Karim M. Khan

Histopathology of common tendinopathies. Update and implications for clinical management.

Tendon disorders are a major problem for participants in competitive and recreational sports. To try to determine whether the histopathology underlying these conditions explains why they often prove recalcitrant to treatment, we reviewed studies of the histopathology of sports-related, symptomatic Achilles, patellar, extensor carpi radialis brevis and rotator cuff tendons.The literature indicates that healthy tendons appear glistening white to the naked eye and microscopy reveals a hierarchical arrangement of tightly packed, parallel bundles of collagen fibres that have a characteristic reflectivity under polarised light. Stainable ground substance (extracellular matrix) is absent and vasculature is inconspicuous. Tenocytes are generally inconspicuous and fibroblasts and myofibroblasts absent.In stark contrast, symptomatic tendons in athletes appear grey and amorphous to the naked eye and microscopy reveals discontinuous and disorganised collagen fibres that lack reflectivity under polarised light. This is associated with an increase in the amount of mucoid ground substance,which is confirmedwithAlcian blue stain. At sites of maximal mucoid change, tenocytes, when present, are plump and chondroid in appearance (exaggerated fibrocartilaginous metaplasia). These changes are accompanied by the increasingly conspicuous presence of cells within the tendon tissue, most of which have a fibroblastic or myofibroblastic appearance (smooth muscle actin is demonstrated using an avidin biotin technique). Maximal cellular proliferation is accompanied by prominent capillary proliferation and a tendency for discontinuity of collagen fibres in this area.Often, there is an abrupt discontinuity of both vascular and myofibroblastic proliferation immediately adjacent to the area of greatest abnormality. The most significant feature is the absence of inflammatory cells.These observations confirmthat the histopathological findings in athletes with overuse tendinopathies are consistent with those in tendinosis — a degenerative condition of unknown aetiology. This may have implications for the prognosis and timing of a return to sport after experiencing tendon symptoms.As the common overuse tendon conditions are rarely, if ever, caused by ‘tendinitis’, we suggest the term ‘tendinopathy’ be used to describe the common overuse tendon conditions.We conclude that effective treatment of athletes with tendinopathiesmust target the most common underlying histopathology, tendinosis, a noninflammatory condition.

The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy

Background—There is no disease specific, reliable, and valid clinical measure of Achilles tendinopathy. Objective—To develop and test a questionnaire based instrument that would serve as an index of severity of Achilles tendinopathy. Methods—Item generation, item reduction, item scaling, and pretesting were used to develop a questionnaire to assess the severity of Achilles tendinopathy. The final version consisted of eight questions that measured the domains of pain, function in daily living, and sporting activity. Results range from 0 to 100, where 100 represents the perfect score. Its validity and reliability were then tested in a population of non-surgical patients with Achilles tendinopathy (n = 45), presurgical patients with Achilles tendinopathy (n = 14), and two normal control populations (total n = 87). Results—The VISA-A questionnaire had good test-retest (r = 0.93), intrarater (three tests, r = 0.90), and interrater (r = 0.90) reliability as well as good stability when compared one week apart (r = 0.81). The mean (95% confidence interval) VISA-A score in the non-surgical patients was 64 (59–69), in presurgical patients 44 (28–60), and in control subjects it exceeded 96 (94–99). Thus the VISA-A score was higher in non-surgical than presurgical patients (p = 0.02) and higher in control subjects than in both patient populations (p<0.001). Conclusions—The VISA-A questionnaire is reliable and displayed construct validity when means were compared in patients with a range of severity of Achilles tendinopathy and control subjects. The continuous numerical result of the VISA-A questionnaire has the potential to provide utility in both the clinical setting and research. The test is not designed to be diagnostic. Further studies are needed to determine whether the VISA-A score predicts prognosis.

Shifting the focus in fracture prevention from osteoporosis to falls.

Preventing fractures in older people is important. But Teppo Järvinen and colleagues believe that we should be putting our efforts into stopping falls not treating low bone mineral density

Time to abandon the "tendinitis" myth.

Tendinitis such as that of the Achilles, lateral elbow, and rotator cuff tendons is a common presentation to family practitioners and various medical specialists.1 Most currently practising general practitioners were taught, and many still believe, that patients who present with overuse tendinitis have a largely inflammatory condition and will benefit from anti-inflammatory medication. Unfortunately this dogma is deeply entrenched. Ten of 11 readily available sports medicine texts specifically recommend non-steroidal anti-inflammatory drugs for treating painful conditions like Achilles and patellar tendinitis despite the lack of a biological rationale or clinical evidence for this approach. 2 3 Instead of adhering to the myths above, physicians should acknowledge that painful overuse tendon conditions have a non-inflammatory pathology. Light …

A Randomized School-Based Jumping Intervention Confers Site and Maturity-Specific Benefits on Bone Structural Properties in Girls: A Hip Structural Analysis Study†

