Dual-Barb Microneedle with JAK/STAT Inhibitor-Loaded Nanovesicles Encapsulation for Tendinopathy.

Tendon stem/progenitor cells (TSPCs) are crucial for tendon repair, regeneration, and homeostasis. Dysfunction of TSPCs, due to aberrant activation of the Janus kinase/signal transducer and activator of transcription (JAK/STAT) signaling pathway, contributes to tendinopathy. Unfortunately, the effectiveness of conventional subcutaneous injection targeting at suppressing JAK/STAT signaling pathway is limited due to the passive diffusion of drugs away from the injury site. Herein, a novel poly-gamma-glutamic acid (γ-PGA) dual-barb microneedle (MN) path loaded with TSPCs-derived nanovesicles (NVs) containing JAK/STAT inhibitor WP1066 (MN-WP1066-NVs) for tendinopathy treatment is designed. The dual-barb design of the MN ensures firm adhesion to the skin, allowing for sustained and prolonged release of WP1066-NVs, facilitating enhanced TSPCs self-renewal, migration, and stemness in tendinopathy. In vitro and in vivo experiments demonstrate that the degradation of γ-PGA patch tips facilitates the gradual release of WP1066-NVs at the lesion site. This release alleviates inflammation, suppresses extracellular matrix degradation, and restores normal tendon histological structure by inhibiting the JAK/STAT pathway. These findings suggest that the multifunctional dual-barb MN patch offers a novel and effective therapeutic strategy for tendinopathy treatment.

Is Chronic Tendon Pain Caused by Neuropathy? Exciting Breakthroughs may Direct Potential Treatment.

BACKGROUND: Tendinopathy significantly impacts the quality of life and imposes a high economic burden, accounting for a large proportion of sports and musculoskeletal injuries. Traditionally considered a collagen-related inflammatory disorder, emerging evidence suggests a critical role of neuropathic processes in chronic tendon pain. OBJECTIVE: This review aims to evaluate the neuropathic mechanisms in tendinopathy and discuss innovative treatments targeting these pathways. METHODS: We analyze recent studies highlighting the tendon innervation, pathological nerve sprouting neuronal ingrowth in tendinopathy, and the associated increase in pain and neuronal mediators. RESULTS: Chronic tendinopathy exhibits nociceptive sprouting from paratenon into the fibrous tendon proper. Innovative treatments such as Percutaneous Ultrasound-Guided Tenotomy (PUT) or high-frequency ultrasound interventions show promise in targeting these neuropathic components by paratenon separation. These approaches focus on disrupting the pathological innervation cycle. CONCLUSION: Chronic tendon pain may be predominantly neuropathic, driven by pathologic neuronal ingrowth from paratenon into the tendon proper. Interventions that accurately target and disrupt these nerve pathways could revolutionize the treatment of tendinopathy. Further research is required to validate these findings and refine treatment modalities to ensure safety and efficacy.

Running biomechanical and isokinetic strength differences in masters runners with and without Achilles tendinopathy.

Masters runners are an increasing proportion of the running community. The most significant musculoskeletal changes in runners occur after the age of 50 in addition to changes in injury rates and types, the most common being Achilles tendinopathy (AT). Previous evidence has suggested similarities between risk factors for AT and age-related changes that are focused at the hip and the ankle during the propulsive stage of running. The purpose of this study was to investigate biomechanical and peak torque association to AT in masters runners. Thirty-two masters runners over age 50 with AT (60.31 ± 8.37, n = 16) and without (59.94 ± 4.95 n = 16) were included. 3D motion capture and force plates were used to assess running biomechanics. A motor-driven dynamometer was used to assess isokinetic peak torque production. No significant differences in running biomechanics were found between masters runners with and without AT. Hip peak isokinetic torque production was found to be significantly less in masters runners with AT, but no significant differences in ankle plantarflexion peak isokinetic torque production were found. Masters runners with AT may be able to adapt their running biomechanics and muscular torque production during submaximal running efforts.

Masters runners with Achilles tendinopathy do not demonstrate differences in peak hip extension moments during the stance phase of running during submaximal efforts compared to healthy masters runners.Masters runners with Achilles tendinopathy do not demonstrate differences in peak ankle plantarflexion moments during the stance phase of running during submaximal efforts compared to healthy masters runners.Masters runners with Achilles tendinopathy do not demonstrate differences in peak ankle plantarflexion concentric or eccentric isokinetic torque compared to healthy masters runners.Masters runners with Achilles tendinopathy demonstrate differences in peak hip extension concentric and eccentric isokinetic torque compared to healthy masters runners.

