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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. 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

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  1. Nicola Maffulli Department of Trauma and Orthopaedic Surgery Keele University School of Medicine Tendinopathies in Sport

  2. Where on earth is Stoke on Trent?

  3. Tendon problems Human studies Cell models Animal models

  4. 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

  5. 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

  6. Tendinopathy Do we get the right picture? Unknown factors Onset of symptoms Surgery Histology Biochemistry Molecular biology • Risk Factors • Injury? • Overuse? • Metabolic disorder?

  7. Tendinopathy Confusion Confusion Confusion Confusion Confusion Confusion Confusion Confusion Confusion Confusion Confusion Confusion Confusion

  8. 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.

  9. TENDINOPATHIES • Difficult to manage • Management • often anecdotal • rarely evidence-based • often emotional • dubiously effective

  10. We do not know where the pain originates from! Therefore, we do not know why and how any therapeutic modality, including surgery, works

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. PATIENTS Failure of three to six months of conservative management

  17. Use the KISSO principle

  18. K eepI tS imple for theS impleO rthopods

  19. Surgical management of tendinopathies of elbow • needling • coblation • percutaneous (ultrasound guided) tenotomy • arthroscopic approach • (mini)open approach • No validated surgical protocols

  20. Surgical management of tendinopathies • Aims: • promote repair • return to pre-injury activity level

  21. 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

  22. THE FUTURE

  23. 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

  24. Why do tendinopathies occur? Is there an underlying metabolic disorder?

  25. 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

  26. 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

  27. 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

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

  29. 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

  30. 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

  31. 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

  32. 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

  33. IP3 traversing gap junctions to communicate a load signal by Ca2+ wave propagation Pipet Ca2+ ion free Ca2+ ion bound intercellular messenger gap junction

  34. Functional tissue engineering of tendons and OCT Normal tendon Ruptured tendon

  35. N Maffulli JB King F Franceschi UG Longo L Ruzzini V Denaro M Ronga

  36. More frequent tendon changes on the articular side of the rotator cuff

  37. 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

  38. 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

  39. 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

  40. … in the end ...

  41. … still a mountain to climb...

  42. … but progress is being made

  43. Thank you Thank you

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