Talk:Tendinosis

A note
Why should tendonitis and tendinosis be merged? They are different injuries which happen to occur in the same place and which have similar symptoms. 216.254.25.199 06:03, 2 October 2006 (UTC)

Agreed. Tendinosis (no signs of inflammation) and tendonitis (inflammatory cells present) can usually only be diagnosed after histopathological examination of the tissue. Until this is done, the term tendinopathy is probably more correct. (Ref: J Musculoskelet Neuronal Interact. 2006 Apr-Jun;6(2):181-90. )
 * as if there is any doubt over if tendonitis and tendinosis should be merged, read this article: Time to abandon the "tendinitis" myth Mathmo Talk 05:16, 19 March 2009 (UTC)
 * Agreed, from what I know, tendinosis and tendinitis are totally distinct, and the main problem is that there is a widespread cultural use of the term "tendinitis" to refer to what in an overwhelming majority of cases is tendinosis. Cazort (talk) 17:22, 6 June 2012 (UTC)

I am not a native English speaker, so I had to look up "degeneration", and it means both: 1. the process of degenerating. 2. the condition or state of being degenerate (those are exactly the two, I had in mind before looking them up). So now I dont know if "cronic degeneration", means an ungoing and unstoppable worsening, or just a degenerate state that cant be helped. Maybe we should change it for another word. Is the meaning clear to native English speakers? Velle (talk) 11:02, 31 October 2008 (UTC)

Good point. —Preceding unsigned comment added by 69.76.116.28 (talk) 02:44, 6 February 2009 (UTC)

Eccentric loading, tendon strength, healing, etc.
I notice that there were a lot of unsourced statements saying things like "tendons rarely recover their original strength" and "treatment of tendon injuries is largely palliative". On the other hand, the single statement about eccentric loading has eight sources which not only back it up, but contract these unsourced statements. From a personal perspective, I have twice gone through physical therapy for tendon related injuries, in one case, very straightforward tendinosis. It was treated successfully by a combination of eccentric exercise followed by rest and return to the original activity, and the tendon is now not only healed, but dramatically stronger than before...muscle weakness in the muscle attaching to that tendon, was the primary cause. I have no idea where the old ideas came from but since they're totally unsourced, and they contradict the other given sources, I've tried to root out these ideas. Cazort (talk) 17:31, 6 June 2012 (UTC)

Tendinosis.org
Does somebodyknow what happened to the site www.tendinosis.org ? It doesn't answer anymore. 216.221.38.120 (talk) 03:58, 23 May 2013 (UTC)

Tendon Bioengineering
The section ends, "Results from the trial are expected by April 2013." Does anybody know if these have been released? It's June 2013, but the section still refers to the future. Yodalover (talk) 04:10, 19 June 2013 (UTC)

Less technical introduction
At the end of the introduction, without linking or explanation the terms "degenerative changes in the collagenous matrix, hypercellularity, hypervascularity" are used. That is not understandable to someone without a medical degree. Can someone rewrite in less technical language at the beginning. Maximilianklein (talk) 06:08, 27 November 2013 (UTC)

A paper on using autologous tenocyte injection for the treatment of severe, chronic resistant lateral epicondylitis was published in the American Journal of sports medicine on September 2013
A paper on using autologous tenocyte injection for the treatment of severe, chronic resistant lateral epicondylitis was published in the American Journal of sports medicine on September 2013. A patellar tendon needle biopsy was performed under local anesthetic, and tendon cells were expanded by in vitro culture. Tenocytes used for the injection were characterized by flow cytometry and real-time polymerase chain reaction. Autologous tenocytes were injected into the site of tendinopathy identified at the origin of the extensor carpi radialis brevis tendon under ultrasound guidance on a single occasion. In this study, patients with chronic LE who had previously undergone an unsuccessful full course of nonoperative treatment showed significantly improved clinical function and structural repair at the origin of the common extensor tendon after ATI.

