What Works, What Does Not, and What is on the Horizon. Orthopaedic Research Institute, St George Hospital, University of New South Wales, Level 2 Research and Education Building, 4- 1.
South Street, Kogarah, Sydney, NSW 2. Australia Brett M. Andres, Phone: 0. Fax: 0. 11- 6. 1- 2- 9.
- Tendinopathy is a broad term encompassing painful conditions occurring in and around tendons in response to overuse. Recent basic science research suggests.
- Process modeling and design concepts were implemented to aid in the manufacturing of heat-enhanced transdermal drug-delivery systems. The simulated prototype co.
Email: moc. oohay@serdnab. Corresponding author. Received 2. 00. 7 Dec 2. Accepted 2. 00. 8 Apr 3. Copyright © The Association of Bone and Joint Surgeons 2. This article has been cited by other articles in PMC.
Abstract. Tendinopathy is a broad term encompassing painful conditions occurring in and around tendons in response to overuse. Recent basic science research suggests little or no inflammation is present in these conditions.
Thus, traditional treatment modalities aimed at controlling inflammation such as corticosteroid injections and nonsteroidal antiinflammatory medications (NSAIDS) may not be the most effective options. We performed a systematic review of the literature to determine the best treatment options for tendinopathy. We evaluated the effectiveness of NSAIDS, corticosteroid injections, exercise- based physical therapy, physical therapy modalities, shock wave therapy, sclerotherapy, nitric oxide patches, surgery, growth factors, and stem cell treatment.
NSAIDS and corticosteroids appear to provide pain relief in the short term, but their effectiveness in the long term has not been demonstrated. We identified inconsistent results with shock wave therapy and physical therapy modalities such as ultrasound, iontophoresis and low- level laser therapy. Current data support the use of eccentric strengthening protocols, sclerotherapy, and nitric oxide patches, but larger, multicenter trials are needed to confirm the early results with these treatments.
Preliminary work with growth factors and stem cells is promising, but further study is required in these fields. Surgery remains the last option due to the morbidity and inconsistent outcomes. The ideal treatment for tendinopathy remains unclear.
Level of Evidence: Level II, systematic review. See the Guidelines for Authors for a complete description of levels of evidence. Introduction. Traditionally, pain in and around tendons associated with activity has been termed tendonitis. This terminology implies the pain associated with these conditions results from an inflammatory process. Not surprisingly, treatment modalities have mainly been aimed at controlling this inflammation.
The mainstays of treatment have included rest, nonsteroidal antiinflammatory medications (NSAIDs), and periodic local corticosteroid injections. There are two problems with this approach. First, several studies demonstrate little or no inflammation is actually present in tendons exposed to overuse [8. Second, traditional treatment modalities aimed at modulating inflammation have had limited success in treating chronic, painful conditions arising from overuse of tendons. More recently, the term tendinopathy has been advocated to describe the variety of painful conditions that develop in and around tendons in response to overuse.
Histopathologic changes associated with tendinopathy include degeneration and disorganization of collagen fibers, increased cellularity, and minimal inflammation [8. Macroscopic changes include tendon thickening, loss of mechanical properties, and pain [1. Recent work demonstrates several changes occur in response to overuse including the production of matrix metalloproteinases (MMPs), tendon cell apoptosis, chondroid metaplasia of the tendon, and expression of protective factors such as insulin- like growth factor 1 (IGF- 1) and nitric oxide synthetase (NOS) [1.
A wart (also known as a plantar wart when it occurs on the sole of the feet or on toes) is generally a small, rough tumor, typically on hands and feet but often other. Tropical Journal of Pharmaceutical Research, Vol. 6, No. 1, March 2007, pp. 633-644. Review Article. Modified Transdermal Technologies: Breaking the Barriers of. Peyronie’s Disease Peyronie’s disease is characterized by a plaque, or hard lump, that forms within the penis. The plaque, a flat plate of scar tissue, develops. Elbow injuries in vehicle accidents either occur from bracing against the steering wheel, dashboard, or back of the seat, or a direct impact against some part.
Although many of these biochemical changes are pathologic and result in tendon degeneration, others appear beneficial or protective. Tendinopathy appears to result from an imbalance between the protective/regenerative changes and the pathologic responses that result from tendon overuse. The net result is tendon degeneration, weakness, tearing, and pain.
My experience was similar, but ~ 10 years ago. I'm now having chronic problems with the ischial tuberosity point of insertion. Recently had iontophoresis along with.
As the basic science of tendinopathy has evolved, so have the treatment options for these conditions. We investigated the multitude of options proposed for the treatment of tendinopathy. Based on the authors’ knowledge of the field and an extensive literature review, we evaluated the following treatment options: NSAIDS; exercise- based physical therapy; physical therapy modalities including iontophoresis, phonophoresis, ultrasound, transverse friction massage, and low- level laser therapy; corticosteroid injections; glyceryl trinitrate patches; shock wave therapy; sclerotherapy; surgery; growth factor treatment; and stem cell treatment. Our goal was to provide a comprehensive and up- to- date review of these treatment options with recommendations based on the best level of evidence available. Search Strategies and Criteria. The available literature was reviewed using Pub.
