TENDONITIS – TENDONOSIS MODERN BIOLOGIC THERAPIES
Tendons are the final part of the muscles. They are strips of fibrous connective tissue that are attached to the bones and are involved in joint motion. These are structures that sustain great loads, which cause wear. The term “tendonitis”, which means inflammation of the tendon, has been replaced in the literature with the term “tendonosis”, which better describes not only the inflammation, but the pre-existing degeneration of the tendon. This highlights the difficulties in the radical treatment of the disease regardless of the pateint’s age.
Tendonosis can occur in a number of tendons, most usually in the shoulder (supraspinatus, biceps brachialis), in the lateral epicondyle of the elbow, the Achilles tendon, the patellar tendon, and the quadriceps tendon.
The causes of tendinosis vary. The tendons anatomy, heredity, the body weight, injuries, overuse or overtraining, systematic diseases, like rheumatoid arthritis, as well as the use of specific drugs, like quinolones (a category of antibiotics), have all been associated with tendinosis.
Tendinosis presents with acute, and sharp pain in the affected area. In special cases, like in the shoulder, it presents with nocturnal symptoms, while in superficial tendons, like the Achilles or the patellar tendon it can present with local edema and heat. The motion of the adjacent joint becomes painful. The progression of the degeneration can shrink the tendon with joint stiffness. In some cases, the tendon can be torn leading to loss of motion. When the symptoms insist, the acute tendinitis turns into chronic tendinosis, with severe degeneration of the tendon, which is a difficult to solve clinical situation.
Diagnosis of tendinosis is based on clinical examination. X-rays cannot show the tendons, and are useful only in the presence of calcifications in the tendon, which are more common in the shoulder and the hip. Ultrasound and magnetic tomography (MRI) are the most useful imaging tools, as they can portray the degenerative part of the tendon as well as the surrounding soft tissues.
In the acute phase of the disease treatment starts with ice, non-steroid anti-inflammatory drugs and sometimes immobilizations for a short period. In persistent cases local injections of steroid can be used, although the chronic use of these injections can cause rupture of the tendon. Physiotherapy is also a useful tool. Surgical therapy can also be used in cases of tendon rupture or persistent symptomatology. The tendon is debrided and it can be sutured or reconstructed where needed.
The biggest issue is when the disease becomes chronic. In these cases, the extended degeneration of the tendon, makes it difficult to thoroughly debrided the tendon, as this could endanger its strength and function. Lately, new therapy modalities have been used, based on the better understanding of the local biochemical changes on the connective tissue in cases of tendinosis:
PRPs (platelet rich plasma): Blood serum with high concentration in platelets and growth factors. Blood is taken from the patient and is centrifuged for about 20 minutes. The serum that is isolated has high concentration of platelets, and growth factors, that are very helpful for tissue healing.
This solution is then injected in the lesion, either through the skin or directly in cases of surgical debridement. A second injection can be performed in rare cases that the symptoms do not resolve. The platelets and growth factors activate the mechanisms of healing and restoration of the tendon, that are usually less functional in cases of tendinopathies. Thus, therapy is accelerated with the use of biologic factors that come from the patient him/herself.
Many studies coming from major scientific centres have validated the use of PRPs in tendinopathies (Foster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo SA (2009). “Platelet-rich plasma: from basic science to clinical applications”. Am J Sports Med 37 (11): 2259–72). This method is currently been investigated for the treatment of other diseases, like cartilage lesions, osteoarthritis, fractures etc. The low cost, ease of use, lack of complications and excellent outcomes have turned PRPs in an attractive, safe and efficient method for the treatment of tendinosis.
Collagen: Injecting collagen is also a method that can improve the symptoms in cases of tendinosis, by enhancing the quality of the tendon, and accelerating the return to activities.
EPI (Transdermal Electrolysis): Applying galvanic and micro-currents through the skin with the use of a special needle can significantly improve tendinosis.
(MOJ Immunology. A Molecular Mechanisms of Regeneration in Chronic Tendinopathy Using Ultrasound-Guided Intratissue Percutaneous Electrolysis (EPI®). MOJ Immunol 5(1): 00148. DOI: 10.15406/moji.2017.05.00148 Sánchez-Ibáñez JM (2017)
In 2-3 sessions pain subsides, the scar tissue diminishes, collagen is produced, the adjacent joint gains mobility and return to activities is faster. TheMIS Orthopaedic Center has been using this method since 2015 for the treatment of soft tissue diseases with great outcomes.
When should a tendinosis be operated?
In patients that did not improve with conservative treatment (L Jozsa and P Kannus in Human Tendons 1997). Surgical treatment is the last resort when all other conservative methods have failed (ΒΜ Andres and AC Murrell Clinical Orthopaedics and Rel Res 2008).
Surgical treatment is saved for 3rd-4th degree tendinosis. It can be performed open or arthroscopically. The scar tissue is excised, tiny holes are created in the surrounding tendon tissue to promote reperfusion of the lesion, and growth factors are injected in the area.
The aim of surgical therapy is:
- Modification of the tendon structure and strengthening of the tendon through its regeneration
- Promotion of tendon reperfusion
- Removal of any external tissue (bone or soft tissue) that causes mechanical pressure or irritation
- Reduction of tensile overload
- Removal of ectopic damaged tissue, like:
- Chronic granulomatous tissue
- Scar tissue
- Degenerated or necrotic tendon tissue
- Hypertrophic peritendinous membrane or bursa
Success can range from 46% to 100%, with an average of 81.5%.