Tendons, research and diagnostics

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Lotta Willberg• Specialist in Orthopedic surgery, 2000

• PhD Sportsmedicine, 2013

• Special interest in sportstrauma/arthroscopic surgery(knee, ankle, shoulder), overuse injuries, tendons and musculoskelettal US

• Headphysician team Sweden in diving 2000-2016

• Headphysician team Sweden in wrestling 2000-2012

• Primary responsible physician Swedish Olympic Committe, summersports and figureskating 2003-2009

• Physician for the Swedish Olympic Team, Athens 2004, Beijing 2008, London 2012

• Consultant and head of developing the medical support and clinic in Catella Arena for Good to Great Tennis Academy 2016-

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Why US as an arthroscopist?• US has been used for clinical musculoskeletal examinations for a long

time (Fornage 1986) but not focused on tendon pathology• In the past, US was considered a complement to MRI for the imaging of

tendons

• Modern highresolution US is highly competitive, and it is today the preferred choice when imaging tendon injuries (Rasmussen 2000)

• It is proven to be accurate, cost-effective (Jacobson 1999) and a valid method (Martinoli et al. 1993).

• It is recommended to be the most suitable method when it comes to investigating superficially located structures such as tendons, for example Achilles and patellar tendons (Soila et al. 1999; Ostlere 2013)

• US is a dynamic examination which is an important advantage compared to MRI

• There are studies comparing the accuracy of MRI and US when confirming clinically diagnosed patellar tendinopathy. US/CD and interestingly also grey scale (GS) ultrasound proved to be more accurate than MRI (Warden et al. 2007; Garrick et al. 2008) 3

Patellar and Achilles tendinopathy –sclerosing injections and ultrasound guided arthroscopic

shaving

Definitions

• There is a lack of consistent terminology relating to chronic painful conditions in tendons

• The terminology can be confusing with the consequences that scientific studies and descriptions of US/CD findings are difficult to compare and interpret

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• Tendinopathy is widely recommended to describe a condition with tendon pain, swelling and impaired function, thereby not assuming any information of the underlying pathology (Khan et al. 1998; Maffulliet al. 1998; Peers et al. 2005; Riley 2005)

• Peritendinitis is characterized by a true inflammation in the paratenon (Åström 1997).

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• Tendinitis and tendonitis have been widely used, assuming that there was a true inflammation within the tendon

• Tendinitis is primarily involving the tendon showing an inflammatory response within the tendon and is often associated with reactive paratendinitis (Józsa et al. 1997)

• Research in this area has evolved during the years, several observations, including histological and biochemical studies (Khan et al. 1996) and intratendinous microdialysis (Alfredson et al. 1999,2001), have shown an absence of a true prostaglandin-mediated inflammatory process inside the chronic painful tendon (Kannus et al. 1991; Åströmet al. 1995; Alfredson et al. 1999, 2003)

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• Tendinosis has been proposed to describe the findings interpreted as being degenerative in this chronically painful state of the tendon (Khan et al. 1999; Peers et al. 2005)

• The term tendinosis can be used regardless of pain or symptoms and it refers to intratendinoushistopathological changes which can be visualized and objectively verified by US, MRI or biopsies (Maffulli et al. 1998; Alfredson et al. 2005)

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P atholog ic al c las s ific ation of tendon dis orders (C lanc y)P athological label C oncept (macroscopic pathology) His tological findingTendinos is Intratendinous degeneration, commonly due to aging Non-inflammatory intratendinous collagen degeneration with fibre

(microtrauma, vascular compromise) disorientation, hypocellularity, scattered vascular ingrowth,occas ional local necros is or calcification

P aratenonitis Inflammation of the outer layer of the paratenon Inflammatory cells in the paratenon or peritendinous areolar alone, whether or not the paratenon is lined by synovium tissue

P aratenonitis with tendinos is P aratenon inflammation associated with intratendinous Inflammatory cells in the paratenon or peritendinous areolardegeneration tissue with loss of tendon collagen, fibre disorientation, scattered

vascular ingrowth and no prominent intratendinous inflammationTendinitis S ymptomatic degeneration of the tendon with vascular Acute haemorrhage and tear, inflammation superimposed on

disruption and inflammatory repair response exis ting degeneration. Includes the conditions of tendon s trainand tear

What will mostly be adressed in this talk?

Chronic painful tendinopathy – what are wedealing with/imaging?