We compared 7‐month changes in bone structural properties in pre‐ and early‐pubertal girls randomized to exercise intervention (10‐minute, 3 times per week, jumping program) or control groups. Girls were classified as prepubertal (PRE; Tanner breast stage 1; n = 43 for intervention [I] and n = 25 for control [C]) or early‐pubertal (EARLY; Tanner stages 2 and 3; n = 43 for I and n = 63 for C). Mean ± SD age was 10.0 ± 0.6 and 10.5 ± 0.6 for the PRE and EARLY groups, respectively. Proximal femur scans were analyzed using a hip structural analysis (HSA) program to assess bone mineral density (BMD), subperiosteal width, and cross‐sectional area and to estimate cortical thickness, endosteal diameter, and section modulus at the femoral neck (FN), intertrochanter (IT), and femoral shaft (FS) regions. There were no differences between intervention and control groups for baseline height, weight, calcium intake, or physical activity or for change over 7 months (p > 0.05). We used analysis of covariance (ANCOVA) to examine group differences in changes of bone structure, adjusting for baseline weight, height change, Tanner breast stage, and physical activity. There were no differences in change for bone structure in the PRE girls. The more mature girls (EARLY) in the intervention group showed significantly greater gains in FN (+2.6%, p = 0.03) and IT (+1.7%, p = 0.02) BMD. Underpinning these changes were increased bone cross‐sectional area and reduced endosteal expansion. Changes in subperiosteal dimensions did not differ. Structural changes improved section modulus (bending strength) at the FN (+4.0%, p = 0.04), but not at the IT region. There were no differences at the primarily cortical FS. These data provide insight into geometric changes that underpin exercise‐associated gain in bone strength in early‐pubertal girls.

Exercise in the prevention of falls in older people: a systematic literature review examining the rationale and the evidence.

Falls are a major source of death and injury in elderly people. For example, they cause 90% of hip fractures and the current cost of hip fractures in the US is estimated to be about 10 billion dollars. Age-related changes in the physiological systems (somatosensory, vestibular and visual) which contribute to the maintenance of balance are well documented in older adults. These changes coupled with age-related changes in muscle and bone are likely to contribute to an increased risk of falls in this population. The integrated rehabilitation-based model of fall risk factors reveals multiple sites for interventions that may reverse fall risk factors. Regular exercise may be one way of preventing falls and fall-related fractures. The evidence for this contention comes from a variety of sources. On the basis of 9 randomised controlled studies conducted since 1996, exercise appears to be a useful tool in fall prevention in older adults, significantly reducing the incidence of falls compared with control groups. However, current limitations such as inconsistencies in the measurement of key dependent and independent variables do not, at present, permit a meta-analysis of intervention trials. Further investigation, using trials designed with the current limitations in mind, is necessary to establish the optimum exercise programme to maximise fall prevention in older adults.

Is there a critical period for bone response to weight-bearing exercise in children and adolescents? a systematic review

This systematic review examines and compares the bone mineral changes in children and adolescents, as measured by dual energy x ray absorptiometry, reported in exercise intervention studies. The effects of hormonal factors and growth on bone mineral change during puberty are examined, and the possibility of a critical period during which bone is especially adaptable to exercise is discussed.

Augmented trochanteric bone mineral density after modified physical education classes: A randomized school-based exercise intervention study in prepubescent and early pubescent children ☆ ☆☆

BACKGROUND Of the few exercise intervention studies focusing on pediatric populations, none have confined the intervention to the scheduled physical education curriculum. OBJECTIVE To examine the effect of an 8-month school-based jumping program on the change in areal bone mineral density (aBMD), in grams per square centimeter, of healthy third- and fourth-grade children. STUDY DESIGN Ten elementary schools were randomized to exercise (n = 63) and control groups (n = 81). Exercise groups did 10 tuck jumps 3 times weekly and incorporated jumping, hopping, and skipping into twice weekly physical education classes. Control groups did regular physical education classes. At baseline and after 8 months of intervention, we measured aBMD and lean and fat mass by dual-energy x-ray absorptiometry (Hologic QDR-4500). Calcium intake, physical activity, and maturity were estimated by questionnaire. RESULTS The exercise group showed significantly greater change in femoral trochanteric aBMD (4.4% vs 3.2%; P <.05). There were no group differences at other sites. Results were similar after controlling for covariates (baseline aBMD change in height, change in lean, calcium, physical activity, sex, and ethnicity) in hierarchical regression. CONCLUSIONS An easily implemented school-based jumping intervention augments aBMD at the trochanteric region in the prepubertal and early pubertal skeleton.

Resistance and agility training reduce fall risk in women aged 75 to 85 with low bone mass: a 6-month randomized, controlled trial.

Objectives: To compare the effectiveness of group resistance and agility‐training programs in reducing fall risk in community‐dwelling older women with low bone mass.

The VISA score: An index of severity of symptoms in patients with jumper's knee (patellar tendinosis)

Symptoms of jumpers knee (patellar tendinosis) are not easily quantified and this may explain why there are no evidence-based guidelines for managing the condition. A simple, practical questionnaire-based index of severity would facilitate jumpers knee research and subsequently, clinical management. Thus we devised and tested the Victorian Institute of Sport Assessment (VISA) questionnaire. The brief questionnaire assesses (i) symptoms, (ii) simple tests of function and (iii) ability to play sport. Six of the eight questions are scored on a visual analogue scale from 0-10 with 10 representing optimal health. The maximal VISA score for an asymptomatic, fully performing individual is 100 points and the theoretical minimum is 0 points. We found the VISA scale to have excellent short-term test-retest, and inter-tester reliability (both, r>0.95) as well as good short-term (one week) stability (r=0.87). Mean (SD) of the VISA scores ranged from 95 (8) points in asymptomatic control subjects to 55 (12) points in patients who presented to a sports medicine clinic with jumpers knee and 22 (17) points in patients before surgery for chronic jumpers knee. Six- and twelve-months after surgery VISA scores returned to 49 (15) and 75 (17) points respectively, mirroring clinical recovery. We conclude that the VISA score is a reliable index of the severity of jumpers knee that has potential to aid clinicians and researchers.