Tendinous Signal Alterations on MRI in the Asymptomatic Elbow: A Retrospective Cross-Sectional Study.

Objectives: It is clinically relevant to prevent overtreatment of tendinopathy diagnosed solely on imaging. Therefore, the prevalence of presumable asymptomatic signal changes in the common flexor origin, biceps insertion, brachialis insertion, and triceps insertion were assessed. Materials and methods: Two hundred and five magnetic resonance imaging (MRI) exams of the elbow with coronal and axial fat-saturated fluid-sensitive sequences between January 1, 2018 and July 31, 2022 were retrospectively identified in our center.Two radiology residents reviewed the exams independently. The elbow tendons were given a score from 0 to 4. Score 0: no signal abnormality; score 1: increased T2-weighted signal around the tendon; score 2: increased T2-weighted signal compared to muscle within the tendon; score 3: partial tear; and score 4: complete tear. Results: The common flexor tendon showed signal alterations in 8% of patients; nine patients had an increased signal around the tendon, and eight patients had an increased signal within the tendon. Three patients (1.5%) had an altered signal intensity in the biceps tendon. All triceps tendons showed a linear hyperintense signal, suggesting that it is physiological. There were no partial or complete tears. No signal abnormalities were noted in the brachialis tendon among all patients. Conclusion: The prevalence of presumable asymptomatic signal alterations seen in the common flexor origin on MRI is not negligible; therefore, clinical correlation is advised to prevent overtreatment of tendinopathy in these cases. No partial or complete tears were seen.

Changes in patellar tendon complaints and shear wave velocity patterns among competitive alpine skiers during a 4-year post-growth spurt follow-up.

Patellar tendon (PT) complaints are frequent in competitive alpine skiers and such complaints are characterized by a long-lasting affection. Since PTs are subject to maturation up to 1-2 years after growth spurt, this early career stage may be decisive for the further course of complaints. The aim of this study was to investigate the evolution of PT complaints and shear wave velocity patterns among competitive alpine skiers during a 4-year post-growth spurt follow-up. The PT complaints and SWV patterns of forty-seven skiers were analysed at baseline (i.e., immediately after their peak height growth at 13-15 years of age) and were re-analysed at 4-year follow-up. The PTs were scanned via three-dimensional SWE. Symptomatic skiers were identified based on pain sensation under loading and pressure-induced pain around the PT. The prevalence of PT complaints decreased from 29.8% at baseline to 12.8% at follow-up (Pearson's χ2 = 9.429; p = 0.002). SWV decreased from the baseline assessment to the follow-up in the proximal and distal regions (p < 0.05). SWV coefficient of variation (CV) in the distal and mid-portion regions was greater at baseline than at follow-up (p < 0.05). At the follow-up assessment, compared to "healthy" skiers, "healed" skiers who recovered from PT complaints had lower SWVs in the proximal region (p = 0.020) and greater SWV CVs in the proximal region (p = 0.028). Moreover, symptomatic skiers had significantly greater SWV CVs in the mid-portion region than did "healthy" subjects with no history of PT complaints (p = 0.020). The average SWV was negatively correlated with the SWV (proximal: r = -0.74, p < 0.001; mid-portion: r = -0.37 p = 0.011; and distal: r = -0.58, p < 0.001). The occurrence of PT complaints decreased over a 4-year post-growth spurt follow-up. "Healed" skiers who were symptomatic at baseline had an even greater average decrease in the proximal and mid-portion SWV than "healthy" skiers with no history of PT complaints. This may lead to the hypothesis that PT complaints in adolescent skiers are not self-eliminating towards the end of adolescence, as at least structural irregularities appear to persist for several years after the onset of initial symptoms. Furthermore, "healed" and symptomatic tendons exhibited increased SWV variability, supporting the hypothesis that SWV CV may provide additional valuable information on the mechanical properties of PTs affected by overuse-related complaints.

Effectiveness of Low-Level Laser Therapy Combined With Eccentric Exercise in Treating Midportion Achilles Tendinopathy: A Randomized Controlled Trial.