- A LOT OF NERVES OUTSIDE THE TENDON -

A small amount inside the tendonNerve system in tendons

Biopsies

Immunohistochemistry

general, sensory, autonomic nerve system

Substance-P, CGRP, Acetylcholin, Catecholamins

2007 Dissertation - Patrik Danielsson, Umeå

• Tenocytes - First step”- change shape – metaplastic

Forsgren et al. Umeå 2004-2006

Cook et al. Melbourne 2005

Scott et al. Vancouver 2006

Ultrasound and colourDoppler

Normal Achilles tendon

Midportion tendinosis, structural changes

Tendinosis with transverse bloodflow

Background2D greyscale US visualizes the tendonstructure with relatively hyperechoic linear echoes, in the longitudinal view, which are the secondary fiberbundles (~0,2 mm) surrounded by loose ffibrous tissue (Kainberger et al 1990, Martinoli et al 1993)

Normal values concerning thickness of some specific tendons; - midportion Achilles tendon ca 4,5 – 6,0 mm (Fornage 1986, Mathieson et al 1988, Koivunen-Niemelä et al 1995, Ying et al 2003)

- proximal patellartendon ca 3,5 – 5,5 mm (Kartus et al 2000, Nyland et al 2006, Skou et al 2013 )

- rotatorcuff ca 3.5 - 5.5 mm (Cholewinski et al 2008, Karthikeyan et al 2014)

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Hypoechoic findings – greyscale US

• All non-artefactual disturbances of a homogeneous tendon structure indicate abnormality (Kainberger1990). Hypoechoic areas, grey-scale US, are interpreted to correlate with areas of focal degeneration, seen in immunehistochemical analyses, where the collagen fibres become invisible.

• Hypoechogenicity in such areas is assumed to be a result of an increase in water stored by proteoglycans (Kainberger et al 1990, Kannus 2000)

• Tendon echogenicity is angle-dependent, and it has been shown that tendons appear hypoechoic when scanned at an angle greater than 2-7º (Crass et al 1988) and this is important to have in mind when interpreting the findings.

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The bloodsupply• Mostly longitudinally oriented vessels located in the

paratenon and endotenon. • The paratenon is a highly vascular tissue which

contributes to blood supply throughout the whole length of the Achilles tendon, with three different origins: the osseo-tendinous junction, the mesotendineum and the musculotendinous junction (Carr et al 1989)

• The blood flow in a normal tendon is known to be low.• Adding CD or PD to the US examination will not reveal

any signs of increased vascularity or blood flow in the majority of normal cases (Ohberg et al 2001).

• The mid-portion of the Achilles tendon has shown to have less numbers of blood vessels and a low mean percentage area occupied by blood vessels.

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CD/PD – in the studies we used CD• CD technique is analysing the frequency shift of the

returning echo - the higher blood velocity the stronger the signal

• PD is detecting the energy in the returning echo - the higher amount of blood corpuscles the stronger the signal.

• Advantage of CD is the ability to show the direction of the flow – typically displayed on the screen in red for one direction and in blue for the opposite.

• PD, shows all flow in one colour regardless of the direction.

• PD is not sensitive to the angle of the flow in relation to the US transducer, it is capable of detecting very low flow also when it is directed in 90° to the beam.

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US and CD!

Studies have shown that US and CD has a high sensitivity and specificityin diagnostics concerning Achilles- and patellartendinopathy (Warden et al 2007).

Aim of the study……. To evaluate intra- and inter-examiner reliabilityconcerning both quantitative measures (thickness)and qualitative measures (tendonstructure and visiblebloodflow) – Achilles- and patellartendons withgreyscale US and CD using a specific score Öhbergscore (0-3).

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In studies and during examinations where US is used, normally, tendonthickness, structuralchanges and bloodflow are described….

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Measuring thickness at the thickest part (mm)(longitudinal and cross section)

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• Tendon structure:

0 = normal (homogenous ecogenicity)

1 = minor structural changes(discrete hypoechoic areas)

2 = moderate structural changes (some well defined hypoechoic areas)

3 = severe structural changes (widespread hypoechoic areas)

Modified Öhberg score

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Öhberg score – structure (patellartendon)

• Visible bloodflow with CD:

0 = no visible vessels

1 = minor visible vessels

2 = moderate visible vessels

3 = extensive visible vessels

Modified Öhberg score

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Öhberg score – increased bloodflow

Both asymptomatic tendons and symptomatic tendons were included

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Three different levels of reliability

1) Absolute inter-observer – comparison between two experienced US-specialists, both made a complete scanning of the same tendons

2) Definied inter-observer – comparison between 4 different observers with different background and experience of US scanning and overloadinjuries. Measurements of the same US pictures.

3) Intra-observer – comparison of the same observer making several evaluations over time and measurements on different occasions of the same pictures (x 4 observers).