Med and the Cochrane register of controlled trials. An initial search of these databases using the terms “tendinopathy” OR “tendonitis” OR “tendinosis” OR “epicondylitis” resulted in 5. Limiting the search to English language clinical trials and meta- analyses resulted in 3. The titles and abstracts of these articles were then individually reviewed. Only studies evaluating the treatment modalities described above were kept for this review. In addition, studies evaluating tendinopathy of the fingers and hand were discarded as tendinopathy seen in these tendons, which typically have synovial sheaths, appear to involve a different, often inflammatory process. Upon completion of this literature search, a total of 1.
Based on the magnitude of this review, no attempt was made to grade these studies in terms of methodological quality. In the emerging treatment areas where few or no clinical trials have been performed, the literature search was expanded to include pilot studies and animal studies to better define the current and future options in these areas. FDA- approved NSAIDs. Oral NSAIDs have been used extensively for decades to treat pain associated with tendon overuse.
More recently, the local administration of NSAIDs through gels or patches has been advocated. Our literature search identified 3. NSAIDS in the treatment of tendinopathy.
Of these, only 1. Overall, the evidence suggests both oral and local NSAIDS are effective in relieving the pain associated with tendinopathy in the short term (7–1. Only three of the 1.
NSAIDS [1. 3, 7. 1, 8. Oral and local NSAIDs appear effective in the treatment of acute shoulder bursitis/tendonitis [1. One study also showed some success treating longer- standing shoulder pain with naprosyn sodium [1.
In a randomized, placebo- controlled, double- blind study, naprosyn sodium was more effective than placebo but not as effective as a corticosteroid injection in the treatment of shoulder bursitis/tendonitis at 4 weeks. Not surprisingly, the patients who presented with a longer duration and greater severity of symptoms were more likely to have a poor response to both corticosteroid injection and/or oral NSAIDs.
NSAIDs do not seem nearly as effective in treating lateral epicondylitis or Achilles tendinopathy [1. The only study to look at the effectiveness of NSAIDS for the treatment of lateral epicondylitis in the long term reported no difference between placebo and naproxen treatment groups at 1- year followup [7.
A systematic review of NSAID use for lateral epicondylitis identified data to support the use of local NSAIDs with a decrease in pain in the short term (2 weeks) [6. However, there is little evidence to support or refute the use of topical or oral NSAIDs in the long term. In addition, long- term NSAID use increases the risk of gastrointestinal, cardiovascular, and renal complications associated with these medications. Overall, a short course of NSAIDs appears a reasonable option for the treatment of acute pain associated with tendon overuse, particularly about the shoulder. There is no clear evidence that NSAIDS are effective in the treatment of chronic tendinopathy in the long term.
Physical Therapy. Physical therapy has been commonly used for the treatment of tendinopathies. There is, however, mixed data to support its use.
The type of therapy used can be quite variable from one therapist to the next, and orthopaedic surgeons are often not involved in choosing the type of therapy used. Stretching and strengthening programs are a common component of most therapy programs.
Therapists also use other modalities, including ultrasound, iontophoresis, deep transverse friction massage, low- level laser therapy, and hyperthermia. Stretching/Strengthening. Eccentric strengthening programs have recently been advocated in the treatment of tendinopathy (Fig. 1. A–C) [7, 1. 03, 1.
Our literature review identified 1. One of these studies had a control group that received no treatment [1.
This study showed improvement in the eccentric strengthening group compared to a “wait and see” group at 4 months. The other clinical trials evaluating eccentric strengthening compared it to other treatment modalities [1. A 1. 2- week course of eccentric strengthening exercises was more effective than a traditional concentric strengthening program for treating Achilles and patellar tendinopathy in recreational athletes [7.
In the Achilles tendinopathy study, 8. Imaging of the Achilles tendon before and after a 1. MRI [1. 20, 1. 57]. Interestingly, eccentric strengthening produced better results in tendinopathy of the midsubstance of the Achilles compared with insertional tendinopathy [5. An eccentric training protocol for the treatment of Achilles tendinopathy is demonstrated. A) The patient starts in a single- leg standing position with the weight on the forefoot and the ankle in full plantar flexion. B) The Achilles is then eccentrically..
Eccentric strengthening protocols have also been successful in the treatment of lateral epicondylitis [4. In a well- designed study, 9.
Elbow Injuries In Vehicle Accidents. Elbow injuries in vehicle accidents either occur from bracing against the steering wheel, dashboard, or back of the seat, or a direct impact against some part of the inside of the vehicle. While fractures are uncommon, they certainly can occur. Usually the elbow will be extremely swollen and painful and an x- ray will show a fracture. Immediate referral to an orthopedic surgeon is appropriate to either cast or operate on the area.
Much more common is the syndrome called radial head dysfunction. The radius runs from the base of the thumb to the outer aspect of the elbow.
The radial head attaches to the elbow and can be “jammed” during the trauma of an accident. This usually leads to significant muscle spasm over the surrounding tissues. The tight muscle then “tugs” on its tendon as it inserts onto the elbow, causing “lateral epicondylitis” or the more commonly known name of “tennis elbow”. A similar syndrome can occur on the inside of the elbow and is called “medial epicondylitis” or “golfer’s elbow”. Both injuries respond well to ice and anti- inflammatories (if they are not contraindicated), gentle stretching of the forearm muscles, the use of cortisone via iontophoresis (patch) or cortisone injection, or laser therapy.
While these injures can be extremely painful and temporarily debilitating, they normally respond well to the above- noted management. A Better Way to Get Better,Adrian Lewis.
Adrian Lewis, MD.