Taking care of tender tendons - The British Society for Rheumatology

Centre for Sports and Exercise Medicine
Nicola Maffulli
Taking care of tender tendons
Centre for Sports and Exercise Medicine
Nicola Maffulli
Achilles tendon
Epidemiology

Scientifically sound epidemiological data are lacking

Achilles tendinopathy is common in athletes, accounting for 6–17%
of all running injuries

The condition can also present in middle-aged, overweight,
nonathletic patients without a history of increased physical activity

No data are available to establish the incidence and prevalence of
Achilles tendinopathy in other populations, although the condition
has been correlated with seronegative arthropathies (e.g. ankylosing
spondylitis)
Increased demands
on tendon
Predisposition to
further injury
Further alteration
in collagen and
matrix production
Adequate repair
(adaptation)
Inadequate repair
(inadequate collagen and
matrix production)
Tenocyte
disruption
HYPERTROPHY
TRAINING
Increased matrix
synthesis
microdamage
CELL DAMAGE
Ineffective
repair
Poor blood supply
Hyperthermia
Free radicals
Hypoxia
Poor blood supply
Inability to repair damage
EXTRACELLULAR
MATRIX FAILED
HEALING RESPONSE
Mechanical loading
RUPTURE
Tendinopathy
Confusion
Confusion
Confusion
Confusion
Confusion
Confusion
Differential diagnosis of pain at and around the Achilles tendon
Arthritic conditions
Rheumatoid arthritis
Hyperuricaemia and gout
Reiter's syndrome
Pseudogout
Ankylosing spondylitis
Juvenile onset rheumatoid arthritis
Psoriatic arthritis
Sever's
Calcaneal traction apophysitis
Haglund's
Pre-Achilles and retrocalcaneal bursitis
Tibial stress #
Posterior aspect, with secondary Achilles
spasm
Osteomyelitis of tibia and calcaneus
Neoplasms of tibia and calcaneus
Achilles tendon xanthomatosis
Idiopathic hyperostosis
Calcific tendinopathy
Flexor hallucis longus tendinopathy
Flexor digitorum longus tendinopathy
Posterior tibial tendinopathy
Peroneal tendinopathy
Os trigonum syndrome
Secondary Achilles tendon spasm
Achilles tendon
Achillodynia
 Tenalgia
 Tendinitis
 Tendinosis
 Paratendinitis
 Peritendinitis

Tendonitis
 Paratendonitis
 Peritendonitis
 Peri/para … itis
with tendi/tendo
… itis
 Partial rupture

Tendinopathy
Tendinopathy of the main body of
the tendon
 Tendinopathy of the surrounding
tissues
 Pantendinopathy
 Insertional tendinopathy
Maffulli N, Khan KM, Puddu G.
 Ruptures
Overuse tendon conditions:

time to change a confusing terminology.
Arthroscopy 1998; 14 (8): 840-843.

Mid-portion Achilles tendinopathy: a clinical syndrome characterized
by a combination of pain, swelling and impaired performance.

Achilles paratendinopathy: an acute or chronic inflammation and/or
degeneration of the thin membrane around the Achilles tendon.

Insertional Achilles tendinopathy: located at the insertion of the
Achilles tendon onto the calcaneus, bone spurs and calcifications in
the tendon proper at the insertion site may exist.

Retrocalcaneal bursitis: an inflammation of the bursa in the recess
between the anterior inferior side of the Achilles tendon and the
posterosuperior aspect of the calcaneus (retrocalcaneal recess).

Superficial calcaneal bursitis: inflammation of the bursa located
between a calcaneal prominence or the Achilles tendon and the skin.

Previous terms as Haglund’s disease; Haglund’s syndrome; Haglund’s
deformity; pump bump (calcaneus altus; high prow heels; knobbly
heels; cucumber heel), are no longer used.
Achilles tendinopathy
Pain, swelling, limitation of activities
Tendinopathy
Do we get the right picture?
Unknown
factors
Onset of
symptoms
• Risk Factors
• Injury?
• Overuse?
• Metabolic disorder?
Surgery
Histology
Biochemistry
Molecular biology
We do not know
where the pain
originates from!
Therefore, we do not know why and how any
therapeutic modality, including surgery,
works

European Veterans Athletics Championships in Poznan, Poland,
July 2006: 178 athletes (110 men and 68 women; mean age, 54.1
years; range, 35-94 years) evaluated with the Victorian Institute of
Sport Assessment–Achilles (VISA-A) questionnaire.

No effect of gender on the presence of Achilles tendinopathy (P =
.14).

No significant track and field specialty effect on the frequency of
Achilles tendinopathy on VISA-A questionnaire scores (P = .32).

No effect of track and field specialty on VISA-A score (P = .31).
 In
master track and field athletes, impact
profile, weight, height, age and gender
did not exert any influence on
developing patellar tendinopathy
Histology

Failed healing response, with haphazard proliferation
of tenocytes, some evidence of degeneration in
tendon cells and disruption of collagen fibers, and a
subsequent increase in non-collagenous matrix
Tendon pathology is largely
consistent across sites…..
Do we truly understand the details
of the pathology?
Think out of the box
1.
2.
3.
4.
Tendinopathy: FHR
Neovascularity and neoinnervation
Deleterious neo-innervation
Not necessary to excise the lesion
L Ohberg, H Alfredson
Ultrasound guided sclerosis of
neovessels in painful chronic Achilles
tendinosis: pilot study of a new
treatment.
Br J Sports Med 2002; 3: 173-175
1.
Neovascularity
Neoinnervation
Re-thinking about role of surgery
The lesion!
High volume injections at interface between
Kager’s triangle and Achilles tendon
Skin
Achilles tendon
Neovessels
Needle
High volume injections at interface between
Kager’s triangle and Achilles tendon
Skin
Achilles tendon
Neovessels no more
Fluid
Needle
Use the KISSO
principle
K eep
I t
S imple for the
S imple
O rthopods
Achilles tendinopathy
Open
surgery
Minimally Invasive Achilles
Tendon Stripping
Minimally Invasive Achilles Tendon Stripping
Skin
Achilles tendon
Suture thread
Neovessels
Minimally Invasive Achilles Tendon
Stripping
Skin
Achilles tendon
Suture thread
Neovessels
Minimally Invasive Achilles Tendon
Stripping
Skin
Achilles tendon
Suture thread
Neovessels
Minimally Invasive Achilles Tendon
Stripping
Skin
Achilles tendon
Suture thread
Neovessels no more!
THE FUTURE
From the operating room to
the field and to the lab
Not all that glitters is gold
If you wish to know more…
Centre of Excellence
Research Ethos

Basic science, translational and clinical
research

A multi-disciplinary team of clinical and
academic experts

To produce high quality tendon-related
research that advances understanding
and clinical practice in tendinopathy
Track record
 The
largest collaborative tendon
research centre in Europe
 Over
80 tendon related articles
published since 2006
 Over
250 peer review articles
published since 2009
Centre for Sports and Exercise Medicine
iBSc in SEM
MSc in SEM
If you just cannot wait …
 Gateway
Surgical Centre, NUH
 Sportscare
UK, LIH
17-20 October 2012
MLTJ.ORG
Italian Society of Muscles, Ligaments and Tendons
… in
the
end ...
… still a
mountain
to climb...
… but progress
is being made
[email protected]