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Outcome

Reliability concerning measures of distance was generally high

Correlation between different observers was moderatly strong - strong concerning bloodflow and concerning structural changes weak –moderatly strong

Reliability was moderate to strong concerning both bloodflow nd structural changes when looking at the results from the same observerover time

Evaluation of structure was harder to reproduce than bloodflow

Inter-reliability was higher when comparing the two US specialists

Intra-reliability was generally higher

Conclusion

• The modified, 4-graded, Öhberg score showed qualifications to be a useful and reliable instrument when evaluating status and progress of Achilles and patellar tendon disorders.

• However, when comparing sonographic findings over time, we suggest that evaluations are performed by the same sonographer/observer, both in research and in clinical practice.

Chronic painful midportion Achillestendinosis?

Who is affected?

• A recent study estimated the incidence of Achilles tendinopathy in the 21–60-year age group as 235/100,000

• The exact cause of pain in tendinopathy remains elusive, it is generally accepted that tendinopathy is the result of a failure of one of two processes:

• 1. The healing response • 2. The normal turnover/remodelling response.

Ultrasound?Data suggest that presence of an ultrasonographic hypoechoic area is associated with a greater risk of developing jumper's knee symptomsUltrasonographic patellar tendon changes may resolve, but this is not necessary for an athlete to become asymptomatic

Qualitative or quantitative analysis of baseline ultrasonographic images revealed it was not possible to predict which tendons would develop symptoms or resolve ultrasonographically

J Ultrasound Med. 2000 Jul;19(7):473-9 Prospective imaging study of asymptomatic patellar tendinopathy in elite junior basketball players.Cook JL, Khan KM, et al

Can ultrasound imaging predict the development of Achilles and patellar tendinopathy? A systematic review and meta-analysisSeán McAuliffe, Karen McCreesh, Fiona Culloty, Helen Purtill, Kieran O’SullivanBJSM Online First, published on September 15, 2016 as 10.1136/bjsports-2016-096288

• What are the findings?• Asymptomatic athletes with tendon abnormalities at baseline are more

likely to develop Achilles or patellar tendinopathy compared to those with structurally normal tendons

• The likelihood of developing Achilles or patellar tendinopathy was nearly five times greater in those with tendon abnormalities (RR 4.97)

• Since the relationship between structural abnormalities and future symptoms was only moderate, structural abnormalities should not be considered as a sole predictor of the development of tendinopathy

• Combining the monitoring of tendon imaging with other factors linked to the development of pain, such as trainingload and psychosocial health, may enhance the management regarding the prediction of Achilles or patellar tendinopathy

What about treatment?

• Rest, immobilisation• NSAIDs and cortisone injections

• Extracorporeal shockwave• Physiotherapy• Sclerosing injections

• Other injections – PRP, MMP inhibitors, autologous blood, hyperosmolar dextrose…

• Surgery – open, miniopen

Kerstin Sunding 33

Midportion Achilles tendinosis

ca 5 – 7 mm ”Normal”

”Skarp smärta i belastning

ca 7 – 10 mm

ca 10 – 15 mm

”Normalising”

ca 7 – 10 mm

”Healing respons?”

Kerstin Sunding 34

”Normalising”

Bloodflow during different phases

”Normal”

Tid: ?

Tid: ca 3 månTid: ca 3 mån

Tid: 2-3 år

ca 7 – 10 mm

ca 10 – 15 mm ”Läkningsfas”

Normal mechanisms to respect during the healing of a tendon?

• Inflammatory phase – a couple of days to one week. Tenocytes reproduces, new bloodvessels are formed

• Proliferative phase – week 2-6, high levels of fluid, collagen is produced

• Remodelling – consolidation and maturation – 6 weeks to one year

We can immediately rule out…

• Rest• Immobilisation

• NSAIDs• Cortisone injections

• All these treatment methods are heavily questionned today

Wilson et al. 2005; Rees et al. 2009; Józsa et al. 1997; Andres et al. 2008

Extracorporeal shockwave therapy: a review. Chung B, Wiley JPSports Med 2002; 32(13) :851-65

• The highest strength of evidence is shown in randomised controlled trials, of which there are a small number

• There is still much debate over several issues surrounding ESWT that have not been adequately addressed by the literature: high- versus low-energy ESWT, shockwave dosage and number of sessions required for a therapeutic effect

• Further research is needed to ascertain the most beneficial protocol for patient care.

ESWT today - 10 years later

• Small studies• Diagnose solely by clinical examination• A lack of RCTs• Often a complement to eccentric training in studies• Still no protocol for treatment• Sparse evidence in the literature still!• Further studies are needed

Rompe et al. 2008; Foldhager et al. 2012

Physiotherapy – there are a lot of studies concerningAchilles tendinopathy….

