Tendinopathy

Tendon injuries can involve acute overuse tendinopathy, chronic tendinosis, partial-thickness tears, or complete rupture of the tendon. The exact role of NSAIDs in the treatment of tendinopathy remains uncertain. NSAIDs are potentially helpful initially following acute tendon injury, when inflammation is most likely to be present. For tendinopathy of longer duration, use of NSAIDs, although an adjunct to pain control, does not contribute to tendon healing. The exact mechanism of action of corticosteroid injections, such as in the treatment of lateral epicondylosis and rotator cuff ten-dinopathies, is also unclear. Corticosteroid injections bathe the region of tendinosis, alter the chemical composition of the matrix, and may modify nociceptors on nearby structures (Khan and Cook, 2000). NSAIDs and corticosteroids also may have an effect on other biochemical irritants (yet to be defined) that play a role in the generation of tendon pain.

The use of therapeutic methods to stimulate collagen repair is also a major focus in the treatment of tendinopa-thy. Common strategies to induce collagen remodeling include manual therapies such as deep-friction massage, eccentric conditioning of the tendon, tenotomy (needling a degenerated tendon), and injection of autologous growth factors. Eccentric strengthening programs have shown favorable results for patients with chronic Achilles tendinopathy as well as for athletes with chronic patellar tendinopathy (Alfredson et al., 1998; Purdam et al., 2004). When conservative treatments such as physical therapy fail, treatment options are limited and often lead to either the discontinuation of exercise or surgery. In competitive athletics, chronic tendon injuries can lead to persistent pain, lost time from participation, and suboptimal performance. In occupational injuries, chronic tendon trauma leads to significant cost and morbidity.

With a better understanding of the pathogenesis of tendon injury and healing, newer therapies strive to stimulate the failed healing response in tendinopathies, including percutaneous tenotomy with or without injection of autolo-gous blood or growth factor into the degenerative tendon

(McShane et al., 2006; Housner et al., 2009). The most common form of autologous growth factor therapy is platelet-rich plasma (PRP) and is increasingly used to treat tendi-nosis. Although a relatively novel option for sports-related injuries, PRP has been used in other medical conditions for two decades. The use of PRP migrated to orthopedic procedures, where it has been used effectively to augment bone and soft tissue healing in the operating room, especially in poorly healing fractures and those at high risk for nonunion. Most recently PRP has been used in the outpatient setting for a variety of sports-related soft tissue injuries, including the treatment of chronic tendinopathies, as well as moderate to severe acute ligament, muscle, and tendon injuries. Autologous growth factor therapy in the treatment of chronic tendinosis can initiate a stalled or failed healing response, leading to a healthier and less symptomatic tendon. In the management of chronic lateral epicondylosis (tennis elbow), injection of PRP demonstrated significant pain reduction at 6 months versus injection of anesthetic alone (Mishra and Pavelko, 2006). In the setting of acute soft tissue injury, it is hypothesized that PRP augments the healing response, leading to faster healing, more rapid recovery, and earlier return to sport or activity. In a series of acute muscle injuries in elite soccer players, PRP therapy was found to significantly shorten the time to return to play (Sanchez et al., 2009).

Although research is still needed to understand the optimal indications and treatment protocols for autologous growth factor therapies, initial findings provide optimism that a new, minimally invasive therapeutic option is available in the management of chronic tendinopathies.

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