Treatment of Tendon Injury Using Mesenchymal Stem Cells (ALLO-ASC) - clinical trial
As of November 2013, researchers at the Seoul National University Hospital will be looking to recruit participants into a clinical trial to evaluate the efficacy of allogenic adipose-derived mesenchymal stem cells (ALLO-ASC) in treatment of a tendon injury (symptom duration is over six months). ALLO-ASC will be administrated to the patients with lateral epicondylitis (tennis elbow) by ultrasonographic guided injection. — Preceding unsigned comment added by Bboyjkang2 (talk • contribs) 21:58, 3 August 2014 (UTC)

Stage 2 clinical trials for Achilles tendinosis treatment – take non-bulbar dermal sheath (NBDS) cells surrounding patient's own hair follicles and injecting them into injured tendons
I plan to add the following clinical trial information to the future treatment section:

A company has planned a Phase 2 Achilles tendinosis trial using a new source of cells, which are fibroblasts isolated from nonbulbar dermal sheath cells of a hair follicle. This tendon technology will be tested in approximately 90–120 subjects in a Phase 2 trial, and will commence in Q3 2014. The company’s focus on the use of nonbulbar dermal sheath cells is based on the fact that these cells produce significantly more type I collagen than fibroblasts derived from adipose tissue. Type I collagen is the primary collagen in tendons. NBDS cells will be replicated, and then reintroduced into the wounds within the tendon via ultrasound. After injections are performed, subjects will return to the clinic for assessments of safety, function and pain, as well as changes in tendon thickness, echotexture, interstitial tears and neovascularity. The work extends off of papers including, “Skin-Derived Fibroblasts for the Treatment of Refractory Achilles Tendinosis: Preliminary Short-Term Results”, published in the Journal of Bone and Joint Surgery in 2012.

== Autologous Tenocyte paper references 2 skin-derived tenocyte-like cells papers – couple authors in 2 papers also in Achilles tendinosis prelim paper – will mention 2 papers since 2 trials on wiki reference them, and skin-derived not mentioned yet ==

Autologous Tenocyte Injection paper references 2 papers about skin-derived tenocyte-like cells – couple authors in 2 papers also in Achilles tendinosis Skin-Derived Fibroblasts preliminary results paper – will mention 2 papers since 2 trials on the Wikipedia page reference them, and skin-derived tenocyte-like cells haven’t been mentioned yet

The paper, “Autologous Tenocyte Injection for the Treatment of Severe, Chronic Resistant Lateral Epicondylitis: A Pilot Study” references 2 papers: “Treatment of lateral epicondylitis using skin-derived tenocyte-like cells”, published in the British Journal of Sports Medicine in 2009, and “Skin-Derived Tenocyte-like Cells for the Treatment of Patellar Tendinopathy”, published in the American Journal of Sports Medicine in 2010 (at the bottom of the American Journal of Sports Medicine website, it says, “Articles citing this article”). Some of the authors (Connell and Clarke) are part of the paper, “Skin-Derived Fibroblasts for the Treatment of Refractory Achilles Tendinosis: Preliminary Short-Term Results”, published in the Journal of Bone and Joint Surgery in 2012, which seems to be part of the Achilles tendinosis non-bulbar dermal sheath (NBDS) cells clinical trial.

To the end of the Autologous Tenocyte Injection section, I think I’m going to mention the 2 papers about skin-derived tenocyte-like cells, since 2 of the trials reference them, and skin-derived tenocyte-like cells haven’t been mentioned yet (perhaps skin-derived tenocyte-like cells should get their own section later on).

I will add the following: The work extends off of papers including, “Treatment of lateral epicondylitis using skin-derived tenocyte-like cells”, published in the British Journal of Sports Medicine in 2009, and “Skin-Derived Tenocyte-like Cells for the Treatment of Patellar Tendinopathy”, published in the American Journal of Sports Medicine in 2010.

== New ultrasound technology - Acoustoelastography - EchoSoft from University of Wisconsin-Madison and Echometrix - give quantitative data about mechanical properties, like stiffness, and status of musculoskeletal (tendon and ligament) tissue ==

New ultrasound technology - Acoustoelastography - EchoSoft from University of Wisconsin-Madison (Wisconsin Alumni Research Foundation) and Echometrix - waves not just for vision, but give quantitative data about mechanical characteristics and properties, like stiffness, and functional status of musculoskeletal (tendon and ligament) tissue

Someone at http://www.sorehand.org/ (repetitive strain injury mailing list) posted a link about a new type of ultrasound technology.

http://www.news.wisc.edu/23139

Echometrix was just granted a patent on September 19.

http://wisconsintechnologycouncil.com/newsroom/?ID=2708

Wikipedia should be updated, so I need to find proper peer-reviewed articles with good information about it.

