- Email: [email protected]
Five year prospective comparison study of topical glyceryl trinitrate treatment of chronic lateral epicondylosis at the elbow
Abstracts / Journal of Science and Medicine in Sport 12 (2010) e1–e232
Results: 28 men and 27 women (mean age = 73, SD = 6, range 65–89) were interviewed. 45% did not have a university degree. Problems were found with all questionnaires. Problems included difficulty with the phrasing and terminology (e.g., misunderstanding of “moderate” and “vigorous” [all questionnaires]), making accurate estimations of the time spent in activities (e.g., calculating time spent sitting per day [IPAQ]), deciding which activities to include in responses (e.g., some included only activities listed as examples; others included activities beyond the examples [BRFSS]), reporting the same activity multiple times on one questionnaire (e.g., reporting walking behaviour in both walking and moderate activity questions [AAQ]), and the intensity of the activities given as examples did not match with participants’ perceptions of the intensity of these activities [vacuuming was not perceived as “heavy housework” [PASE]. Conclusions: The results indicate that the four commonlyused PA questionnaires are not working for older adults as intended by the questionnaire developers. The problems uncovered in this study can be used to improve the questionnaires for use in national and international PA surveillance of older adults.
e79
Results: In the short term, corticosteroid injection has a large effect on tennis elbow, achilles and patellar tendinopathies, and a small but inconsistent effect on rotator cuff tendinopathies. No effects or negative effects are observed compared to most other conservative interventions in the long term for upper limb tendinopathies, while the effect on lower limb tendinopathies is not known. The incidence of reported adverse effects of corticosteroid was low, the majority of mild, transient nature. In comparison, study of other types of injections has occurred in only one or two small randomized controlled trials each and with only short or medium follow-up. Clinically relevant effects were found following botulinum toxin and prolotherapy injections in tennis elbow, polidocanol injection for achilles tendinopathy and aprotinin injection for patellar tendinopathy. The long term effects of these injections are not known. Conclusion: With an advancing number of injections available for the treatment of tendinopathy, systematic comparison of their efficacy may help practitioners and patients make informed choices about the relative benefits and harms of these treatments. doi:10.1016/j.jsams.2009.10.162
doi:10.1016/j.jsams.2009.10.161 162 161 Corticosteroid, polidocanol, botulinum toxin, aprotinin, prolotherapy and glycosaminoglycan injections in the management of common tendinopathies: A systemtic review and meta-analysis B. Coombes 1,∗ , L. Bisset 2 , B. Vicenzino 1 1 University 2 Griffith
of Queensland University
Introduction: Tendinopathies, of which tennis elbow and achilles tendinopathy are the most common, can significantly affect both recreational and professional athletes, particularly those over 40 years of age. Patients with tendon pain are frequently treated with local intratendinous or paratendinous injections to relieve pain and allow earlier return to sport. Given the uncertainty surrounding the validity of using corticosteroid injections in non-inflammatory conditions and the emergence of other injectable medications in the management of tendinopathy, a systemtatic review evaluating the effectiveness of all local injections across five common sites of tendinopathy was performed. Methodology: Randomised controlled trials evaluating tennis elbow, rotator cuff, achilles, patellar and medial epicondylalgia tendinopathies were identified using a highly sensitive search strategy. Methodological quality was assessed, and qualitative synthesis or meta-analysis of studies displaying clinical and statistical homogeneity was performed.
Five year prospective comparison study of topical glyceryl trinitrate treatment of chronic lateral epicondylosis at the elbow S. McCallum 1,∗ , J. Paoloni 2 , G. Murrell 2 1 University
of NSW Research Institute
2 Orthopedic
Background: Topical glyceryl trinitrate treatment has previously demonstrated short-term efficacy in the treatment of lateral epicondylosis. No long term follow up has been performed. Hypothesis: Benefits from topical gylceryl trinitrate persist five years after cessation of therapy. Study design: Prospective comparative study. Methods: A follow up study of 58 patients treated with 6 months of topical glyceryl trinitrate or placebo, combined with a tendon rehabilitation program, was performed 5 years after discontinuation of therapy. Assessment included patient rated pain scores, clinically assessed lateral epicondylar and proximal common extensor tendon tenderness, hand-held dynamometer measurement of resisted 3rd finger metacarpophalangeal extension with a fully extended elbow (Maudsley’s test) and wrist extensor tendon mean peak force using a modified chair pick-up test (ORI-TETS). Results: Patients in both the glyceryl trinitrate group and those in the placebo group had significant improvements in symptoms, clinical signs and provocative functional tests compared with baseline week 0 measures. Glyceryl trinitrate
e80
Abstracts / Journal of Science and Medicine in Sport 12 (2010) e1–e232
did not offer any additional clinical benefit over a standard tendon rehabilitation program at five years. Conclusion: While glyceryl trinitrate appears to offer short term benefits up to 6 months in the treatment of lateral epicondylosis, at five years there does not appear to be significant clinical benefits when compared with patients undertaking a standard tendon rehabilitation program alone. This is in contrast to findings of continued benefits at long term follow up described in the literature for patients with Achilles tendinopathy treated with glyceryl trinitrate.
