Dr James Brown MBChB MSc FFSEM(UK) Consultant Sports Physician Sports Doc British Triathlon Director Health Partners Europe Director Benchmark 54 Injury Analytics james.brown5@nhs.net

Interventional treatment for Tendons

When

Why

What

How

Overview

•  Anatomy •  What happens to tendons in tendinopathy •  Histopathology – Clues for therapies ? •  Science** - What science its mainly theoretical •  When do you need an interventionist ? – not

often but If you do choose carefully we are not all the same !

Achilles Tendon Anatomy

Achilles tendon encased by paratenon –there is no synovial sheath. Functions as an elastic sleeve that permits free movement of tendon against surrounding tissue

The tendon comprised of an extra celluar matrix tenoblasts, fibroblasts and dry mass comprised largely of type 1 collagen

Endotenon septae

FAT

Crural Fascia

Nerve fibres form rich plexuses of the paratenon pierce the epitenon and lay on the tendon surface responsible for nocioceptors and mechanoreceptors

Paratenon highly vascularised provides part of tendons blood supply, however there is a hypovascular area 4cm from insertion on calcaneus

Endotenon: –  thin network of

crisscross collagen fibrils

–  envelopes the primary, secondary and tertiary fiber bundles together

–  allows fiber bundles to glide with respect to each other

–  carry blood vessels, nerves and lymphatics to tendon

(From “Human Tendons” by Józsa and Kannus)

collagen fibril (20-150 nm), collagen fiber (1-50 µm), tendon(2-12 mm) Vitamin C important in

collagen synthesis!

(From “Human Tendons” by Józsa and Kannus)

ECM GAG’s Different in different loading conditions WATER Gycoproteins

repair regenerate adhesive

Proteoglycans •  water retention [hydrophllyic] •  collagen fibrillogenesis •  “gluing” of collagen fibrils

Fibroblasts / Tenocytes aligned along fibrils EC Matrix synth from tenoblasts

STRESS

The cellular deformation which occurs with ECM strain produces tension in the cytoskeleton which can be sensed by the cell nucleus through a mechano-sensory tensegrity system to elicit a metabolic response

Science

Science

Mechanical Strain

Change cellular activity of tenocytes

Increased rate of collagen turnover mainly Anabolic max at 11 weeks

Other factors Age / Genetic predisposition / fatigue / neuromuscular

control /smoking / vascularity ..

Flouroquinolone Antibiotics e.g. Ciprofloxacin

Single Event

Collagen fibrillar

damage

Smaller strains microscopic

trauma repetitive

No Clinical symptoms

Change cellular activity of tenocytes

Changes in activity of MMP’s Collagenases other enzymes Increase Collagen

cleaving à + denaturing

Increase immature collagen

Increase PG / Intra-fibrillar GAG

Increase Water Content

Matrix remodelling process abnormal due to failure of the regulatory process MMP-3 MMP-1 responsible

Collagen fibrillar

damage

Relaxation of surrounding ECM

Understress of ECM

Smaller strains microscopic

trauma repetitive overuse!!

Matrix disorganisation Increased immature collagen Increased water content due to increased amounts of ECM - PG’s GAG’s

Normal Tendon 0.6 cm

ACHILLES TENDON

The Art of treating Tendinopathy! •  Tendinopathy can be cured in a clinical sense. •  Overload is bad for tendons but so is drastic

underload (i.e. complete rest, plaster). •  The ‘art’ of managing tendinopathy is being

able to teach the patient to moderately load the tendon and increase this load gradually as tendon function improves

•  Eccentric only – no longer panacea. Add in concentric strengthening. Monitor load carefully everyone is different.

Non Responders

Continue Alfredson Program

Paratenon* distension

Focal * dry needling

Intratendinous* prolotherapy

Autologous Blood / PRP Stem Cells*

GTN Patches Imaging

Consider other diagnoses ASTM

*Level IV evidence only

*

*

*

Sero negative spondyloarthropathy

Intervention ?

Phase 1: pain after activity (immediate - 12 hours) which is

palpable at injury site

Phase 2: pain during & after activity - no significant impairment - eventually resolves

Phase 3: pain during & after activity - significant impairment - eventually

resolves

Phase 4: pain all the time accompanied by significant impairment – prognosis not great

High Volume Injection High Volume injection Total 50mls Large volume of saline Paratenon US guidance (With LA and small dose of Steroid) Results 80+% return to sport Numerous Premiership & Championship players Long term results may depend on continuing eccentric loading 200+ performed Submitted for publication in CJSM

Post procedure management 3 days rest Eccentric loading Return to running after 7-10 days under supervision Full training at 2 weeks depending on duration of symptoms Repeat only if still pain or recurs

Prolotherapy – dextrose / PRP

Mechanism

Proliferation of fibroblastic activity decrease in tendon repair time increased collagen fibre organisation increased cellular proliferation Increase in certain growth factors responsible for tissue healing Overall somewhat theoretical however there are a number of studies now showing some positive value

Research quality is still of low value and certainly more studies are needed one of the main issues in PRP is quantifying concentrations of platelets and the actual preparation of the sample

AJR:189, October 2007 1ml 2% lidocaine + 1ml 50% dextrose Ultrasound Guided 0.5ml per injection site max 4 – 5 injections 6 weeks apart Outcomes VAS Activity Changes on US

Intratendinous Prolotherapy

INTRATENDINOUS PROLO

Better outcome and lower cost than conventional care

Physio cost – 14 sessions over 6/12 £ 960

Injection cost inc staff and equip £ 234

Patient playing cricket again biking and happy

Ostenil Tendon – us guided injection of the paratenon possible use in fascio – crural disruption of the Achilles tendon

Lubricating the tendon could reduce pain, improve tendon function and reduce the potential for adhesions.

The lubricating and visco-elastic properties of OSTENIL® TENDON promote tendon gliding and the physiological repair process. In addition,

due to its macro-molecular structure

My Summary

Intervention should only be considered if it is justified Most athletic tendons can be rehabilitated Match the intervention with the structural problem found Often this is done by experience of using different modalities Don’t just stick to one you need experience in all to offer the best outcome Don’t be pushed into intervention in elite sport by the athlete or the “specialist” weigh up the pros and cons and the likelyhood of success in a given time frame