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Published Date : 01:43PM 19 Sep 2007
Research Update - Histopathology of Common Tendinopathies
Update & Implications for Clinical Management
Sports Med (1999) 27(6): 393-408 K.M Khan, J.L Cook, F.Bonar, P.Harcourt, M.Astrom
This article is a comprehensive review of recent literature on Tendinopathy, which is a generic descriptive term to include all pathologies that arise in and around the tendon.?Specific pathologies that underline a patients symptoms determine the prognosis and influence choice of treatment.? The healthy tendon consists of dense clearly defined parallel and slightly wavey collagen bundles, with a characteristic reflective appearance of the collagen fibres under polarised light.? In contrast histopathological studies of symptomatic achilles tendons revealed degeneration and disordered arrangement of collagen fibres and an increased vascularity.
Many of these studies have failed to detect inflammatory lesions and acute or chronic inflammatory cells.? The term Tendinosis was thus applied to the above pathology, which indicates tendon degeneration without clinical or histological signs of an inflammatory response.? It was also concluded that minor variations of this pathology may co-exist, depending on the anatomical site and the nature of the causative event.? Tendinosis can then be summarised as the end result of a number of aetiological processes, mainly characterised by degeneration of collagen fibres and subsequent increase in non-collagenous matrix.?
A theoretical model of the Tendinosis cycle was postulated.
Empirical evidence for the use of any particular treatment modality for Tendinosis is lacking, primarily because previous studies have focussed on treating an inflammatory condition, when the histopathology clearly reveals a degenerative Tendinosis.? It is theorized that Tendinosis may require a longer healing period than has been traditionally afforded to this condition, as tendons often sustain over ten times the normal body weight, yet the tissues have a slow metabolic rate, having only 13% of the oxygen uptake of muscle and requiring greater than a 100 days to synthesise collagen.? Thus tissue repair in Tendinosis may take months rather than weeks.? There are clinical studies that point to the efficacy of eccentric strengthening exercises for Tendinosis, particularly Achilles Tendinosis and lateral Tendinosis of the elbow, or tennis elbow.? Mechanical loading accelerates tenocyte metabolism and may speed repair by increasing collagen production.? There remains little evidence to support the use of non-steroidal antiinflammatory drugs or cortico steroid injection for treatment of Tendinosis.? It is evident that corticosteroid injection into tendon tissue leads to cell death and tendon atrophy, particularly as corticosteroids inhibit collagen synthesis and reduce tendon load to failure.
Physiotherapists employ a wide variety of modalities including ultrasound, laser and heat to treat tendonsis.? Studies of severed tendons have shown that ultrasound increases collagen production, increases the tensile strength of healing tendons and has little affect on inflammation and thus may have a role in reversing the pathology of Tendinosis by stimulating fibrosis and repair.
To conclude, treatment aimed at minimising inflammation is unlikely to address the problem of tendinosis. Instead the aim of treatment should be to increase collagen and matrix production and stimulate tenocyte activity to regain tensile strength of the tendon and interrupt the failed healing response mechanism.
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