I grabbed some search results from the top of Google scholar.

>(Research has shown that Google Scholar puts high weight especially oncitation counts[20]and words included in a document's title.[21]As a consequence the first search results are often highly cited articles.)

I'll dump some of what I found so far here: https://docs.google.com/document/d/1iCJE0d1cpUneSrtiEK3oi2H9nuYX812gL6g1rFdfP20/edit#

If you have the time, it's worth reading some of it.

I grabbed the most prominent articles, extracted abstracts, introductions, and concluding discussions, segmented by sentences, made headings, and created a table of contents.

The various articles frequently reference the same thing, so as you read, you sort of get the gist of what they're talking about.

I'll research more later.

I'll figure out what can be added to Wikipedia later.

From this, I'll make a second, smaller document that contains what I think could be added.

— Preceding unsigned comment added by Bboyjkang2 (talk • contribs) 10:52, 15 October 2014 (UTC)

Adding some ultrasound information.
Paraphrased:

Ultrasound imaging can be used to evaluate tissue strain, as well as other mechanical properties.

Ultrasound-based techniques are becoming more popular because of its affordability, safety, and speed. Ultrasound can be used for imaging tissues, and the sound waves can also provide information about the mechanical state of the tissue.

Elastography ultrasound
I will put this:

Researchers have tried to analyze tissue strain and mechanical properties using elastography, which is an acoustical imaging technique that measures strain distributions in tissues that result from stress or compression of the tissue. Strain is inversely related to stiffness, so under a given amount of stress, tissue that displays less strain is assumed to be stiffer than tissue that exhibits more strain. Elastography is therefore an indirect method to estimate tissue stiffness.

One limitation of elastography is that it is inherently linear when ultrasound wave velocity and the material properties do not change during the strain measurement. This is a problem in soft tissues like tendons, as they are nonlinear in stiffness, and can undergo large deformations in activity. Elastography measures strain, and to more completely described the mechanical behavior, more data, like stiffness or stress would be required.

When papers talk about using Elastography ultrasound on tendons, I’m not sure if they’re talking about human tendons or animal tendons.

The papers mention the limitations of Elastography for things like tendons, so for now, I’ll assume that it’s not used in common practice to diagnose injuries of the regular population, and I’ll place the Elastography information under the “research” heading and not the “diagnosis” section.

Acoustoelastography ultrasound
Just like elastography ultrasound, I don’t think that acoustoelastography ultrasound is being used in common practice for human tendons yet.

However, acoustoelastography doesn’t have the limitations of elastography.

Therefore, while both ultrasound methods have been used to test tendons in research scenarios, I think that there are acoustoelastography products that are available for Veterinary customers, and have an intention to move to humans.

I’ll post some of the following acoustoelastography information under the “research” section, just like the elastography information.

Some information will go into the “animals” section later when I add 2 animal tendon papers.

The information will probably go under “medical imaging”, and not “research”, since acoustoelastography is apparently already being used to diagnose tendon injuries for animals.

I’ll post the following:

Acoustoelastography ultrasound

Acoustoelastic theory is based on the principle that the acoustic properties of a material are altered as the material is loaded and deformed. The properties can be measured as a change in amplitude and wave velocity.

With the use of A-mode ultrasound, researchers have derived an acoustic relationship between reflected wave amplitude, and strain-dependent stiffness and stress in a deformed material.

As tendon tension increases, the intensity of reflected ultrasonic echoes increases. The increased intensity results in a brighter B-mode ultrasound image

Acoustoelastography is an ultrasound technique that relates ultrasonic wave amplitude changes to the mechanical properties of a tendon.

It is an ultrasound-based model that can be used evaluate tendon function. Gradual deformations of a tendon can produce cine loops, where changes in echo intensity can be observed. By analyzing the echo intensity changes with Acoustoelastography, one can deduce the stiffness gradient, which is the rate of change of normalised stiffness as a function of strain.

EchoSoft ultrasound software from the Wisconsin Alumni Research Foundation and Echometrix applies the theory of acoustoelasticity to measure musculoskeletal (tendon and ligament) tissue. The software examines previously unused information found by ultrasound waves to quantify the extent of musculoskeletal injuries, or a patient's progress in a healing process.

