Tendinopathy

Tendinopathy refers to a disease of a tendon. The clinical presentation includes tenderness on palpation and pain, often when exercising or with movement.[1]

Three terms have evolved in the medical terminology to refer to injuries that cause tendon pain:

Tendon injuries arise from a combination of intrinsic and extrinsic factors; acute tendon injuries may be predominantly caused by extrinsic factors, whereas in overuse syndromes as in the case of tendinopathy it may be caused by multifactorial combinations of both intrinsic and extrinsic factors. An example of an intrinsic factor for tendinopathies are: poor biomechanics such as limb malalignments and hyperpronation that may cause increased traction loads acting on the foot and ankle that may increase the incidence of Achilles, flexor hallucis longus muscle, and tibialis posterior muscle tendinopathies.

Epidemiology

Tendon injury and resulting tendinopathy are responsible for up to 30% of consultations to sports doctors and other musculoskeletal health providers.[2] Tendinopathy is most often seen in tendons of athletes either before or after an injury but is becoming more common in non-athletes and sedentary populations. For example, the majority of patients with Achilles tendinopathy in a general population-based study did not associate their condition with a sporting activity.[3] In another study the population incidence of Achilles tendinopathy increased six fold from 1979-1986 to 1987-1994.[4]

Etiology

The exact etiology of tendinopathy has not been fully elucidated and different stresses may induce varying responses in different tendons. There are multifactorial theories that could include: tensile overload, tenocyte related collagen synthesis disruption, load-induced ischemia, neural sprouting, thermal damage, and adaptive compressive responses. The intratendinous sliding motion of fascicles and shear force at interfaces of fascicles could be an important mechanical factor for the development of tendinopathy and predispose tendons to rupture.[5] Obesity, or more specifically, adiposity or fatness, has also been linked to an increasing incidence of tendinopathy.[6]

The most commonly accepted cause for this condition however is seen to be an overuse syndrome in combination with intrinsic and extrinsic factors leading to what may be seen as a progressive interference or the failing of the innate healing response.

Tendinopathy can be induced in animal models by a surgical injury to the tendon. In both sheep shoulder (infraspinatus)[7] and horse forelimb (superficial digitor flexor)[8] tendons, a mid-tendon transection caused pathology in the entire tendon after four and six weeks respectively.

Treatment

Steroid injections are helpful in the short term (first approximately 4 weeks) however, their long term effectiveness is not known, and quality of evidence for its use remains poor and controversial.[9] Other, more conservative and non-surgical, treatment options available for the management and treatment of tendinopathy include: rest, ice, massage therapy, eccentric exercise, NSAIDs, ultrasound therapy, LIPUS, electrotherapy, taping, sclerosing injections, blood injection, glyceryl trinitrate patches, and (ESWT) extracorporeal shockwave therapy. Studies with a rat model of fatigue-damaged tendons suggested that delaying exercise until after the initial inflammatory stage of repair could promote remodelling more rapidly.[10]

References

  1. ↑ "Management of tendinopathy". Am J Sports Med 37: 1855–67. Sep 2009. doi:10.1177/0363546508324283. PMID 19188560.
  2. ↑ "Assessing health needs in primary care. Morbidity study from general practice provides another source of information". BMJ 310: 1534. Jun 1995. doi:10.1136/bmj.310.6993.1534d. PMID 7787617.
  3. ↑ de Jonge S; et al. (2011). "Incidence of midportion Achilles tendinopathy in the general population". Br J Sports Med 45: 1026–8. doi:10.1136/bjsports-2011-090342. PMID 21926076.
  4. ↑ Leppilahti J, Puranen J, Orava S. Incidence of Achilles tendon rupture. Acta Orthop Scand. 1996;67:277-9
  5. ↑ Sun, Y-L; et al. (2015). "Lubricin in Human Achilles Tendon: The Evidence of Intratendinous Sliding Motion and Shear Force in Achilles Tendon". J Orthop Res 33: 932–7. doi:10.1002/jor.22897.
  6. ↑ Gaida JE, Ashe MC, Bass SL, Cook JL. (2009). "Is adiposity an under-recognized risk factor for tendinopathy? A systematic review". Arthritis Rheum 61: 840–9. doi:10.1002/art.24518. PMID 19479698.
  7. ↑ Smith MM; et al. (2008). "Modulation of aggrecan and ADAMTS expression in ovine tendinopathy induced by altered strain". Arthritis Rheum 58: 1055–66. doi:10.1002/art.23388. PMID 18383380.
  8. ↑ Jacobsen E; et al. (2015). "Focal experimental injury leads to widespread gene expression and histologic changes in equine flexor tendons". PLOS ONE 10 (4): e0122220. doi:10.1371/journal.pone.0122220. PMC 4383631. PMID 25837713.
  9. ↑ "Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials : The Lancet". 2010.
  10. ↑ Bell R, Boniello MR, Gendron NR, Flatow EL, Andarawis-Puri N (2015). "Delayed exercise promotes remodeling in sub-rupture fatigue damaged tendons.". J Orthop Res 33 (6): 919–25. doi:10.1002/jor.22856. PMID 25732052.

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