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Nicola Maffulli Department of Trauma and Orthopaedic Surgery Keele University School of Medicine. Tendinopathies in Sport. Where on earth is Stoke on Trent?. Tendon problems. Human studies. Cell models. Animal models. Increased demands on tendon. Adequate repair (adaptation) ‏.

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nicola maffulli department of trauma and orthopaedic surgery keele university school of medicine
Nicola Maffulli

Department of Trauma and Orthopaedic Surgery

Keele University School of Medicine

Tendinopathies in Sport

slide3

Tendon problems

Human studies

Cell models

Animal models

slide5

Increased demands on tendon

Adequate repair (adaptation)‏

Inadequate repair (inadequate collagen and matrix production)‏

Predisposition to further injury

Tenocyte disruption

Further alteration in collagen and matrix production

slide6

HYPERTROPHY

TRAINING

Increased matrix synthesis

Poor blood supply

Hyperthermia

Free radicals

Hypoxia

microdamage

CELL DAMAGE

Ineffective

repair

Poor blood supply

Inability to repair damage

EXTRACELLULAR MATRIX FAILED HEALING RESPONSE

Mechanical loading

RUPTURE

slide7

Tendinopathy

Do we get the right picture?

Unknown factors

Onset of symptoms

Surgery

Histology

Biochemistry

Molecular biology

  • Risk Factors
  • Injury?
  • Overuse?
  • Metabolic disorder?
tendinopathy
Tendinopathy

Confusion

Confusion

Confusion

Confusion

Confusion

Confusion

Confusion

Confusion

Confusion

Confusion

Confusion

Confusion

Confusion

modern classification of tendinopathy
Modern classification of Tendinopathy
  • Tendinopathy of the main body of the tendon
  • Tendinopathy of the surrounding tissues
  • Pantendinopathy
  • Insertional tendinopathy
  • Ruptures

Maffulli N, Khan KM, Puddu G.

Overuse tendon conditions:

time to change a confusing terminology.

Arthroscopy 1998; 14 (8): 840-843.

tendinopathies
TENDINOPATHIES
  • Difficult to manage
  • Management
    • often anecdotal
    • rarely evidence-based
    • often emotional
    • dubiously effective
we do not know where the pain originates from
We do not know where the pain originates from!

Therefore, we do not know why and how any therapeutic modality, including surgery, works

light microscopy tendon disarray
Light microscopy – tendon disarray

Normal

Abnormal

Failed healing response

  • Collagen degeneration = disarray
  • Increased ground substance
  • Prominent cell nuclei & neovascularization

Puddu et al AJSM 1976; Maffulli et al AJSM 2001;

Khan et al., BMJ 2002

no evidence of classical inflammatory cells in human overuse tendon injuries
No evidence of ‘classical’ inflammatory cells in humanoveruse tendon injuries
  • Light or electron microscopy
  • Biochemistry (common extensor origin, PGE 2 absent in Achilles, patellar tendons)‏

Alfredson 1999, 2000, 2001

– in vivo microdialysis

hurdles to optimal management of tendinopathies
Hurdles to optimal management of tendinopathies

DIAGNOSIS IS CLINICAL!

Tennis elbow: an ultrasonographic study in tennis players.Br J Sports Med 1990; 24: 151-5.N Maffulli, R Regine, F Carrillo, G Capasso, S Minelli

hurdles to optimal management of tendinopathies1
Hurdles to optimal management of tendinopathies
  • relative rest
  • physical therapy
  • NSAIDs
  • deep frictions
  • hyperthermia
  • HOT
  • fibrolysis
  • eccentric loading
  • ultrasound
  • No validated conservative management protocols
  • laser treatment
  • ozone
  • injections

corticoteroids

heparin

aprotinin

others

  • ESWT
  • topical glyceryl trinitrate
slide16

Short-term effectiveness of hyperthermia for supraspinatus tendinopathy in athletes: a short-term randomized controlled study.Am J Sports Med 2006;34(8):1247-153.A Giombini, A Di Cesare, MR Safran, R Ciatti, N MaffulliHyperthermia induced by microwave diathermy in the management of muscle and tendon injuries.A Giombini, V Giovannini, A Di Cesare, P Pacetti, H Naito, N MaffulliBr Med Bull 2007;83:379-396

patients
PATIENTS

Failure of three to six months of conservative management

surgical management of tendinopathies of elbow
Surgical management of tendinopathies of elbow
  • needling
  • coblation
  • percutaneous (ultrasound guided) tenotomy
  • arthroscopic approach
  • (mini)open approach
  • No validated surgical protocols
surgical management of tendinopathies
Surgical management of tendinopathies
  • Aims:
  • promote repair
  • return to pre-injury activity level
surgical management of tendinopathies1
Surgical management of tendinopathies
  • Classical orthopaedic operation:
  • I do not know what it does
  • … but I use a bigger scalpel with a heavier hammer!