3x15 2 daily

at least 12 weeks

Eccentric training seems to be superior toconcentric training

Studies are reproducibleCompliance?

Rehabilitation with discomfort and pain during a long period

Photobiomodulation and eccentric exercise for Achillestendinopathy: a randomized controlled trialSteve Tumilty & Ramikrishnan Mani & George D. BaxterPublished online: 26 November 2015# Springer-Verlag London 2015

• Methods:• A double blind randomized controlled trial and intention-to-treat analysis were

performed. Eighty participants, 18–65 years with Achilles tendinopathy and symptoms for longer than 3 months, were included in the trial.

• Conclusions:• Twice-daily exercise sessions are

not necessary as equivalent results can be obtained with two exercise sessions per week.

Why heavy eccentric load?• Tendon-loading programmes have emerged as the treatment of choice for

Achilles tendinopathy. Mechanotransduction is thought to be the mechanism behind such effects.

• (Khan KM, Scott A (2009) Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. Br J Sports Med 43(4):247–251.)

• Cells under mechanical stress respond by producing enzymes and proteins that enhance the remodelling process, resulting in increased collagen synthesis and improved viscoelastic properties and these effects can last more than 72 h.

• Kongsgaard M, Qvortrup K, Larsen J, Aagaard P, Doessing S, Hansen P et al (2010) Fibril morphology and tendon mechanical properties in patellar tendinopathy: effects of heavy slow resistance training. Am J Sports Med 38(4):749–756. doi:10.1177/

• Kubo K, Kanehisa H, Fukunaga T (2002) Effects of resistance and stretching training programmes on the viscoelastic properties ofhuman tendon structures in vivo. J Physiol 538(1):219–226

• Langberg H, Ellingsgaard H, Madsen T, Jansson J, Magnusson SP, Aagaard P et al (2007) Eccentric rehabilitation exercise increases peritendinous type I collagen synthesis in humans with Achilles tendinosis. Scand J Med Sci Sports 17(1):61–66

• Mafi N, Lorentzon R, Alfredson H (2001) Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis. Knee Surg Sports Traumatol Arthrosc9(1):42–47 3–15].

US guided Sclerosing injections Achilles midportion

Prospective randomized double-blind study - Achilles mid-portion

Sclerosing substance (Polidocanol)Non-sclerosing substance(lidocain+adrenalin)

Results: No effect with non-sclerosing substance

Sclerosing substance 80% good effectAlfredson et al. 2005

The original method for US guided sclerosing therapy

• 0,1-0,2 ml/inj

• Max 2 ml per treatment

• Ventral to the tendon, let the transverse vessels from the ventral side guide the injection

• Aethoxysklerol® (polidocanol)

• 6-8 weeks between treatments

• We normally wait 12-14 weeks today

Needle

Injection of Polidocanol 0,1 ml

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Before and immediately after injection

Sclerosing injections to treat midportion Achilles tendinosis: a randomised controlled study evaluating two different concentrations of Polidocanol.

• Willberg L, Sunding K, Ohberg L, Forssblad M, Fahlström M, Alfredson HKnee Surg Sports Traumatol Arthrosc Sep 2008; 16(9) :859-64

RESULTS

• NO significant differences between the two groups

• VAS pain during activity decreased significantly in both groups at follow upaverage 14 months

• Grupp A, (5 mg/ml), 66±14 till 25±28 (P<0.05)

• Grupp B, (10 mg/ml), 66±21 till 24±31 (P<0.05)

• 52/52 satisfied patients after a mean follow up of 24 months (VAS 66 decreasedto 5)

• 3,1 ml mean volume of Polidocanol needed

• 2,5 treatments average

•Willberg L, Sunding K, Ohberg L, Forssblad M, Fahlström M, Alfredson HKnee Surg Sports Traumatol Arthrosc Sep 2008; 16(9) :859-64

Sclerosing injections – a treatment which is debated

• Our results have been reproduced, when using US/CD for diagnose and treatment according to the original method the results seems to be good

• Studies with poor result have not used the original method up until today

• The method is hard to learn and is resource demanding• A good knowledge of US is required

• The direction and amount of vessels should probably be considered beforetreatment

• It needs to be further evaluated in larger studies• There seems to be no side effects of treatment

• Sclerosing polidocanol injections in mid-portion Achilles tendinosis: remaining good clinical results and decreased tendon thickness at 2-year follow-up.

• Lind B, Ohberg L, Alfredson HKnee Surg Sports Traumatol Arthrosc Dec 2006; 14(12) :1327-32

Kerstin Sunding 51

”Normalising”

Bloodflow during different phases

”Normal”

Tid: ?

