novel treatments for muscle-tendon injury€¦ · applications for msk us shoulder rotator cuff...
TRANSCRIPT
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Novel Treatments for Tendon Injury
Peter Gonzalez, MD Assistant Professor
Department of Physical Medicine & Rehabilitation Eastern Virginia Medical School Director, EVMS Sports Medicine
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Nothing to disclose
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Define tendon injury
Review traditional treatments
Discuss emergence of MSK US for muscle-tendon pathology
Discuss novel procedures for treatment of tendon disorders
Conclusions
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Tendon Pathology
Tendinitis: acute tendon injury ◦ Presumed inflammatory
mediators ◦ Limited evidence
Tendinosis: chronic tendon pain (?injury) ◦ Result of cumulative trauma ◦ Absence (minimal)true
inflammation ◦ Weakening of collagen
cross-linking ◦ Poor vascularity-
neovascularization of tendon
Tendinopathy: Clinical term
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Normal Tendon
Injury
Degeneration
Inflammatory Phase
1. 2.
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Theory of Tendinosis
Mechanical ◦ Repeated loading within physiological stress range of the
tendon ◦ Chronic repetitive injury or cumulative trauma
Vascular ◦ Hypovascularity to tendons ◦ Proximal to tendon-bone interface ◦ Blood flow decreased w overuse
Neural ◦ Uncertain hypothesis ◦ Chronic overuse leads to increased neural stimulation
and mast cell degranulation
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Susceptible Tendons
Area Tendons
Shoulder Rotator cuff (SupS), biceps
Forearm Forearm extensors/flexors
Knee Patella, quadriceps tendon
Leg/foot Achilles, post. tibialis
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Traditional treatments
RICE
NSAIDs
Bracing or splinting
Physical therapy ◦ Modalities-ICE,heat, US, electrical stimulation, iontophoresis, phonophoresis
◦ Eccentric strengthening
◦ Flexibility program
Corticosteroid injections
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,
Coombes et al (JAMA,2013) ◦ PT/corticosteroid/placebo injection for lateral
epicondylagia ◦ 165 patients w unilateral LE for >6m ◦ At 4weeks:
◦ Corticosteroid effect w/wo PT ◦ CS>placebo injection
◦ At 1 yr: ◦ Corticosteroid (CS) group showed lower recovery rates and
greater recurrence compared to placebo injection ◦ No difference in PT or no-PT groups
◦ Conclusion: CS injections for LE may have short-term benefits but
poorer results in the long-term Physiotherapy did not provide LT benefit
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MSK US
Growth of MSK Ultrasound for diagnosis
Percutaneous procedures with US-guidance
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Applications for MSK US
Shoulder
Rotator cuff tear
Bursitis
Elbow
Tennis elbow
Golfers elbow
Cubital tunnel syndrome
Wrist
Arthritis
Carpal tunnel syndrome
Hand Trigger finger
Cysts
Hip
Tendonitis/bursitis
Knee
Baker’s cyst
Tendon tear
Foot/Ankle
Achilles tendon injury
Nerves
Muscles
Etc, etc, etc, etc…..
