Professor Maffulli has had more than 300 articles published in peer reviewed journals on various aspects of trauma and orthopaedic surgery, sports medicine and sports traumatology. One of his clinical specialties is the treatment of overuse tendon conditions. Here he brings clarity to an historically confusing condition and in doing so explains logical treatment plans to overcome this condition.
Professor Maffulli, tendinopathies are largely associated with overuse during work or sports related activities. Is it as simple as that and what other factors are associated with the development of tendon problems?
“It is true that most patients that present to my care are athletes or manual workers. However, there is an increasing number of patients who have not overused their musculo-skeletal system, and who do not seem to respond to any form of treatment. When I started to be interested in Achilles tendinopathy, for example, essentially all my patients were involved in sports requiring running, hopping or jumping. Nowadays, more than one third of patients referred to me are relatively sedentary individuals who do not seem to have undertaken high levels of physical activities.”
“In our laboratory experiments, we have shown that the cells harvested at surgery from tendinopathic tendons produce increased quantities of collagen which is not the appropriate collagen for tendons. It is possible that some patients are ‘primed’ in this direction, and react in an anomalous manner to near-physiological (almost normal) stimuli, and develop a tendinopathy.”
Why is tendon healing so slow and how does this affect the rehabilitation of tendon problems?
“A single molecule of the main protein that constitutes tendons, collagen, takes about 100 days to fully mature. Therefore, things do not happen fast. Also, tendons have a slow rate of metabolism, and they take a long time to adapt to new stimuli. A muscle, for example, hypertrophies (gets bigger) or atrophies (wastes) within days, while the tendon retains its characteristics for a much longer period, and requires prolonged stimuli to change its biomechanical behaviour. Also, very often by the time the patients are referred to me, they have had the condition for a long while. In these instances, the biological potential of the tendons is close to being exhausted, and they need to be stimulated for longer to effect appropriate healing.”
What is the management of tendinopathy?
“By the time a tendon becomes symptomatic, the histological appearance (appearance of cells tissue under the microscope) is of a failed healing response, and the clinical syndrome is a tendinopathy. Modified rest should be implemented, and physiotherapy modalities (procedures) used. This means that patients should still train, avoiding however the activities which cause them pain. For example, a runner with an Achilles tendinopathy should not hop or jump, although gentle jogging may be allowed. There is much ‘art’ attached to the management of tendinopathy, and few modalities have been tested in a scientific manner. The only non-invasive modality tested in a randomised controlled trial is eccentric exercise (a muscle contraction with the muscle / tendon lengthening), and this has been shown to be superior to concentric exercises (muscle contraction with the muscle / tendon shortening) and to stretching. However, benefits are experienced only after three months of treatment. Also, when we repeated the studies in the UK, the rate of success was lower than that found in the original studies from Scandinavia.
“In my hands, corticosteroids and NSAIDs (anti-inflammatory drugs) do not play a role: again, well controlled studies have shown that they do not have a lasting effect. Indeed, they should not have any such effect, as the condition that we are facing is not an inflammatory condition! Corticosteroids are catabolic (i.e. do not favour protein synthesis, while we want new protein based material to be produced by these tendons), inhibits cell growth, and may interfere with local immunity, causing a higher rate of infection if one needs to operate at a later stage.
If conservative management has failed, I use a peritendinous injection of Aprotinin (Aprotinin is a protein which inhibits the enzyme ‘metalloprotease’ that breaks down protein that makes up tendon tissue), a metalloprotease inhibitor. In tendinopathies, there is an imbalance between metalloprotease I and III, and, in this fashion, we try and address this imbalance. Also, Aprotinin does not have the serious side effects of corticosteroids, and, if necessary, can be injected several times.
Researchers in Sweden (Ohberg and Alfredson 2002) analysed blood flow in painful Achilles tendons and hypothesised that new blood vessels in the tendon were the cause of tendon pain. By injecting a ‘sclerosant’ (a substance which destroys these blood vessels) into these vessels the patient’s pain improved considerably. Could you explain more about this procedure and it’s implications for the management of tendinopathies?
“This procedure is promising, though still experimental. In the original article, the authors only report on a very limited number of patients. It is possible that the sclerosing agent acts on the nerve endings that accompany the new blood vessels in the tendinopathic tendon, and thus eliminate the pain. The procedure is appealing, but, being a ‘quick fix’, may well remove an important signal that tells us that the tendon is diseased, and that therefore we should abstain from continuing to use it.
“Theoretically, as the sclerosing agent does not act on the altered structure of the tendon, one may continue to train, and produce further damage to the tendon, possibly resulting in a rupture. The results of the long term randomised trial that Ohberg and Alfredson have just finished seems to show that after two years the tendon returns to its normal appearance, and that only one of more than 50 patients treated in this fashion experienced a rupture. With colleagues from London, we have started a new form of treatment which interferes with neovascularisation of the tendon in a ‘gentler’ way. We are now analysing the results of our first two years of using this treatment. What I can tell you is that my rate of operation on these patients has decreased markedly.”
When is surgery indicated in the management of tendinopathies?
“I consider offering surgery to my patients after three to six months of well supervised and executed conservative management. I really regard surgery as an extreme measure: there is still a definite rate of insuccesses and complications and, when one analyses data accurately, one finds out that good surgeons obtain up to 80-85 % of good to excellent results. Even in my hands, it is hard to beat these figures, especially if patients have waited too long before seeking professional advice. I use a staged approach. If the patient has a well defined intratendinous lesion (damamge within the tendon), I use a minimally invasive percutaneous longitudinal tenotomy (surgery to the tendon without a large incision). If the involvement is more extensive, then a formal operation is necessary. I try to perform most of these procedures under local anaesthesia, so that patients can collaborate with me during the operation, and I can interact with them in real time.”