Tid: ca 3 månTid: ca 3 mån

Tid: 2-3 år

ca 7 – 10 mm

ca 10 – 15 mm ”Läkningsfas”

Nonoperative treatment of midportion Achilles tendinopathy: a systematic review. Magnussen RA, Dunn WR, Thomson ABClin J Sport Med Jan 2009; 19(1) :54-64

Of 707 abstracts reviewed, 16 randomized trials met our inclusion criteria.

CONCLUSIONS:- Eccentric exercises have the most evidence of effectiveness in treatment of midportion Achilles tendinopathy.

- More investigation is needed into the utility of extracorporeal shockwave therapy, local corticosteroid treatments, injections of sclerosing agents or deproteinized hemodialysate, and topical glyceryl nitrate application.

FINALLY - Surgery• Unfortunately there is no evidence for surgery• Often recommended if conservative treatment

fails• Numerous different procedures described!• A lack of randomized trials!• Successrate doubtful – some studies include

partial ruptures

MidsubstanceTendinopathy, Surgical ManagementWilliam T. DeCarbo, Mark J. BullockClin Podiatr Med Surg - (2016)

• KEY POINTS

• -For an athlete with isolated paratendinopathy, open paratenon release/excision and ventral paratenon scraping have high reported success rates.

• -If a core area of tendinopathy is present, longitudinal excision is the treatment of choice.

• -Minimally invasive techniques have lower wound complication rates but require further study.

• -A flexor hallucis longus (FHL) tendon transfer or turndown flap can supplement the repair when there is extensive tendinopathy.

• -Gastrocnemius recession has higher reported success rates in the treatment of noninsertional Achilles tendinopathy compared with insertional Achilles tendinopathy.

Surgical treatment for achilles tendinopathy – a systematic reviewLohrer et al. BMC Musculoskeletal Disorders (2016) 17:207 DOI 10.1186/s12891-016-1061-4

• Conclusion: We conclude that success rates of minimally invasive and open treatments are not different and that there is no difference in patient satisfaction but there is a tendency for more complications to occur in open procedures.

• A total of 4453 studies were electronically identified for inclusion in the review. After adjusting for duplicates 4378 potentially relevant studies remained. After reviewing the titles and abstracts 4302 of these studies were discarded because it appeared that these papers clearly did not meet the criteria.

• The full text of the remaining 76 papers was obtained and examined in more detail. Fifty-six studies did not meet the inclusion criteria as described. The hand search of the references identified one more relevant article which was not detected from the electronic search.

• Twenty-one articles were considered to be relevant and the respective full texts were further analysed.

Ongoing at our clinic…

• Prospective randomized study• Three treatment groups• Randomized to eccentric training, US guided sclerosing

injections or US guided mini invasive surgery

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Localanestetics , Xylocain 1%, 10 ml1 cm surgical incision medially medialt1.2 × 50 mm needle

US guided miniinvasive surgery

To conclude…Is there a state of art in treatment?

• Correct/specified diagnose is required in coming studies• US/CD to confirm the diagnose and to follow the

tendonchanges over time• Eccentric training has the most evidence concerning

treatment of midportion Achillestendinopathy• Further controlled, better specified and larger studies are

still needed though

At last - take a vote….

Which Achilles tendon is the most painful?

Patellar tendinopathy

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About patellar tendinopathy…Have we come further today?

In conclusion so far –”Poor study design - good results!Good study design - poor results!”

Coleman BD, Khan KM, Maffulli N, Cook JL, Wark JD (2000) Studies of surgical outcome after patellar tendinopathy: clinical significance of

methodological deficiencies and guidelines for future studies. Scand J Med Sci Sports 10: 2-11.

Diagnostics before treatment…?

• Patient history – no acute onset, impairing pain duringactivity for 3 months or more (chronic per definition)

• Sharp pain when palpating the apex patella, kneeextended, quadriceps relaxed, no intrarticular findings

• MRI???• Ultrasound and colourDoppler!• Arthroscopy?

Patellartendinopathy: Clinical diagnosis, Load management, and advice for challenging Case Presentations Malliaras et al, J of Orth ad Sports Phys Ther, 2015

Tenderness while palpating apex patella

• Palpation is a reliable and reproducible test (intraobserver)

• In symptomatic tendons, palpation is a moderately sensitive but not specific test

• Mild tenderness in the patellar tendons in asymptomatic jumping athletes should be considered normal

Br J Sports Med. 2001 Feb;35(1):65-9.Reproducibility and clinical utility of tendon palpation to detect patellar tendinopathy in young basketball players. Victorian Institute of Sport tendon study group.Cook JL, Khan KM, Kiss ZS, Purdam CR, Griffiths L