subscapularis (PGP9.5:1.8 ± 0.5/field, GAP: 1.2 ± 0.5/field, p < 0.05) and torn supraspinatus (PGP9.5:1.2 ± 0.3/field, GAP: 0.3 ± 0.2/field, p < 0.01). Conclusion: The data supports the hypothesis that early tendinopathy is associated with increases of nerve fibres and blood vessels around tendinopathic tendon, and these new nerves may be the source of pain in tendinopathy. The low expression of nerve fibres, especially growing nerve fibres, in torn tendons may reflect a poor healing response in the chronic tendinopathy.
doi:10.1016/j.jsams.2009.10.163
doi:10.1016/j.jsams.2009.10.164
163
164
Expression of neuronal markers PGP9.5 and GAP43 in tendinopathic rotator cuff tendon
Are structures in the knee extensor mechanism associated with patellar tendinopathy?
Y. Xu 1,∗ , F. Bonar 2 , G. Murrell 1
A. Culvenor 1,∗ , J. Cook 2 , K. Crossley 3
1 Orthopaedic
1 StVincent’s
2 Douglas
2 School
Research Institute, St George Hospital Hanly Moir Pathology
Introduction: The source of pain in tendinopathy is undetermined. The aim of this study was to compare the innervation pattern of torn, tendinopathic, and “normal” tendon. Methods: The edges of torn supraspinatus and biopsies of intact subscapularis tendons were collected from 25 patients undergoing arthroscopic rotator cuff repair. Control subscapularis tendon biopsies were also collected from 12 patients undergoing arthroscopic shoulder stabilization. Tendon samples were analysed using immunohistological staining with antibodies against a general nerve marker (protein gene product 9.5, PGP9.5), a nerve growth marker (growth associated protein 43, GAP43) and an endothelial cells marker (CD34). Results: The mean (±SEM) pathologic grade of torn supraspinatus tendon was significantly greater than that of intact matched and control subscapularis tendons (3.8 ± 0.1,1.9 ± 0.2 and 1.6 ± 0.2 respectively, p < 0.01). Regional degenerative changes were commonly seen in matched subscapularis tendons but rarely in controls. Tendinopathic tendon displayed a varying degree of hypercellularity and hypervascularity. Groups of nerve fascicles with PGP9.5 or GAP43 immunoreactivity were found predominantly in the paratendinous tissue. Stronger immunoreactions and larger groups of nerve fascicles were seen in torn and tendinopathic tendons compared to normal tendons. PGP9.5 and GAP43 immunoreactions were seen in the nerve fibres in close apposition to blood vessels in both tendinopathic and normal tendons. To some extent, nerve fibres exhibiting immunoreactivity to PGP9.5 were observed in association with tiny blood vessels in tendinopathic tendons. Interestingly, the expression of PGP9.5 and GAP43 were significantly higher in matched subscapularis (PGP9.5: 3.7 ± 0.5 /field, GAP: 3.1 ± 0.5/field) compared to control
Hospital, Melbourne of Exercise and Nutrition Sciences, Deakin Univer-
sity 3 LaTrobe
University, Melbourne
Introduction: Patellar tendinopathy (PT) is one of the most common overuse injuries of the knee seen in the athletic population, yet its etiology and pathogenesis are poorly understood. The ability to target and improve current prevention and management strategies is limited by an incomplete understanding of the causes and features of PT. The aim of this cross-sectional study was to investigate the association between PT and three hypothesised factors: infrapatellarfat pad size, patellar height and patellofemoral joint (PFJ) alignment. Methods: Axial and sagittal magnetic resonance (MR) imaging scans, from 26 participants with PT and 28 control participants were obtained. Infrapatellarfat pad size, patellar height and PFJ alignment were measured digitally, using measurement software, and the results compared between the PT and control groups. Results: The fat pad volume was not significantly different between groups on either measurement method (axial method: p = 0.20, sagittal method: p = 0.61). However, participant height was found to be a strong predictor of fat pad volume (p < 0.001), thus the calculated fat pad volumes were adjusted using height as a covariate. When corrected for participant height, the fat pad volume was significantly larger in the PT group using the axial measurement method (p = 0.04) but was not significantly larger in the PT group using the sagittal measurement method (p = 0.62). The height of the patella was not significantly different between groups (p = 0.16), nor were there between group differences for the various measures of PFJ alignment in the axial plane (p = 0.07-0.76). Discussion: This study found that the infrapatellar fat pad, corrected for participant height, was larger in those with PT than those without PT. A larger fat pad may precede and be
Results: 28 men and 27 women (mean age = 73, SD = 6, range 65–89) were interviewed. 45% did not have a university degree. Problems were found with all questionnaires. Problems included difficulty with the phrasing and terminology (e.g., misunderstanding of “moderate” and “vigorous” [all questionnaires]), making accurate estimations of the time spent in activities (e.g., calculating time spent sitting per day [IPAQ]), deciding which activities to include in responses (e.g., some included only activities listed as examples; others included activities beyond the examples [BRFSS]), reporting the same activity multiple times on one questionnaire (e.g., reporting walking behaviour in both walking and moderate activity questions [AAQ]), and the intensity of the activities given as examples did not match with participants’ perceptions of the intensity of these activities [vacuuming was not perceived as “heavy housework” [PASE]. Conclusions: The results indicate that the four commonlyused PA questionnaires are not working for older adults as intended by the questionnaire developers. The problems uncovered in this study can be used to improve the questionnaires for use in national and international PA surveillance of older adults.