Background Achilles tendinopathy is a common overuse tendon injury, affecting athletes in running and similar sports. Repetitive overload of the Achilles tendon is the primary cause of inflammation, collagen degeneration, and tendon thickening. This study aims to investigate the efficacy of combining low-level laser therapy (LLLT) with eccentric exercises in treating midportion Achilles tendinopathy. Methods This prospective randomized controlled trial was conducted at the Sports Injury Centre, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, from 2019 to 2022. Sixty clinically diagnosed patients with midportion Achilles tendinopathy, aged 18 to 60, were randomly assigned to two groups: Group A received eccentric exercises with LLLT, and Group B received eccentric exercises with placebo LLLT. The Victorian Institute of Sport Assessment-Achilles (VISA-A) score and the visual analog scale (VAS) score were used to measure treatment effectiveness at baseline and three, six, 12, and 24 weeks. Results The study included 60 participants, with no dropouts observed. The mean age was 33.9 ± 8.3 years in Group A and 33.40 ± 8.64 years in Group B, with no significant difference between the groups (p = 0.821). Both groups showed significant improvement in VISA-A and VAS scores over time (p < 0.001), but there was no statistically significant difference between the groups at any time point (p > 0.05). Conclusion Adding LLLT to eccentric exercises did not provide significant additional benefits compared to eccentric exercises alone in treating midportion Achilles tendinopathy. Practitioners should prioritize evidence-based interventions, such as eccentric exercises, as the primary treatment modality while considering alternative therapies for adjunctive purposes. Further research is needed to explore additional modalities or combination therapies that may enhance outcomes for patients with Achilles tendinopathy.

Rehabilitation With Eccentric Training Using Kettlebell and Kinesio Taping in a Young Volleyball Player With Proximal Biceps Tendinopathy: A Case Report.

A prevalent overuse injury among athletes, especially to those participating in sports like volleyball that demand repeated overhead motions, is biceps tendinopathy. The painful condition known as biceps brachii tendinopathy is characterized by changes in the structure of the tendon together with chronic degeneration. Furthermore, the biceps aid in the acceleration and deceleration of the arm in numerous overhead sports. The biceps may experience excessive strain as a result of poor training or exhaustion. It is commonly known that the long head of the biceps tendon plays a significant role in producing pain, particularly when it comes to anterior shoulder discomfort and dysfunction in athletes and working people. Athletes' biceps tendon conditions fall into three broad categories: degeneration, instability, and abnormalities that are of source. This case details the use of kettlebell eccentric exercise and kinesio taping in the rehabilitation of a young volleyball player with biceps tendinopathy. The four primary aspects of the rehabilitation regimen were kinesio taping, pain management and rest, eccentric training with kettlebells, and initial assessment and patient education. Kettlebell eccentric training was used to enhance eccentric strength and encourage tendon remodeling, and kinesio taping was used to give pain relief and structural stability. This case study emphasizes the value of an all-encompassing rehabilitation strategy catered to the unique requirements of every athlete by demonstrating the effectiveness of kinesio taping and eccentric exercise with kettlebells in the treatment of biceps tendinopathy.

Dutch multidisciplinary guideline on anterior knee pain: Patellofemoral pain and patellar tendinopathy.

PURPOSE: The purpose of this study was to develop a multidisciplinary guideline for patellofemoral pain (PFP) and patellar tendinopathy (PT) to facilitate clinical decision-making in primary and secondary care. METHODS: A multidisciplinary expert panel identified questions in clinical decision-making. Based on a systematic literature search, the strength of the scientific evidence was determined according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) method and the weight assigned to the considerations by the expert panel together determined the strength of the recommendations. RESULTS: After confirming PFP or PT as a clinical diagnosis, patients should start with exercise therapy. Additional conservative treatments are indicated only when exercise therapy does not result in clinically relevant changes after six (PFP) or 12 (PT) weeks. Pain medications should be reserved for cases of severe pain. The additional value of imaging assessments for PT is limited. Open surgery is reserved for very specific cases of nonresponders to exercise therapy and those requiring additional conservative treatments. Although the certainty of evidence regarding exercise therapy for PFP and PT had to be downgraded ('very low GRADE' and 'low GRADE'), the expert panel advocates its use as the primary treatment strategy. The panel further formulated weaker recommendations regarding additional conservative treatments, pain medications, imaging assessments and open surgery ('very low GRADE' to 'low GRADE' assessment or absence of scientific evidence). CONCLUSION: This guideline recommends starting with exercise therapy for PFP and PT. The recommendations facilitate clinical decision-making, and thereby optimizing treatment and preventing unnecessary burdens, risks and costs to patients and society. LEVEL OF EVIDENCE: Level V, clinical practice guideline.

A Comparative Study of the Graston Technique and Alfredson Protocol in the Management of Achilles Tendinopathy.