Strictly clinical diagnose accordingto existing definitions

• The progression of proximal patellar tendinopathy begins with Stage I (pain only after exercise), and it can progress to stage III and IV (continuous pain, the athlete cannot longer train or compete)

Blazina 1973, Feretti 1986

MRI?• Could be used to identify the exact location and extent of tendon

involvement, help to exclude other clinical conditions such as bursitis and maybe chondromalacia

• Disadvantages of MRI include cost and also slow and often incomplete resolution of signal changes

• Abnormal signal without change in size must be interpreted with caution, as the normal patellar tendon has a range of appearances because of technical factors and intrinsic fibre differences

• Whether MRI abnormalities occur in asymptomatic patellar tendons has not been examined, but other tendons contain high-signal abnormality on MRI in nearly a quarter of young volunteers

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US and CD!Studies have shown that US and CD has a high sensitivityand specificity in diagnostics concerning Achilles- and patellartendinopathy (Warden et al 2007).

So what are we adressing right now in this talk?

The chronic painful impairing

tendinotic proximal

patellartendinopathy verified by

ultrasound and colourDoppler -

Jumper’s knee!

Treatment• Rest• NSAIDs (non steroidal antiinflammatory drugs)• Corticosteriod injections• PRP (platelet rich plasma) injections• Injection treatments (dextrose, highvolume injections,

autologous blood and more…)• ESWT shockwave treatment• Sclerosing injections• Rehabtraining• Surgery – open/arthroscopic• …and more

We immediately rule out…

• Rest (Józsa 1997, Peers 2005)

• NSAIDs (non steroidal antiinflammatory drugs) (Almekinders 1998,1999)

• Corticosteriod injections (Józsa 1997, Andres 2008)

• Other injection treatments - needs more research (Maxwell et al 2007, Wiley et al 2013, 2014,2015)

PRP injections

• Small studies• Conflicting results• Clinical or MRI diagnosis• Often combined with some other treatment• More controlled studies needed• Sparse knowledge concerning patellartendinopathy

Platelet-Rich Plasma as a Treatment for Patellar Tendinopathy, A Double-Blind, Randomized Controlled Trial – ” the apparent benefit of PRP dissipates over time” Dragoo et al, Am J of Sports Med 2014

Platelet-Rich Plasma in the Treatment of Patellar Tendinopathy - A Systematic Review” its superiority over other treatments such as physical therapy remains unproven. Further RCTs are required to determine the relative effectiveness of the many available treatments for PT Liddle et al, Am J of Sports Med 2015

ESWT extra corporeal shockwave

• Small studies• Conflicting results• Clinical or MRI diagnosis• Often combined with some other treatment• More controlled studies needed (Rompe et al 2008, Foldager et al 2012)

• Sparse knowledge concerning patellartendinopathyExtracorporeal shockwave therapy for patellar tendinopathy: a review of the literature” ESWT seems to be a safe and promising treatment for patellar tendinopathy with a positive effect on pain and function. Based on current knowledge it is impossible to recommend a specific treatment protocol. Further basic and clinical research into the working mechanism and effectiveness of ESWT for patellar tendinopathy are necessary”Akker-Scheek et al Br J Sports Med 2009

Current concepts of shockwave therapy in chronic patellar tendinopathy Hernandez-Sierra et al, International Journal of Surgery, 2015

Effectiveness of Shockwave Treatment Combined WithEccentric Training for Patellar Tendinopathy:A Double-Blinded Randomized Study

Karin M. Thijs, MD,* Johannes Zwerver, MD, PhD,† Frank J. G. Backx, MD, PhD,*Victor Steeneken, PT, MSc,‡ Stephan Rayer, PT,§ Petra Groenenboom, MD,¶ andMaarten H. Moen, MD PhD*k** (Clin J Sport Med 2016;0:1–8)

• Objective: To evaluate the effectiveness of a combined treatment of focused shockwave therapy (ESWT) and eccentric training compared with sham-shockwave therapy (placebo) and eccentric training in participants with patellar tendinopathy (PT) after 24 weeks

• Fifty-two physically active male and female participants with a clinical diagnosis of PT (mean age: 28.6 years; range, 18-45) were randomly allocated to the ESWT (n = 22) or sham shockwave (n = 30).

• Conclusions: This study showed no additional effect of 3 sessions ESWT in participants with PT treated with eccentric exercises. The results should be interpreted with caution because of small sample size and considerable loss to follow-up, particularly in the ESWTgroup.