e79
Results: In the short term, corticosteroid injection has a large effect on tennis elbow, achilles and patellar tendinopathies, and a small but inconsistent effect on rotator cuff tendinopathies. No effects or negative effects are observed compared to most other conservative interventions in the long term for upper limb tendinopathies, while the effect on lower limb tendinopathies is not known. The incidence of reported adverse effects of corticosteroid was low, the majority of mild, transient nature. In comparison, study of other types of injections has occurred in only one or two small randomized controlled trials each and with only short or medium follow-up. Clinically relevant effects were found following botulinum toxin and prolotherapy injections in tennis elbow, polidocanol injection for achilles tendinopathy and aprotinin injection for patellar tendinopathy. The long term effects of these injections are not known. Conclusion: With an advancing number of injections available for the treatment of tendinopathy, systematic comparison of their efficacy may help practitioners and patients make informed choices about the relative benefits and harms of these treatments. doi:10.1016/j.jsams.2009.10.162
doi:10.1016/j.jsams.2009.10.161 162 161 Corticosteroid, polidocanol, botulinum toxin, aprotinin, prolotherapy and glycosaminoglycan injections in the management of common tendinopathies: A systemtic review and meta-analysis B. Coombes 1,∗ , L. Bisset 2 , B. Vicenzino 1 1 University 2 Griffith
of Queensland University
Introduction: Tendinopathies, of which tennis elbow and achilles tendinopathy are the most common, can significantly affect both recreational and professional athletes, particularly those over 40 years of age. Patients with tendon pain are frequently treated with local intratendinous or paratendinous injections to relieve pain and allow earlier return to sport. Given the uncertainty surrounding the validity of using corticosteroid injections in non-inflammatory conditions and the emergence of other injectable medications in the management of tendinopathy, a systemtatic review evaluating the effectiveness of all local injections across five common sites of tendinopathy was performed. Methodology: Randomised controlled trials evaluating tennis elbow, rotator cuff, achilles, patellar and medial epicondylalgia tendinopathies were identified using a highly sensitive search strategy. Methodological quality was assessed, and qualitative synthesis or meta-analysis of studies displaying clinical and statistical homogeneity was performed.
Five year prospective comparison study of topical glyceryl trinitrate treatment of chronic lateral epicondylosis at the elbow S. McCallum 1,∗ , J. Paoloni 2 , G. Murrell 2 1 University
of NSW Research Institute
2 Orthopedic
Background: Topical glyceryl trinitrate treatment has previously demonstrated short-term efficacy in the treatment of lateral epicondylosis. No long term follow up has been performed. Hypothesis: Benefits from topical gylceryl trinitrate persist five years after cessation of therapy. Study design: Prospective comparative study. Methods: A follow up study of 58 patients treated with 6 months of topical glyceryl trinitrate or placebo, combined with a tendon rehabilitation program, was performed 5 years after discontinuation of therapy. Assessment included patient rated pain scores, clinically assessed lateral epicondylar and proximal common extensor tendon tenderness, hand-held dynamometer measurement of resisted 3rd finger metacarpophalangeal extension with a fully extended elbow (Maudsley’s test) and wrist extensor tendon mean peak force using a modified chair pick-up test (ORI-TETS). Results: Patients in both the glyceryl trinitrate group and those in the placebo group had significant improvements in symptoms, clinical signs and provocative functional tests compared with baseline week 0 measures. Glyceryl trinitrate
e80
Abstracts / Journal of Science and Medicine in Sport 12 (2010) e1–e232
did not offer any additional clinical benefit over a standard tendon rehabilitation program at five years. Conclusion: While glyceryl trinitrate appears to offer short term benefits up to 6 months in the treatment of lateral epicondylosis, at five years there does not appear to be significant clinical benefits when compared with patients undertaking a standard tendon rehabilitation program alone. This is in contrast to findings of continued benefits at long term follow up described in the literature for patients with Achilles tendinopathy treated with glyceryl trinitrate.