BACKGROUND AND OBJECTIVES: The Achilles tendon, the largest and strongest tendon in the human body, is frequently injured by overuse; this condition is known as Achilles tendinopathy (AT). It serves as a link between the heel bone and the calf muscles and is necessary for motions, such as walking, sprinting, and jumping. Evidence is presented to support the efficacy of the Graston technique and Alfredson protocol for pain reduction and improvement of function and calf muscle strength. The objective of this study is to compare the efficacy of the Graston technique versus the Alfredson protocol in patients with AT. Methods and data collection: After obtaining approval from the ethical review board of the Rawalpindi Medical University, all patients fulfilling the inclusion criteria are divided into two groups, A and B, by generating random identity numbers using Microsoft Excel for allocation. Group A comprises patients who undergo treatment with the Graston technique as conventional therapy with Alfredson protocol (12-week calf muscle eccentric exercises), while those in group B follow a Graston technique with sole heel lift. Individuals in the eccentric exercises group follow an Alfredson method-based 12-week eccentric exercise plan for their leg muscles. The workouts need to be done twice a day, seven days a week for 12 weeks. The plan includes two exercises: the first done with the knee straightened to work the gastrocnemius and the second done with the knee bent to work the soleus. Three sets of 15 repetitions with no rest interval for each exercise are completed twice a day on the affected limb to yield functional improvement. RESULTS: The results showed that both the Alfredson protocol and the Graston technique were effective in managing AT symptoms. The study involved dividing 32 participants into two groups who received either treatment for four weeks. The main way to measure improvement was a score called the Villalta-Scanlon Achilles Tendonitis Index score. In both groups, these scores showed significant improvement (with a p-value less than 0.001, which means that the results are very statistically significant). For Group A (who received the Alfredson protocol), the average Villalta-Scanlon Achilles Tendonitis Index score before treatment was 29.25. This score increased to 31.25 at mid-treatment and 34.38 after the full four weeks of treatment. Group B (who received the Graston technique) started with an average Villalta-Scanlon Achilles Tendonitis Index score of 22.94. Their scores also increased throughout the treatment, reaching 34.94 at mid-treatment and 42.88 after four weeks. These findings provide evidence that both treatments can improve AT symptoms, with some suggestions that the Graston technique might be even more effective based on the higher average Villalta-Scanlon Achilles Tendonitis Index scores after treatment. CONCLUSIONS: The Graston technique shows promising results, particularly in the mid- and post-treatment phases, indicating its potential efficacy in comparison to the Alfredson protocol in the treatment of AT.

Upregulation of FABP4 induced inflammation in the pathogenesis of chronic tendinopathy.

Objectives: Excessive inflammation contributes to the pathogenesis of tendinopathy. Fatty acid binding protein 4 (FABP4) is a pro-inflammatory adipokine mediating various metabolic and inflammatory diseases. This study aimed to examine the expression of FABP4 and its association with the expressions of inflammatory cytokines in tendinopathy. The effects of a single injection of FABP4 on tendon pathology and inflammation were examined. The effect of FABP4 on the expressions of inflammatory cytokines and the effect of IL-1ß on the expression of FABP4 in tendon-derived stem/progenitor cells (TDSCs) were also investigated. Methods: 1) Clinical patellar tendinopathy samples, healthy hamstring tendon samples, and healthy patellar tendon samples, 2) rotator cuff tendinopathy samples and healthy hamstring tendon samples; and 3) Achilles tendons of mice after saline or collagenase injection (CI) were stained for FABP4, IL-1ß, IL-6, TNF-α and IL-10 by immunohistochemistry (IHC). For the rotator cuff tendinopathy samples, co-localization of FABP4 with IL-1ß and TNF-α was done by immunofluorescent staining (IF). Mouse Achilles tendons injected with FABP4 or saline were collected for histology and IHC as well as microCT imaging post-injection. TDSCs were isolated from human and mouse tendons. The mRNA expressions of inflammatory cytokines in human and mouse TDSCs after the addition of FABP4 was quantified by qRT-PCR. The expression of FABP4 in TDSCs isolated from rotator cuff tendinopathy samples and healthy hamstring tendon samples was examined by IF. Mouse Achilles TDSCs were treated with IL-1ß. The mRNA and protein expressions of FABP4 were examined by qRT-PCR and IF, respectively. Results: There was significant upregulation of FABP4 in the patellar tendinopathy samples and rotator cuff tendinopathy samples compared to their corresponding controls. FABP4 was mainly expressed in the pathological areas including blood vessels, hypercellular and calcified regions. The expressions of IL-1ß and TNF-α increased in human rotator cuff tendinopathy samples and co-localized with the expression of FABP4. Collagenase induced tendinopathic-like histopathological changes and ectopic calcification in the mouse Achilles tendinopathy model. The expressions of inflammatory cytokines (IL-1ß, IL-6, TNF-α, IL-10) and FABP4 increased in hypercellular region, round cells chondrocyte-like cells and calcified regions in the mouse Achilles tendons post-collagenase injection. A single injection of FABP4 in mouse Achilles tendons induced histopathological changes resembling tendinopathy, with increased cell rounding, loss of collagen fiber alignment, and additionally presence of chondrocyte-like cells and calcification post-injection. The expressions of IL1-ß, IL-6, TNF-α and IL-10 increased in mouse Achilles tendons post-FABP4 injection. FABP4 increased the expressions of IL10, IL6, and TNFa in human TDSCs as well as the expressions of Il1b, Il6, and Il10 in mouse TDSCs. Human tendinopathy TDSCs expressed higher level of FABP4 compared to healthy hamstring TDSCs. Besides, IL-1ß increased the expression of FABP4 in mouse TDSCs. Conclusion: In conclusion, an upregulation of FABP4 is involved in excessive inflammation and pathogenesis of tendinopathy. TDSCs is a potential source of FABP4 during tendon inflammation. Translation potential of this article: FABP4 can be a potential treatment target of tendinopathy.

