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Lui PPY, Liang Z, Tan RM, Yung PSH. Establishment of a Mouse Degenerative Model of Patellar Tendinopathy with Upregulation of Inflammation. Int J Mol Sci 2024; 25:3847. [PMID: 38612656 PMCID: PMC11011606 DOI: 10.3390/ijms25073847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/21/2024] [Accepted: 03/26/2024] [Indexed: 04/14/2024] Open
Abstract
There is no mouse model of patellar tendinopathy. This study aimed to establish a mouse inflammatory and degenerative patellar tendon injury model, which will facilitate research on patellar tendinopathy using advanced molecular tools including transgenic models. Collagenase at different doses (low dose (LD), medium dose (MD), high dose (HD)) or saline was injected over the mouse patellar tendon. At weeks 1, 2, 4, and 8 post-injection, the tendons were harvested for histology and further examined by micro-computed tomography (microCT) imaging at week 8. The optimal dose group and the saline group were further evaluated by immunohistochemical staining, gait pattern, and biomechanical properties. The histopathological score increased dose-dependently post-collagenase injection. Ectopic mineralization was observed and increased with collagenase dose. The LD group was selected for further analysis. The expression of IL-10, TNF-α, and MMP-1 significantly increased post-injection. The changes of limb idleness index (ΔLII) compared to preinjury state were significantly higher, while the ultimate load, stiffness, ultimate stress, and maximum Young's modulus were significantly lower in the LD group compared to the saline group. A mouse inflammatory degenerative model of patellar tendon injury resembling tendinopathy was established as indicated by the dose-dependent increase in tendon histopathology, ectopic calcification, decrease in biomechanical properties, and pain-associated gait changes.
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Affiliation(s)
- Pauline Po Yee Lui
- Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong, China
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2
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Patel SH, Campbell NWC, Emenim CE, Farino DO, Damen FW, Rispoli JV, Goergen CJ, Haus JM, Sabbaghi A, Carroll CC. Patellar tendon biomechanical and morphologic properties and their relationship to serum clinical variables in persons with prediabetes and type 2 diabetes. J Orthop Res 2024. [PMID: 38400550 DOI: 10.1002/jor.25816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 01/08/2024] [Accepted: 01/27/2024] [Indexed: 02/25/2024]
Abstract
Tendon biomechanical properties and fibril organization are altered in patients with diabetes compared to healthy individuals, yet few biomarkers have been associated with in vivo tendon properties. We investigated the relationships between in vivo imaging-based tendon properties, serum variables, and patient characteristics across healthy controls (n = 14, age: 45 ± 5 years, body mass index [BMI]: 24 ± 1, hemoglobin A1c [HbA1c]: 5.3 ± 0.1%), prediabetes (n = 14, age: 54 ± 5 years, BMI: 29 ± 2; HbA1c: 5.7 ± 0.1), and type 2 diabetes (n = 13, age: 55 ± 3 years, BMI: 33 ± 2, HbA1c: 6.7 ± 0.3). We used ultrasound speckle-tracking and measurements from magnetic resonance imaging (MRI) to estimate the patellar tendon in vivo tangent modulus. Analysis of plasma c-peptide, interleukin-1β (IL-1β), IL-6, IL-8, tumor necrosis factor-α (TNF-α), adiponectin, leptin, insulin-like growth factor 1 (IGF-1), and C-reactive protein (CRP) was completed. We built regression models incorporating statistically significant covariates and indicators for the clinically defined groups. We found that tendon cross-sectional area normalized to body weight (BWN CSA) and modulus were lower in patients with type 2 diabetes than in healthy controls (p < 0.05). Our regression analysis revealed that a model that included BMI, leptin, high-density lipoprotein (HDL), low-density lipoprotein (LDL), age, and group explained ~70% of the variability in BWN CSA (R2 = 0.70, p < 0.001). For modulus, including the main effects LDL, groups, HbA1c, age, BMI, cholesterol, IGF-1, c-peptide, leptin, and IL-6, accounted for ~54% of the variability in modulus (R2 = 0.54, p < 0.05). While BWN CSA and modulus were lower in those with diabetes, group was a poor predicter of tendon properties when considering the selected covariates. These data highlight the multifactorial nature of tendon changes with diabetes and suggest that blood variables could be reliable predictors of tendon properties.