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Tendons
In long axis (LA), fibrillar pattern of hyperechoic parallel patterns
In short axis (SA), appears as round/oval hyperechoic structures
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Tendinosis
Normal
Abnormal
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Tenotomy
Needle insertions into tendon
◦ Break up scar tissue
◦ Promote bleeding
◦ Prompt body’s own healing response
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Tenotomy
LE C
Needle
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Tenotomy
Does evidence exist for tenotomy? ◦ McShane et al (J Ultra Med, 2008)
◦ Housner et al (J Ultra Med, 2009)
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Tenotomy
McShane et al (J Ultrasound Med,2008) ◦ US guided percutaneous tenotomy for refractory common extensor tendinosis (Lateral epicondylagia)
◦ 57 consecutive patients ◦ Phone interview follow-up at average 22 months (7-34m)
◦ Procedure: Fenestrate tendinotic tissue, break up calcifications, abrade bone
◦ 58% (excellent), 35% (good), 2% fair, 5.8% poor
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Tenotomy
Housner et al (J Ultrasound Med,2009) ◦ Effectiveness of tenotomy for various tendons in
body ◦ Treated 14 tendons in 13 patients
Patellar tendon (5) Achilles (4) Proximal gluteus medius (1) Proximal ITB (1) Proximal hamstring (1) CET (1) Proximal rectus femoris (1)
◦ Failed phys therapy and >6 month history of pain ◦ Outcomes: VAS prior, at 4 weeks, at 12 weeks
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Tenotomy
◦ Procedure:
US-guided percutaneous needle tenotomy
◦ Results:
Baseline VAS: 5.8 +/- 0.6
Significant pain reduction at 4 weeks (2.4 +/- 0.7) and 12 weeks (2.2 +/- 0.7)
◦ Conclusion:
Effective in improving symptoms without complications
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Tenotomy Pat tendinosis
Housner, 2009
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Tenotomy GMed
Housner, 2009
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PRP
Blood plasma with high concentration of platelets
Drawn from patient and placed to centrifuge
Injected into region of interest
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PRP Process
Sampson, 2008
Platelet-poor Platelet-rich plasma
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PRP
Selected growth factors: ◦ Platelet-derived GF
Mesenchymal stem cells
◦ Transforming GF-B Enhances extracellular
matrix production
◦ Vascular endothelial GF Stimulates
angiogenesis
Other factors/cytokines: ◦ Adenosine
Prevents tissue injury through inflammatory cascade
◦ Serotonin Increases capillary
permeability
Effects on fibroblasts
◦ Histamine Increases capillary
permeability
◦ Calcium
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PRP
Does clinical evidence exist for PRP?
◦ Mishra et al (Am J Sports Med, 2006)
◦ Filardo et al (Int Ortho, 2009)
◦ deVos et al (JAMA, 2010)
◦ Gosens et al (Am J Sports Med, 2011)
◦ Finnoff et al (PMR, 2011)
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PRP
Mishra, et al (AJSM,2006) ◦ 15 PRP, 5 controls for ‘chronic elbow tendinosis’
Autologous PRP vs bupivacaine inj
◦ Reduction in pain seen in PRP-cohort
At 8 weeks, 60% improvement in VAS (vs 16%)
At 6 months, 81% improvement in VAS
At average of 25m, 93% improvement in VAS
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PRP
Filardo et al (Int Ortho, 2009) ◦ Patellar tendinosis (‘jumper’s knee’)
◦ Prospective case control PRP + PT (n=15)
PT-only (n=16)
◦ At 6m: Improved function and pain in both groups Greater improvement in sports
activity in PRP
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PRP
deVos et al (JAMA, 2010) ◦ RCT of PRP vs saline injections for Achilles tendinopathy
N=54
Chronic mid-portion Achilles injury
◦ Both groups treated w eccentric ex
◦ Both groups improved after 24 wks
No sign. benefit in PRP group for pain, function, or patient satisfaction
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PRP
Gosens et al (Am J Sports Med,2011) ◦ DB-RCT w 100 subjects
Compared PRP-corticosteroid injection for lat epi
◦ At 2 yrs, both groups improved in pain and function
Improvement w CS declined over time
Improvement w PRP was maintained
PRP group showed better functional outcomes
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PRP
Finnoff et al (PMR,2011) ◦ Case series (n=34) w
tendinopathy
◦ Patients received tenotomy & PRP
◦ Pre and post MSK US examination
◦ 83% ‘satisfied’ with the results
◦ Sign. improvements in pain and functional scores
◦ MSK US remained ‘abnormal’ improvements noted
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Conclusions
Tendinosis, not tendinitis
Traditional treatments remain traditional ◦ RICE, eccentric exercises
MSK US for diagnostic and therapeutic purposes
Corticosteroids: Use with caution
Novel treatments are emerging ◦ Needle tenotomy/autologous PRP
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Peter G. Gonzalez, MD Assistant Professor
Eastern Virginia Medical School
Department of Physical Medicine and Rehabilitation
Director, EVMS Sports Medicine
Team Physician, Hampton University
Team Physician, Norfolk Public Schools