Topical glyceryl trinitrate (GTN) and eccentric exercises in the treatment of mid-portion achilles tendinopathy (the NEAT trial): a randomised double-blind placebo-controlled trial.

OBJECTIVES: To investigate if daily treatment with glyceryl trinitrate (GTN) ointment, over 24 weeks combined with a 12-week eccentric exercise programme is more effective for chronic mid-portion Achilles tendinopathy than placebo ointment and eccentric exercise. METHODS: This was a single-site randomised double-blind placebo-controlled trial at an acute hospital, Dublin, Ireland. Patients with chronic mid-portion Achilles tendinopathy were randomised to either 24 weeks of daily GTN ointment or placebo ointment. Both groups received an identical 12-week eccentric exercise programme. The primary outcome measure was the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire at 24 weeks, which measures pain, function and activity. Secondary outcomes included pain severity, self-reported physical function, calf muscle function, pressure pain thresholds and ultrasound changes. Statistical analyses were performed according to intention-to-treat principles. RESULTS: 76 patients (30 women; 46 men, mean age±SD, 45.6±8.2 years) were recruited for the trial. Significant improvements in VISA-A scores occurred in both groups at 6-week, 12-week and 24-week follow-up. The increase was not significantly different between groups, adjusted mean between-group difference from baseline to week 6, -1.33 (95% CI -6.96 to 4.31); week 12, -1.25 (95% CI -8.0 to 5.49) and week 24, -3.8 (95% CI -10.6 to 3.0); negative values favour GTN. There was no significant between-group difference in any of the secondary outcome measures at 6, 12 and 24 weeks. CONCLUSIONS: Adding daily GTN ointment over 24 weeks to a 12-week eccentric exercise programme did not improve pain, function and activity level in patients with chronic mid-portion Achilles tendinopathy when compared with placebo ointment.

Oxidative stress induces ferroptosis in tendon stem cells by regulating mitophagy through cGAS-STING pathway.

Tendinopathy is one of the most prevalent sports injury diseases in orthopedics. However, there is no effective treatment or medicine. Recently, the discovery of tendon stem cells (TSCs) provides a new perspective to find new therapeutic methods for Tendinopathy. Studies have shown that oxidative stress will inevitably cause TSCs injury during tendinopathy, but the mechanism has not been fully elucidated. Here, we report the oxidative damage of TSCs induced by H2O2 via ferroptosis, as well, treatment with H2O2 raised the proportion of mitochondria engulfed by autophagosomes in TSCs. The suppression of mitophagy by Mdivi-1 significantly attenuates the H2O2-induced ferroptosis in TSCs. Mechanically, H2O2 actives the cGAS-STING pathway, which can regulate the level of mitophagy. Interfering with cGAS could impair mitophagy and the classical ferroptotic events. In the rat model of tendinopathy, interference of cGAS could relieve tendon injury by inhibiting ferroptosis. Overall, these results provided novel implications to reveal the molecular mechanism of tendinopathy, by which pointed to cGAS as a potential therapeutic target for the treatment of tendinopathy.