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Affiliation(s)
- Shivam H Patel
- Department of Health and Kinesiology, Purdue University, West Lafayette, Indiana, USA
| | - Nathan W C Campbell
- Department of Health and Kinesiology, Purdue University, West Lafayette, Indiana, USA
| | - Chinonso E Emenim
- Department of Health and Kinesiology, Purdue University, West Lafayette, Indiana, USA
| | - Dominick O Farino
- Department of Health and Kinesiology, Purdue University, West Lafayette, Indiana, USA
| | - Frederick W Damen
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana, USA
| | - Joseph V Rispoli
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana, USA
| | - Craig J Goergen
- Department of Health and Kinesiology, Purdue University, West Lafayette, Indiana, USA
- Weldon School of Biomedical Engineering, Purdue University, West Lafayette, Indiana, USA
| | - Jacob M Haus
- School of Kinesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Arman Sabbaghi
- Head of Clinical Methods, Unlearn.AI, San Francisco, California, USA
| | - Chad C Carroll
- Department of Health and Kinesiology, Purdue University, West Lafayette, Indiana, USA
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3
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Theodorou A, Komnos G, Hantes M. Patellar tendinopathy: an overview of prevalence, risk factors, screening, diagnosis, treatment and prevention. Arch Orthop Trauma Surg 2023; 143:6695-6705. [PMID: 37542006 PMCID: PMC10541843 DOI: 10.1007/s00402-023-04998-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 07/18/2023] [Indexed: 08/06/2023]
Abstract
Patellar tendinopathy (PT), or jumper's knee, is an overuse injury that occurs in professional, as well as recreational, athletes. This condition is a noncontact injury, typically characterized by gradually increasing pain in the patellar tendon. It is prevalent in participants of several sports, but it occurs mostly in jumping sports. The diagnosis of PT is primarily clinical; however, imaging techniques can be useful as well. Risk factors differ between sexes, playing conditions, the kind of sport, playing level and personal characteristics. Screening is an essential tool to assess PT. This condition affects athletic performance and often persists for years. The use of preventative methods is imperative because of the persistence of this condition, especially in elite athletes who sometimes end their career after long and failed treatments. There are a wide variety of treatment and rehabilitation options available, the majority of which are non-operative, such as eccentric exercises, cryotherapy, platelet-rich plasma (PRP) injections, and anti-inflammatory strategies. If conservative treatment fails, surgery is the next most preferable step. Even though there are many surgical treatment methods, there is no clear evidence on what is the most effective approach to address PT. Taking this into consideration, as well as the extent of this clinical entity, novel therapeutic techniques, as well as screening and prevention methods, are expected to emerge in the near future.
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Affiliation(s)
- Andreas Theodorou
- Faculty of Medicine, University of Thessaly, 41500, Larissa, Greece.
| | - Georgios Komnos
- Faculty of Medicine, University of Thessaly, 41500, Larissa, Greece
| | - Michael Hantes
- Faculty of Medicine, University of Thessaly, 41500, Larissa, Greece
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4
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Acaröz Candan S, Sözen H, Arı E. Electromyographic activity of quadriceps muscles during eccentric squat exercises: implications for exercise selection in patellar tendinopathy. Res Sports Med 2023; 31:517-527. [PMID: 34856831 DOI: 10.1080/15438627.2021.2010200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 11/09/2021] [Indexed: 10/19/2022]
Abstract
This study investigated the quadriceps muscle activity during eccentric squat exercises (ESE) with different decline angles and arcs of motion regarding the proper exercise selection for patellar tendinopathy management. Electromyographic activity of the rectus femoris, vastus lateralis, and vastus medialis obliquus (VMO) muscles was measured during ESE on 0°, 5°, 10°, 15°, and 20° decline in 20 recreationally active participants. The eccentric phase was divided into 0-30°, 30-60°, 60-90°, 0-60°, 30-90°, and 0-90° of knee flexion simultaneously via motion-analysis system. The analyses showed that there was a significant decline angle × arc interaction effect on electromyographic activity of all muscles during knee flexion movement. The main effect was found for the arc of motion of knee flexion, and the main effect for the decline angle also was present for each muscle, except for VMO. This study demonstrated that most selective quadriceps eccentric activation occurred during ESE performed on 20° decline throughout 60-90° of knee flexion.