Surgical management of tennis elbow. J Sports Med Phys Fitness 2002; 42: 190-197D Das, N Maffulli

slide24

Effect of basic fibroblast growth factor. An in vitro study of tendon healing.Clin Orthop Rel Res 342: 239-247, 1997B Chan, KM Chan, N Maffulli, S Webb, KKH Lee

why do tendinopathies occur
Why do tendinopathies occur?

Is there an underlying metabolic disorder?

slide26

N Maffulli, SWB Ewen, SW Waterston, JA Reaper, V Barrass

Tenocytes from ruptured and tendinopathic Achilles tendon produce greater quantities of collagen type III than tenocytes from normal Achilles tendon.

An in vitro model of human tendon healing.

Am J Sports Med 2000; 28: 499-505

slide27

H Alfredson, H Harstad, S Haugen, L OhbergSclerosing polidocanol injections to treat chronic painful shoulder impingement syndrome-results of a two-centre collaborative pilot study.Knee Surg Sports Traumatol Arthrosc 2006;14:1321-1326

slide28

P Jonsson, P Wahlstrom, L Ohberg,H AlfredsonEccentric training in chronic painful impingement syndrome of the shoulder: results of a pilot study.Knee Surg Sports Traumatol Arthrosc 2006;14:76-81

slide29
CS Bestwick, N MaffulliReactive oxygen species and tendinopathy. Do they matter? Br J Sports Med 2004; 38:672-674
slide30

Exercise

ROS - RNS

Unusual/sudden exercise

Training

Sedentary

Genetic predisposition

Poor nutrition

Adaptive

response

No adaptive response

No/insufficient adaptive response

No problems

Failed healing

response

RUPTURE

biomagnetic manipulation
Biomagnetic manipulation
  • Biomagnetic particles attached to cell
    • membrane ion channels
    • beads internalized into cytoplasm
  • Magnetic force applied to cells
  • Modulates ion cells function
  • Upregulation of cell functions

P Sharma, N MaffulliTendon injury and tendinopathy: injury and repair. J Bone Joint Surg 2005; 87A: 187-202

slide32
M Magra, N Maffulli.

Molecular events in tendinopathy: a role for metalloproteases.

Foot and Ankle Clinics

10: 267-277, 2005

M Magra, N Maffulli.

Matrix metalloproteases: a role in overuse tendinopathies.

British Journal of Sports Medicine

39: 789-791, 2005

slide33
VOCC

TREK

M. Magra, S. Hughes, A. El Haj, N. Maffulli.

VOCCs and TREK-1 ion channel expression in human tenocytes.

American Journal of Physiology, 2006 epub

slide34

IP3 traversing gap junctions to communicate a load signal by Ca2+ wave propagation

Pipet

Ca2+ ion free

Ca2+ ion bound

intercellular messenger

gap junction

slide36

N Maffulli

JB King

F Franceschi

UG Longo

L Ruzzini

V Denaro

M Ronga

slide38
Tendon changes not only localized at the site of rupture, but also in the macroscopic intact tendon portion
  • During cuff repair, not necessary to excessively freshen the torn tendon to bleeding tissue
gene expression and protein analysis in ruptured human achilles tendons

Gene expression and protein analysis in ruptured human Achilles tendons

M Ronga, E Karousou, D Vigetti,

A Passi, N Maffulli

Accepted for publication, CORR

Department of Trauma and Orthopaedic Surgery

Keele University School of Medicine

Departmentof Trauma and Orthopaedic Surgery

University of Insubria, Varese, Italy

slide40
LHB tendons of patients undergoing arthroscopic tenotomy for a refractory biceps tendinopathy show marked histopathological changes
  • The same tendons from aged individuals with no known tendon abnormalities have, as a group, little histological evidence of degenerative changes
slide45

Thank you

Thank you