We are very pleased to present a series of articles written by Dr. Steinman. He has worked closely with not only our dancers but also professionals in the world of Dance and Sports. All of the articles will be technical in nature but we feel that they will have enormous value to all of our members by helping us to understand how to take care of our dancers and knowing what to look out for when they sustain an injury. Dr Steinman works closely with us to ensure that the dancers not only receive the correct treatments but that they also benefit from the best strength training when needed.
THIS ARTICLE DISCUSSES TENDINOSIS AND ITS TREATMENT.
The term "tendonitis" to describe acute symptoms at the insertion of tendons as a result of overuse is a misnomer. The histopathology of these structures show disorganizeded collagen fibers, mucoid patches, and neovascularization. There is an absence of inflammatory cells on microscopic examination of these tendons. The use of the term "tendonitis" is misleading to both clinicians and patients as it implies that the use of strategies that reduce inflammation is the appropriate therapeutic intervention. In actuality this condition is a degenerative process thought to result from an ineffective, abnormal, or aborted inflammatory process. This pathophysiology has a fundamental impact on the approach to therapy.
The effective long-term treatment of tendinopathys may rest on creating and directing an inflammatory process in the affected tendon in order to promote the deposition on new healthy collagen. The role of several new therapies will be presented in this context. Tendinosis is frequently associated with an inflammatory process in the paratenon (paratenonitis). This may explain why anti-inflammatory therapies may cause a transient improvement in symptoms, while at the same time impairing long -term prognosis of patients with tendinopthies. Paratenonitis is best exemplified by DeQuerviens "Tendonitis," where swelling, and crepitus over the tendon sheath are prominent physical findings. The metabolic inactivity of tendons mandate that the recovery period for tendinosis is at least 12 weeks and usually takes six months. It takes 12 weeks for collagen to fully mature, align and form cross-links with adjacent fibers. This must be kept in mind otherwise the patient and the practitioner may prematurely abandon effective therapy.
Therapy begins with pain relief Protection, Relative Rest, Ice Compression, Medications (anti inflammatory for paratenonitis, analgesics for pain), protection from further injury (bracing, orthotics) and modalities should be employed for the first one to two weeks to control symptoms. Symptom relief is not the same as cure.
Once the patients' symptoms are under control, attention can be directed to improving the quality of the tissue. Fibroblasts must be recruited to the site of injury so that collagen can be deposited and matured, thus restoring normal tendon structure. Extra Caporal Shock Wave treatment (ECSWT), Pro-Inflammatory (Prolo) therapy and High Voltage Electrical Stimulation are thought to be of benefit by inciting local inflammation, leading to the recruitment of fibroblasts, deposition of high quality collagen and the improvement in vascularity. Eccentric strengthening exercises promote healing by increasing tenocyte metabolism, thus increasing the rate of collagen production. The axial loading of tendons help to orientate collagen fibrils parallel to the tensile forces and promote normal architecture. Surgery restores normal tissue architecture by excising the degenerative tissue. In addition this surgical intervention stimulates the inflammatory process. Surgery involves a lengthy rehabilitation process, which employs several of the techniques mentioned above. The literature regarding many of the above therapies is sparse and contradictory.
Basic science research coupled with randomized, controlled, blinded clinical trials is necessary before appropriate therapy can be prescribed with confidence.
Dr. Steinman is Board Certified in Emergency Medicine and Primary Care Sports Medicine and has a practice in Westport, Connecticut. He is an adjunct professor of Human Movement Science at Sacred Heart University, Fairfield, Connecticut. His article was published in SPORTSMED a publication of the Connecticut State Medical Society.