[Acute rupture of the Achilles tendon : Diagnostics, treatment and aftercare]. / Akute Achillessehnenruptur : Diagnostik, Therapie und Nachsorge.

With up to 50 incidents per 100,000 inhabitants, Achilles tendon ruptures are among the most frequent tendon injuries encountered in orthopedics and trauma surgery. Apart from high-risk forms of sport, degenerative processes are primarily responsible for weakening and ultimately rupture. In addition to assessing the typical clinical signs with inability to perform powerful plantar flexion, the diagnostics include easy to earn examination techniques, such as the Thompson test and ultrasound as the imaging gold standard. Conservative and surgical treatment are available depending on the constitution, age and requirements of the patient. The latter option is divided into conventional open, minimally invasive or percutaneous procedures. Good to very good results can be expected regardless of the form of treatment, provided that early functional rehabilitation is carried out. The average rerupture rate is 5% and the return to sport rate is around 80%.

The relationship between the duration and the retraction and atrophy grades in traumatic isolated full-thickness supraspinatus tears in young patients.

BACKGROUND: The study aimed to determine the grade of retraction and atrophy according to the time elapsed in traumatic isolated full-thickness supraspinatus (SS) tears in young patients. METHODS: One thousand twenty-six patients, who underwent arthroscopic shoulder surgery, were retrospectively reviewed. Pre-operative magnetic resonance imaging (MRI) of 69 patients aged 18 to 40 years with isolated traumatic full-thickness SS lesions remaining after exclusion criteria were evaluated for tendon retraction and atrophy grades. SS retraction was determined from a T2-weighted oblique coronal MRI slice, and the atrophy grade was determined from the T1-weighted oblique sagittal MRI slice. The patients were divided into four groups 0-1 month, 1-3 months, 3-6 months, and 6-12 months according to the time between trauma and MRI. The relationship of tendon retraction and muscle atrophy with elapsed time was evaluated, in addition, comparisons between groups were made. RESULTS: Thirty-one (45%) of the patients were female and their mean age was 30 ± 7.3 (18-40) years. The mean age of men was 30.5 ± 6.9 (18-39) years (p = 0.880). The time between rupture and MRI was moderately correlated with retraction and strongly correlated with atrophy grades (r = 0.599, 0.751, respectively). It was observed that there was a statistically significant difference between the 1st (0-1 month) and 2nd (1-3 months) groups (p = 0.003, 0.001, respectively), and between the 2nd and 3rd (3-6 months) groups (p = 0.032, 0.002, respectively), but there was no significant difference between the 3rd and 4th (6-12 months) groups (p = 0.118, 0.057, respectively). In addition, there was a moderate correlation between tendon retraction and atrophy grades (r = 0.668). Power (1- b) in post hoc analysis was calculated as 0.826. CONCLUSIONS: The current study, supported by arthroscopy, showed that there is a moderate and strong positive correlation between the time elapsed after trauma and the level of retraction and degree of atrophy in traumatic full-thickness SS tears, and demonstrated the importance of early surgical intervention in young patients.

Metrology of Supraspinatus Tendon Thickness in Swimmers with Tendinopathy Using Ultrasound Imaging: An Intra- and Inter-Rater Reliability Study.

Objective: This study aimed to assess the relative and absolute intra- and inter-rater reliability of supraspinatus tendon (SST) thickness. Materials: Thirty adolescent swimmers with supraspinatus (SS) tendinopathy (n = 15) and a control-matched group (n = 15) were evaluated. Tendon thickness was measured according to four different measure procedures, i.e., (1) at 15 mm, (2) at 10, 20, and 30 mm, (3) at 10, 15, and 20 mm, and (4) 5 and 10 mm lateral to the most hyperechogenic reference point of the biceps tendon. Each examiner took two US images for the test measurements with a 10 min rest period. After 30 min, the subjects underwent retest measurements that were also repeated 1 week later. Results: SST thickness was greater in swimmers with SS tendinopathy compared with the matched control group for each procedure and rater (p < 0.001). Intra- and inter-rater reliability was good to excellent (ICC2.3: 0.78-0.98 and 0.83-0.97, respectively) in both groups. The lowest intra- and inter-rater reliability was found in procedures no. 2 and 4 (ICC2.3: 0.78 and 0.83). However, procedure no. 3 was the most reliable with the lowest error rate (ICC2.3: 0.92-0.97; SEM: 0.05-0.10 mm; MDC: 0.14-0.28 mm). Conclusions: The study confirmed the diagnostic value of ultrasound in SS tendinopathy. A multiple-reference-point procedure including a simple methodology (10, 15, and 20 mm from biceps tendon), was defined as the most reliable, expressed by the highest intra- and inter-rater ICCs.