subscapularis (PGP9.5:1.8 ± 0.5/field, GAP: 1.2 ± 0.5/field, p < 0.05) and torn supraspinatus (PGP9.5:1.2 ± 0.3/field, GAP: 0.3 ± 0.2/field, p < 0.01). Conclusion: The data supports the hypothesis that early tendinopathy is associated with increases of nerve fibres and blood vessels around tendinopathic tendon, and these new nerves may be the source of pain in tendinopathy. The low expression of nerve fibres, especially growing nerve fibres, in torn tendons may reflect a poor healing response in the chronic tendinopathy.
doi:10.1016/j.jsams.2009.10.163
doi:10.1016/j.jsams.2009.10.164
163
164
Expression of neuronal markers PGP9.5 and GAP43 in tendinopathic rotator cuff tendon
Are structures in the knee extensor mechanism associated with patellar tendinopathy?
Y. Xu 1,∗ , F. Bonar 2 , G. Murrell 1
A. Culvenor 1,∗ , J. Cook 2 , K. Crossley 3
1 Orthopaedic
1 StVincent’s
2 Douglas
2 School
Research Institute, St George Hospital Hanly Moir Pathology
Introduction: The source of pain in tendinopathy is undetermined. The aim of this study was to compare the innervation pattern of torn, tendinopathic, and “normal” tendon. Methods: The edges of torn supraspinatus and biopsies of intact subscapularis tendons were collected from 25 patients undergoing arthroscopic rotator cuff repair. Control subscapularis tendon biopsies were also collected from 12 patients undergoing arthroscopic shoulder stabilization. Tendon samples were analysed using immunohistological staining with antibodies against a general nerve marker (protein gene product 9.5, PGP9.5), a nerve growth marker (growth associated protein 43, GAP43) and an endothelial cells marker (CD34). Results: The mean (±SEM) pathologic grade of torn supraspinatus tendon was significantly greater than that of intact matched and control subscapularis tendons (3.8 ± 0.1,1.9 ± 0.2 and 1.6 ± 0.2 respectively, p < 0.01). Regional degenerative changes were commonly seen in matched subscapularis tendons but rarely in controls. Tendinopathic tendon displayed a varying degree of hypercellularity and hypervascularity. Groups of nerve fascicles with PGP9.5 or GAP43 immunoreactivity were found predominantly in the paratendinous tissue. Stronger immunoreactions and larger groups of nerve fascicles were seen in torn and tendinopathic tendons compared to normal tendons. PGP9.5 and GAP43 immunoreactions were seen in the nerve fibres in close apposition to blood vessels in both tendinopathic and normal tendons. To some extent, nerve fibres exhibiting immunoreactivity to PGP9.5 were observed in association with tiny blood vessels in tendinopathic tendons. Interestingly, the expression of PGP9.5 and GAP43 were significantly higher in matched subscapularis (PGP9.5: 3.7 ± 0.5 /field, GAP: 3.1 ± 0.5/field) compared to control
Hospital, Melbourne of Exercise and Nutrition Sciences, Deakin Univer-
sity 3 LaTrobe
University, Melbourne
Introduction: Patellar tendinopathy (PT) is one of the most common overuse injuries of the knee seen in the athletic population, yet its etiology and pathogenesis are poorly understood. The ability to target and improve current prevention and management strategies is limited by an incomplete understanding of the causes and features of PT. The aim of this cross-sectional study was to investigate the association between PT and three hypothesised factors: infrapatellarfat pad size, patellar height and patellofemoral joint (PFJ) alignment. Methods: Axial and sagittal magnetic resonance (MR) imaging scans, from 26 participants with PT and 28 control participants were obtained. Infrapatellarfat pad size, patellar height and PFJ alignment were measured digitally, using measurement software, and the results compared between the PT and control groups. Results: The fat pad volume was not significantly different between groups on either measurement method (axial method: p = 0.20, sagittal method: p = 0.61). However, participant height was found to be a strong predictor of fat pad volume (p < 0.001), thus the calculated fat pad volumes were adjusted using height as a covariate. When corrected for participant height, the fat pad volume was significantly larger in the PT group using the axial measurement method (p = 0.04) but was not significantly larger in the PT group using the sagittal measurement method (p = 0.62). The height of the patella was not significantly different between groups (p = 0.16), nor were there between group differences for the various measures of PFJ alignment in the axial plane (p = 0.07-0.76). Discussion: This study found that the infrapatellar fat pad, corrected for participant height, was larger in those with PT than those without PT. A larger fat pad may precede and be