Novel Treatments for Tendon Injury

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1 Novel Treatments for Tendon Injury Peter Gonzalez, MD Assistant Professor Department of Physical Medicine & Rehabilitation Eastern Virginia Medical School Director, EVMS Sports Medicine

2 Nothing to disclose

3 Define tendon injury Review traditional treatments Discuss emergence of MSK US for muscletendon pathology Discuss novel procedures for treatment of tendon disorders Conclusions

4 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 vascularityneovascularization of tendon Tendinopathy: Clinical term Tendon Pathology

injury) Result of cumulative trauma Absence (minimal)true inflammation

5 Normal Tendon Injury Inflammatory Phase Degeneration

6 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 Theory of Tendinosis

tendon-bone interface Blood flow decreased w overuse Neural Uncertain hypothesis Chronic

7 Area Shoulder Forearm Knee Leg/foot Tendons Rotator cuff (SupS), biceps Forearm extensors/flexors Patella, quadriceps tendon Achilles, post. tibialis Susceptible Tendons

8 RICE NSAIDs Bracing or splinting Physical therapy Modalities-ICE,heat, US, electrical stimulation, iontophoresis, phonophoresis Eccentric strengthening Flexibility program Corticosteroid injections Traditional treatments

iontophoresis, phonophoresis Eccentric strengthening

9 , 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

recovery rates and greater recurrence compared to placebo injection No difference in PT or no-pt groups Conclusion: CS

10 Growth of MSK Ultrasound for diagnosis Percutaneous procedures with USguidance MSK US

11 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.. Applications for MSK US

Cysts Hip Tendonitis/bursitis Knee Baker s cyst Tendon tear Foot/Ankle

12 In long axis (LA), fibrillar pattern of hyperechoic parallel patterns In short axis (SA), appears as round/oval hyperechoic structures Tendons

13 Normal Tendinosis Abnormal

14 Needle insertions into tendon Break up scar tissue Promote bleeding Prompt body s own healing response Tenotomy

15 Needle LE C Tenotomy

16 Does evidence exist for tenotomy? McShane et al (J Ultra Med, 2008) Housner et al (J Ultra Med, 2009) Tenotomy

17 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 Tenotomy

interview follow-up at average 22 months (7-34m) Procedure: Fenestrate tendinotic

18 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 Tenotomy

(1) Proximal ITB (1) Proximal hamstring (1) CET (1) Proximal rectus femoris (1) Failed phys

19 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 Tenotomy

20 Housner, 2009 Tenotomy Pat tendinosis

21 Housner, 2009 Tenotomy GMed

22 Blood plasma with high concentration of platelets Drawn from patient and placed to centrifuge Injected into region of interest PRP

23 Platelet-poor Platelet-rich plasma Sampson, 2008 PRP Process

24 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 PRP

25 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) PRP

26 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 PRP

27 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 PRP

28 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 PRP

29 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 PRP

30 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 PRP

31 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 Conclusions

32 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

Tendinopathy Evaluation and Management. Troy Henning, DO Assistant Professor Dept PM&R University of Michigan AOCPMR

2014 Tendinopathy Evaluation and Management Troy Henning, DO Assistant Professor Dept PM&R University of Michigan AOCPMR Goals Update on Tendinopathy Terms Prevalence Proposed Etiologies Diagnosis Treatment