Efficacy of shock wave therapy and ultrasound therapy in non-insertional Achilles tendinopathy: a randomised clinical trial.

Objective: Physiotherapists and physicians continue to seek effective conservative treatments for Achilles tendinopathy. This study aimed to subjectively and objectively determine the therapeutic efficacy of radial shock wave therapy (RSWT) and ultrasound therapy in non-insertional Achilles tendinopathy. Materials and methods: Thirty-nine patients with non-insertional Achilles tendinopathy were randomly assigned to three experimental groups, i.e., RSWT (group A), ultrasound therapy (group B), and placebo ultrasound (group C) groups. Before the intervention and at weeks 1 and 6 after the treatment, the patients were assessed using the Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire and posturographic measurements of step initiation performed on the force platforms under two different conditions (non-perturbed transit and perturbed transit). Results: Six weeks after therapy, all groups exhibited significantly increased VISA-A scores against the measurement at week 1 after therapy. The post-therapy percentage changes in VISA-A scores were significantly greater in group A compared to group B. The three-way ANOVA demonstrated that treatment type affected sway range in the frontal plane and mean velocity of the centre of foot pressure displacements in the sagittal and frontal planes during quiet standing before step initiation. The Bonferroni post-hoc test showed that the means of all those variables were significantly smaller for group A than for group B patients. The three-way ANOVA revealed an effect of the platform arrangement on transit time and double-support period. The Bonferroni post-hoc test revealed statistically longer transit time for the perturbed vs. non-perturbed trials; a reverse relationship was observed for the double-support period. Conclusion: The VISA-A showed that RSWT was significantly more effective than sonotherapy for alleviation of pain intensity as well as function and activity improvement in patients with non-insertional Achilles tendinopathy. Therefore, RSWT therapy can be used in clinical practice by physiotherapists to alleviate the symptoms of non-insertional Achilles tendinopathy. Objective data registered by force platforms during quiet standing before and after step initiation did not prove useful for monitoring the progress of treatment applied to patients with non-insertional Achilles tendinopathy between consecutive therapy interventions.Clinical trial registration:https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12617000860369, identifier (ACTRN12617000860369).

Role of orthobiologics in managing patellar tendinopathy: A narrative review.

Patellar tendinopathy is a relatively common cause of anterior knee pain in athletes. It is predominantly seen in sports involving jumping, running, abrupt change in direction like basketball, volleyball, soccer, sprinting and jumping. The main pathophysiology is considered to be repetitive microtrauma at the inferior pole of patella along with a poor healing response. Although eccentric exercises have shown to be beneficial, the improvement is often slow and may result in a less than satisfactory outcome. There is a growing interest of orthobiologics, mainly platelet-rich plasma (PRP) in multiple chronic musculoskeletal pathologies. This narrative review aimed to analyse the current evidence on the role of orthobiologics in the management of recalcitrant patellar tendinopathy. Multiple studies have shown significant clinical improvement with negligible adverse effects on PRP injection for patellar tendinopathy. Most studies assessed report that the effects of PRP are sustained. However, among all studies evaluated, there is a considerable heterogeneity in terms of PRP composition, number of injections, dosage interval and postinjection rehabilitation protocol, pointing to the need for further research to enable standardisation of PRP therapy. Stem cells too have shown potential to be effective as a treatment modality for chronic patellar tendinopathy, but there is limited data to recommend its use outside of research setting or to enable a meaningful comparison to PRP. There is a promising role of orthobiologics in management of chronic patellar tendinopathy not responding to conventional treatment. Level of Evidence: Not applicable (narrative review).

The roles and mechanisms of the NF-κB signaling pathway in tendon disorders.