Adding diagnosis, pathophysiology, and medical imaging to animal tendinosis section
Here is what I’ll add:

Diagnosis

When the superficial digital flexor tendon of horses is damaged, there is a thickening of the tendon, giving it a bowed appearance when the leg is viewed from the side.

Medical imaging

A study tested the repeatability and feasibility of using acoustoelastography for in vivo measurement of stiffness gradients in the superficial digital flexor tendons (SDFTs) of clinically normal horses. The results show that acoustoelastography is a repeatable and feasible technique for measuring stiffness gradients of superficial digital flexor tendons in clinically normal horses, and acoustoelastography has the potential to be used for comparing diseased and healthy tendon states.

A report describes the use of acoustoelastography to monitor the mechanical healing of an Achilles tendon laceration in a dog after suture repair. Serial acoustoelastography examinations of the tendon showed that mechanical properties improved throughout the recovery period. At 29 weeks, the mechanical properties of the repaired tendon were similar to that of the normal contralateral Achilles mechanism.

A study shows that acoustoelastography is a repeatable and feasible method for measuring stiffness gradients in equine superficial digital flexor tendons.

The acoustoelastic strain gauge is an ultrasound-based tissue evaluation technique that relates echo intensity changes that are observed during the stretching or relaxation tendons to the mechanical properties of the tissue. The method deduces stiffness gradient (the rate of change of normalized stiffness as a function of tissue strain) by evaluating the ultrasound dynamic images that are captured from tissue as it gradually deforms. Acoustoelastic strain gauge has been shown to accurately model stiffness and strain within tendons in vitro. To determine the repeatability and feasibility of in vivo ASG measurements of canine tendon function, stiffness gradients for the gastrocnemius tendons of dogs were recorded. Findings indicate that acoustoelastic strain gauge is a repeatable and feasible technique for measuring stiffness gradients in canine tendons.

Pathophysiology

Achilles tendons in rats were studied with acoustoelastography ultrasound. After a tendon injury, and during tendon healing, vascularity changes and cellular activity are vital to the formation of granular tissue in the tendon gap, and the subsequent development of neo-tendinous tissue that replaces damaged native tissue. Normal, intact tendon is mainly comprised of type I collagen, and type III collagen increases after injury. Another study has recorded an association between collagen fibers and echogenicity tendon during Achilles tendon healing.

This report further indicates that a decrease in type I procollagen (and increase in type III collagen and periostin) correlates to reduced strength, echo intensity, and normalized stiffness. It shows that tissue normalized stiffness is linearly correlated to procollagen I, while echo intensity is seen to be nonlinearly correlated to type I procollagen. Furthermore, the increase in M1 macrophages, blood vessels, and proliferating cells that occur within two weeks of the injury are associated with a formation of granulation tissue. Ultimate stress, echo intensity, and normalized stiffness are all their lowest during these times. The results assert that the reduction in stress and normalized stiffness that is measured by ultrasonic and mechanical methods correlate well with the biological aspect of tendon healing.

Confusion between Tendonitis versus Tendinosis - cortisone - by user 140 – use “Tendons – time to revisit inflammation” paper
I get your point, but the style of discourse is not appropriate for Wikipedia, and you need a paper.

Cortisone is mentioned in a new paper, and I’ll replace the book reference.

I’ll leave the entry, because it’s important to mention anti-inflammatory treatments like cortisone, but it has to change eventually.

“Tendons – time to revisit inflammation” paper

Br J Sports Med 2014;48:1553-1557 doi:10.1136/bjsports-2012-091957

Tendons – time to revisit inflammation

Lateral epicondylitis (tennis elbow) tendinosis
Tendinosis wasn’t mentioned in the lateral epicondylitis Wikipedia article, so I wanted to see it updated.

I posted the following information in the lateral epicondylitis talk page, and I want to repost it here because it I think that some of the information could potentially be added to the tendinosis page.

I did a Google scholar search a while back with the terms “tendinosis tennis elbow”.

I gathered a few sentences of a few citations from the first 10 pages of Google scholar.

https://docs.google.com/document/d/1l_u4p2Hf7douxpMBbvFTOYLcmPjO2S4B-NayvfFn4b8/edit

I put them in an unlisted Google Docs because I’m not sure if copyrighted material can be on the talk page, even if it’s just for discussion.

