AT should be tailored on patient's needs and level of activity. The aim of this article is to give insights about the pathogenesis and most used and recent treatment options for AT.

Shoulder Tendinopathies and Occupational Biomechanical Overload: A Critical Appraisal of Available Evidence.

BACKGROUND: The aim of this study is to evaluate the association between occupational exposure to biomechanical risk factors and shoulder tendinopathies. METHODS: We updated recent systematic reviews about specific shoulder disorders and work-related risk factors. MEDLINE was searched up to September 2022. Studies satisfying the following criteria were included: i) the diagnosis was based on physical examination plus imaging data (when available), and ii) the exposure assessment was based on video analysis and/or directly measured. RESULTS: Five studies met the inclusion criteria: three cross-sectional studies identified from published systematic reviews and two cohort studies retrieved from the update. Two studies investigated shoulder tendinitis, one supraspinatus tendinitis, and the other two rotator cuff syndrome. The diagnosis was based on physical examination, not supported by imaging techniques for all the included studies. In four out of five studies, the exposure was assessed by experienced ergonomists with the support of video recordings. In two studies, the exposure assessment was further supplemented by force gauge measurements or direct measurements of upper arm elevation. Only the combined exposure of working with arms above shoulder level with forceful hand exertion appears to be associated with rotator cuff syndrome: i) a cohort study reported an HR=1.11 (95%CI 1.01-1.22) for each unit increase in forceful repetition rate when the upper arm is flexed ≥45° for ≥29% of the working time; and ii) a cross-sectional study showed an OR=2.43 (95%CI 1.04-5.68) for the combination of upper arm flexion ≥45° for more than 15% of the time with a duty cycle of forceful exertions more than 9% of the time. CONCLUSIONS: There is moderate evidence of a causal association between shoulder tendinopathy and combined exposures of working above shoulder level with forceful hand exertion. The evidence is insufficient for any single biomechanical exposure on its own. High-quality cohort studies with direct exposure measures and objective diagnostic criteria are needed. The occupational origin of shoulder tendinopathies is still an open question that must be properly answered.