Both acute and chronic tendon injuries are the most frequently occurring musculoskeletal diseases in human and veterinary medicine, with a limited repertoire of successful and evidenced-based therapeutic strategies. Inflammation has been suggested as a key driver for the formation of scar and adhesion tissue following tendon acute injury, as well as pathological alternations of degenerative tendinopathy. However, prior efforts to completely block this inflammatory process have yet to be largely successful. Recent investigations have indicated that a more precise targeted approach for modulating inflammation is critical to improve outcomes. The nuclear factor-kappaB (NF-κB) is a typical proinflammatory signal transduction pathway identified as a key factor leading to tendon disorders. Therefore, a comprehensive understanding of the mechanism or regulation of NF-κB in tendon disorders will aid in developing targeted therapeutic strategies for human and veterinary tendon disorders. In this review, we discuss what is currently known about molecular components and structures of basal NF-κB proteins and two activation pathways: the canonical activation pathway and the non-canonical activation pathway. Furthermore, we summarize the underlying mechanisms of the NF-κB signaling pathway in fibrosis and adhesion after acute tendon injury, as well as pathological changes of degenerative tendinopathy in all species and highlight the effect of targeting this signaling pathway in tendon disorders. However, to gain a comprehensive understanding of its mechanisms underlying tendon disorders, further investigations are required. In the future, extensive scientific examinations are warranted to full characterize the NF-κB, the exact mechanisms of action, and translate findings into clinical human and veterinary practice.

Obesity is associated with muscle atrophy in rotator cuff tear.

Objective: The primary goal of this study is to evaluate the relationship between Body Mass Index (BMI) and muscle atrophy in individuals with rotator cuff tears. Methods: This study consists of patients with rotator cuff tears identified by MRI from two independent cohorts, the Rotator Cuff Outcomes Workgroup (ROW) and the Multicenter Orthopaedic Outcomes Network (MOON). Presence of atrophy (yes/no) and severity of atrophy (as an ordinal variable) were assessed on MRI by expert physicians. We used multivariable regression models to evaluate the relationship between BMI and muscle atrophy while adjusting for age and sex in each study, conducted sensitivity analyses for full-thickness tear and combined results using inverse variance-weighted meta-analysis. Results: A total of 539 patients (MOON=395, ROW=144) from the combined cohorts had MRI data available on muscle atrophy. Among these patients, 246 (46%) had atrophy of at least one of the muscles of the rotator cuff and 282 (52%) had full-thickness tears. In meta-analysis across both cohorts, each 5 kg/m2 increase in BMI was associated with a 21% (aOR=1.21, 95% CI=1.02, 1.43) increased odds of having muscle atrophy among individuals with any tear size, and 36% (aOR=1.36, 95% CI=1.01-1.81) increased odds among individuals with full-thickness tear. Conclusions: Higher BMI was associated with significantly higher odds of muscle atrophy in patiens with rotator cuff tears. More study is needed to unders1tand why and how this relationship exists, as well as whether interventions to reduce BMI may help improve outcomes for these patients. Level of Evidence: III.

Achilles tendon complications of fluoroquinolone treatment: a molecule-stratified systematic review and meta-analysis.

Purpose: The association between fluoroquinolone intake and Achilles tendinopathy (AT) or Achilles tendon rupture (ATR) is widely documented. However, it is not clear whether different molecules have the same effect on these complications. The purpose of this study was to document Achilles tendon complications for the most prescribed fluoroquinolones molecules. Methods: A literature search was performed on Pubmed, Cochrane, Embase, and Web of Science databases up to April 2023. Inclusion criteria: studies of any level of evidence, written in English, documenting the prevalence of AT/ATR after fluoroquinolone consumption and stratifying the results for each type of molecule. The Downs and Black's 'Checklist for Measuring Quality' was used to evaluate the risk of bias. Results: Twelve studies investigating 439,299 patients were included (59.7% women, 40.3% men, mean age: 53.0 ± 15.6 years). The expected risk of AT/ATR was 0.17% (95% CI: 0.15-0.19, standard error (s.e.): 0.24) for levofloxacin, 0.17% (95% CI: 0.16-0.19, s.e.: 0.20) for ciprofloxacin, 1.40% (95% CI: 0.88-2.03, s.e.: 2.51) for ofloxacin, and 0.31% (95% CI: 0.23-0.40, s.e.: 0.77) for the other molecules. The comparison between groups documented a significantly higher AT/ATR rate in the ofloxacin group (P < 0.0001 for each comparison). Levofloxacin and ciprofloxacin showed the same risk (P = n.s.). The included studies showed an overall good quality. Conclusion: Ofloxacin demonstrated a significantly higher rate of AT/ATR complications in the adult population, while levofloxacin and ciprofloxacin showed a safer profile compared to all the other molecules. More data are needed to identify other patient and treatment-related factors influencing the risk of musculoskeletal complications.