Injection from the medial side

Polidocanol® 5 mg/ml (10 mg/ml)

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Maximum volume 2 ml

12 weeks between treatments (average 3 treatments)

US guided Sclerosing injections

Sclerosing injections• Small studies• Promising results (Öhberg et al 2002, Alfredson et al 2003, Hoksrud et al 2006, 2011,

Willberg et al 2008)

• Consistent diagnose (strict inclusion criterias)• More controlled studies needed

The evolution of eccentric training as treatment for patellar tendinopathy (jumper’s knee): a critical reviewof exercise programmes

Håvard Visnes, Roald Bahr

Br. J. Sports Med. 2007;41;217-223;

originally published online 29 Jan 2007

Conclusion: Most studies suggestthat eccentric training may have a positive effect, but our ability torecommend a specific protocol is limited

Rehabtraining

• Relatively small studies – lack of RCTs• Conflicting results• Most often clinical diagnose• Often combined with some other treatment• More controlled studies needed

The evolution of eccentric training as treatment for patellar tendinopathy (jumper’s knee): a criticalreview of exercise programmes

” Most studies suggest that eccentric training may have a positive effect, but our ability to recommend a specific protocol is limited” Håvard Visnes, Roald Bahr, Br. J. Sports Med. 2007

“Surgical treatment compared with eccentric training for patellar tendinopathy (Jumper's Knee)”

A randomized, controlled trial.

• CONCLUSIONS: No advantage was demonstrated for surgical treatment compared with eccentric strength training. Eccentric training should be tried for twelve weeks before open tenotomy is considered for the treatment of patellar tendinopathy.

• Bahr R, Fossan B, Løken S, Engebretsen LJ Bone Joint Surg Am Aug 2006; 88(8) :1689-98

Surgery• Relatively small studies• Many different techniques• Conflicting and varying results (46%-100% good, Coleman)

• Clinical or MRI diagnosis most often• Often the choice after failure from some other

treatment• More controlled studies needed (Muccioli et al, 2013)

Patellartendon greyscale ultrasound and colourDoppler

Longitudinal and cross section

US guided Arthroscopy in Localanesthesia

Sterile ultrasound gelTwo monitorsGreyscale ultrasound - mostly in cross section

Before starting the surgery

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MethodStandard portals – anteromedial and anterolateralPressure controlled pump4,5 mm razor cut shaverblade

The shaving

Deep to the tendon, superficial to the fat pad

The fat pad has a broad attachment to the patella. We do not resect the fat pad we just separate the fat pad from the tendon at the central proximal attachmentTry not to traumatize the tendonLet the ultrasound guide you

Views

Before and after….

Postoperatively

• Standard dressing• No crutches

• Normal walk accepted• Full load after 14 days in daily life• Back to full sports after 6-8 weeks

is accepted and seems possible –but in real life not to recommend

• REHABTRAINING!• Focus on biology…..

Normal mechanisms to respect during the healing ofa tendon?

• Inflammatory phase – a couple of days to one week. Tenocytesreproduces, new bloodvessels are formed

• Proliferative phase – week 2-6, high levels of fluid, collagen is produced

• Remodelling – consolidation and maturation – 6 weeks to one year

Results

GROUP A GROUP B

Variabel Mean (SD) Mean (SD) SignificanceAge (years) 27,0 ( 7,6) 26,6 (7,6) p=0,755Duration of symptoms (months) 20,0 (10,4) 23,8 (15,5) p=0,596VAS at rest at assessment 37,8 (24,9) 44,6 (28,4) p=0,431VAS at activity at assessment 69,0 (17,3) 76,5 (13,6) p=0,143Follow up time (months) 13,7 (6,9) 12,9 (7,8) p=0,719VAS at rest at follow up 19,2 (23,2) 5,0 (8,3) p=0,004VAS during activity at follow up 41,1 (28,5) 12,8 (19,3) p=0,001Satisfaction with result (0-100) 52,9 (32,6) 86,8 (20,8) p=0,000

96

Comparing sclerosing injections and US guidedshaving (Sunding et al, KSSTA, 2015)

Follow-up(~14 months)

Endpoint(~46 months)

Mean (SD) Mean (SD) p-value

VAS for satisfaction A 64 (±29) 81 (±30) 0.016*

(score 0-100) B 86 (±22) 86 (±28) ns

p-value 0.007** ns

Proportion % Proportion % p-value

Back in full activity A 53% 63% ns

B 80% 84% ns

p-value ns ns

A= Scler. injections. B= Arthroscopy

US guided shaving rendered a quicker return to sports and the patients were more satisfied at an earlier stage

97

Results

Pain in activity

Month

0 10 20 30 40 50 60 70

mea

n V

AS

-20

0

20

40

60

80

100

Sclerosing inj.Arthroscopic shav.Cross-over

20 augusti 2017 98

Results

Satisfaction with treatment

VAS-score (0-100)

Group A –Sclerosing Inj.n = 19

Group B –Arthroscopyn = 25

Group C –Cross-overn = 13

Mean (SD) Mean (SD) p Mean (SD)

Follow-up 1-1,5 years (%) 65 (28,7) 86 (22,0) 0,013 51 (31,0)

Endpoint 3-5 years (%) 81 (29,7) 86 (27,7) 0,541 71 (32,2)

After further processing of data we have found a highlysignificant correlation between low local bloodflow and highpatientsatisfaction and low pain

Volleyball – elite level2006 2008

Ultrasound?