(I think that I added the references to my list as the page increased, so the references at the top could be the more reputable ones.

However, I’m not entirely sure.

It would be very convenient if I could post citations somewhere, and then some sort of impact factor or ranking could be displayed beside each citation).

Here are a few top samples:

(The information is not paraphrased yet)

(I used the Reddit editor to additionally skew the text)

> ^The ^general ^opinion ^is ^that ^the ^condition ^is ^due ^to ^overuse, ^and ^that ^the ^extensor ^carpi ^radialis ^brevis ^muscle ^(ECRB) ^plays ^a ^central ^role.1–3

> ^Furthermore, ^there ^is ^no ^traditional ^inflammation.2 ^4

> ^The ^histological ^findings ^vary, ^and ^include ^microrupture, ^granulation ^tissue ^and ^degenerative ^changes.2 ^3 ^5 ^6

> ^Consequently, ^the ^term ^“lateral ^elbow ^tendinopathy ^or ^tendinosis” ^is ^used ^instead ^of ^“lateral ^epicondylitis”.

> ^“The ^histology ^of ^pathologic ^tennis ^elbow ^tissue ^reveals ^noninflammatory ^tissue, ^thus ^the ^term ^angio-fibroblastic ^tendinosis.”

> ^Tennis ^elbow ^tendinosis ^is ^most ^commonly ^caused ^by ^tendon ^overuse ^and ^failed ^tendon ^healing.

> ^Longitudinal ^sonogram ^of ^the ^lateral ^elbow ^shows ^thickening ^and ^heterogeneity ^of ^the ^CET ^consistent ^with ^tendinosis, ^with ^intrasubstance ^tears, ^calcifications, ^and ^marked ^irregularity ^of ^the ^lateral ^epicondyle

> ^Although ^epicondylitis ^is ^a ^term ^often ^used ^to ^describe ^this ^condition, ^most ^studies ^reporting ^on ^the ^histopathologic ^findings ^have ^shown ^no ^evidence ^of ^either ^an ^acute ^or ^a ^chronic ^inflammatory ^process.16

> ^Histologic ^studies ^have ^shown ^that ^this ^disorder ^is ^actually ^the ^result ^of ^tendon ^degeneration ^that ^leads ^to ^replacement ^of ^normal ^tissue ^by ^a ^disorganized ^arrangement ^of ^collagen.20–23

> ^This ^condition ^is ^therefore ^more ^appropriately ^referred ^to ^as ^“tendinosis” ^or ^“tendinopathy” ^rather ^than ^“tendinitis.”20,21,24

> ^Ultrasonography ^(US) ^+ ^colour ^Doppler ^(CD) ^examination ^shows ^structural ^tendon ^changes ^with ^hypo-echoic ^areas, ^and ^a ^vascularity, ^corresponding ^to ^the ^painful ^area ^in ^the ^extensor ^origin.

Tendinosis pathophysiology – Lateral epicondylitis – what I’m ready to add
I already added some information to the Lateral epicondylitis Wikipedia article, so I’ll add some of it to the tendinosis page.

The information is already paraphrased from the talk post that I put above, which had the excerpts from Google Scholar.

What I’ll add:

Histological findings include granulation tissue, microrupture, degenerative changes, and there is no traditional inflammation. As a consequence, “lateral elbow tendinopathy or tendinosis” is used instead of “lateral epicondylitis”.

Examination of tennis elbow tissue reveals noninflammatory tissue, and therefore, the term “angio-fibroblastic tendinosis” is used.

Longitudinal sonogram of the lateral elbow displays thickening and heterogeneity of the common extensor tendon that is consistent with tendinosis, as the ultrasound reveals calcifications, intrasubstance tears, and marked irregularity of the lateral epicondyle. Although the term “epicondylitis” is frequently used to describe this disorder, most histopathologic findings of studies have displayed no evidence of an acute, or a chronic inflammatory process. Histologic studies have demonstrated that this condition is the result of tendon degeneration, which causes normal tissue to be replaced by a disorganized arrangement of collagen. Therefore, the disorder is more appropriately referred to as “tendinosis” or “tendinopathy” rather than “tendinitis.”

Colour Doppler ultrasound reveals structural tendon changes, with vascularity and hypo-echoic areas that correspond to the areas of pain in the extensor origin.