Data suggest that presence of an ultrasonographic hypoechoic area is associated with a greater risk of developing jumper's knee symptoms

Ultrasonographic patellar tendon changes may resolve, but this is not necessary for an athlete to become asymptomatic

Qualitative or quantitative analysis of baseline ultrasonographic images revealed it was not possible to predict which tendons would develop symptoms or resolve ultrasonographicallyJ Ultrasound Med. 2000 Jul;19(7):473-9 Prospective imaging study of asymptomatic patellar tendinopathy in elite junior basketball players.Cook JL, Khan KM, et al

101

Male 35 year - Sclerosing injectionsB

asel

ine

52 m

onth

102

Male 30 year - Arthroscopic shavingB

asel

ine

43 m

onth

In summary - surgeryMinimally invasive arthroscopically assistedprocedures have not reported better statistically significant results when compared to open surgery in the treatment of chronic proximal patellar tendinopathy

The methodology of studies in this field has improved over the past 15 years, but well-designed RCTs using validated patient-based outcome measures are still lacking

Marcacci et al. 2013

WHY ARTHROSCOPY THEN???

104

Jumper’s knee –a describing study comparing MRI and arthroscopic findings in patients with patellartendinosis

• Willberg et al

112 consecutive patients with US/CD verifiedpatellartendinopathy, have been analyzed so far (400 more to go…)

• 105 men, 7 women• All have done the arthroscopic procedure

• All had a preop MRI and US/CD exam• 103 MRIs were normal, the 9 patients with MRI pathology were excluded• Same surgeon and assistent during surgery

• Peroperative photo documentation

Findings so far

• 83 patients – ”other pathology” found during the arthroscopicprocedure

• Cartilage lesions n=32

• Pathological plicaes n=55 • Grade 1-2 arthritis lateral tibiacondyle n=11• Medial meniscus tear n=1

60-70% of the patients seem to have additional intraarticular pathology

Treatment of patellartendinopathy –a systematic review of randomized trials

• Only physical training (particularly eccentric training) could be considered as having strong evidence for the treatment ofpatellar tendinopathy

• Eccentric treatment should be the recommended first choice to treat patellar tendinopathy

• Surgery demonstrated a similar effect to eccentric treatment and might be indicated if conservative treatment is unsuccessful; however, this possibility still requires further investigation.

Nilsson-Helander et al.KSSTA 2012

Treatment Options for Patellar Tendinopathy:A Systematic Review Arthroscopy: The Journal of Arthroscopic and Related Surgery, 2016: pp 1-12Joshua S. Everhart, M.D., M.P.H., Devon Cole, B.S., John H. Sojka, M.D.,John D. Higgins, B.S., Robert A. Magnussen, M.D., M.P.H., Laura C. Schmitt, P.T., Ph.D.,and David C. Flanigan, M.D.

• Fifteen studies met the following inclusion criteria: (1) therapeutic outcome trial for PT, and (2) Victorian Institute of Sports Assessment was used to assess symptom severity at follow-up.

• Increased duration of symptoms resulted in poorer outcomes regardless of treatment (0.9% decrease in improvement per additional month of symptoms; P ¼ .004).

• Eccentric training with or without core stabilization or stretching improved symptoms (61% improvement in the Victorian Institute of Sports Assessment score, 95% confidence interval [CI] 53% to 69%).

• Surgery in patients refractory to nonoperative treatment also improved symptoms (57%, 95% CI 52% to 62%) with similar outcomes among arthroscopic and open approaches.

• Results from shockwave (54%, 95% CI 22% to 87%) and platelet-rich plasma (PRP) studies (55%, 95% CI 5% to 105%) varied widely though PRP may accelerate early recovery.

Take home message• Key – correct diagnose!

• In research – define the condition

• Most evidence – still the eccentric rehabtraining

• Challenging research – there is a need for RCTs

• We are advancing very fast trying to find new treatment methods, which mightexplain why there is so sparse scientific evidence for many of the existing treatment methods used today

• Maybe we should focus on finding evidence instead of inventing new methods????

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