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Affiliation(s)
- Sevim Acaröz Candan
- Faculty of Health Sciences, Department of Physical Therapy and Rehabilitation, Ordu University, Ordu, Turkey
| | - Hasan Sözen
- School of Physical Education and Sport, Ordu University, Ordu, Turkey
| | - Erdal Arı
- School of Physical Education and Sport, Ordu University, Ordu, Turkey
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5
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Bisciotti GN, Bisciotti A, Auci A, Bisciotti A, Eirale C, Corsini A, Volpi P. Achilles Tendon Repair after Tenorraphy Imaging and the Doughnut Metaphor. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:5985. [PMID: 37297589 PMCID: PMC10253009 DOI: 10.3390/ijerph20115985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/15/2023] [Accepted: 05/26/2023] [Indexed: 06/12/2023]
Abstract
After Achilles tendon tenorraphy, tendon tissue undergoes a long period of biological healing. During this period, tissue turnover shows heterogeneity between its peripheral and central regions. This case report concerns the description of the tendon healing process of an athlete who underwent an Achilles tendon tenorraphy. As the reparative processes progressed, magnetic resonance imaging (MRI) showed centralization of the hyperintensity area and the tendon assumed a doughnut-like appearance. At the same time, ultrasound (US) assessment showed a progressive reorganization of the tendon fibrillar structure. Therefore, for the athlete, MRI and US assessment together represent a useful tool for the decision-making process after Achilles tendon tenorraphy.
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Affiliation(s)
- Gian Nicola Bisciotti
- Paris Saint Germain Football Club (France), Kinemove Rehabilitation Centers, 54027 Pontremoli, Italy;
| | | | - Alessio Auci
- Azienda USL Toscana Nord-Ovest, 54100 Massa, Italy;
| | | | - Cristiano Eirale
- Paris Saint Germain Football Club, 78100 Saint Germain en Laye, France;
| | | | - Piero Volpi
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy (P.V.)
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Waugh CM, Mousavizadeh R, Lee J, Screen HRC, Scott A. The impact of mild hypercholesterolemia on injury repair in the rat patellar tendon. J Orthop Res 2023. [PMID: 36866829 DOI: 10.1002/jor.25546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 02/16/2023] [Accepted: 03/01/2023] [Indexed: 03/04/2023]
Abstract
Hypercholesterolemia is associated with tendon pathology and injury prevalence. Lipids can accumulate in the tendon's extracellular spaces, which may disrupt its hierarchical structure and the tenocytes physicochemical environment. We hypothesized that the tendon's ability to repair after injury would be attenuated with elevated cholesterol levels, leading to inferior mechanical properties. Fifty wild-type (sSD) and 50 apolipoprotein E knock-out rats (ApoE-/ - ) were given a unilateral patellar tendon (PT) injury at 12 weeks old; the uninjured limb served as a control. Animals were euthanized at 3-, 14,- or 42-days postinjury and PT healing was investigated. ApoE-/ - serum cholesterol was double that of SD rats (mean: 2.12 vs. 0.99 mg/mL, p < 0.001) and cholesterol level was related to the expression of several genes after injury; notably rats with higher cholesterol demonstrated a blunted inflammatory response. There was little physical evidence of tendon lipid content or differences in injury repair between groups, therefore we were not surprised that tendon mechanical or material properties did not differ between strains. The young age and the mild phenotype of our ApoE-/ - rats might explain these findings. Hydroxyproline content was positively related to total blood cholesterol, but this result did not translate to observable biomechanical differences, perhaps due to the narrow range of cholesterol levels observed. Tendon inflammatory and healing activity is modulated at the mRNA level even with a mild hypercholesterolemia. These important initial impacts need to be investigated as they may contribute to the known consequences of cholesterol on tendons in humans.
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Affiliation(s)
- Charlie M Waugh
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, Canada.,School of Engineering and Materials Science, Queen Mary, University of London, London, UK
| | - Rouhollah Mousavizadeh
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Jenny Lee
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Hazel R C Screen
- School of Engineering and Materials Science, Queen Mary, University of London, London, UK
| | - Alexander Scott
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, Canada
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Jarraya M, Roemer FW, Hayashi D, Crema MD, Guermazi A. Overuse-Related Injuries of the Knee. Radiol Clin North Am 2023; 61:249-259. [PMID: 36739144 DOI: 10.1016/j.rcl.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Overuse-related injuries of the knee joint and periarticular soft tissues include a heterogenous group of sports and nonsports-related injuries. These conditions include friction and impingement syndromes, bone stress injuries, bursitis, and tendon-related pathology such as tendinopathy and snapping. Traction apophysitis are also discussed as commonly seen in the pediatric population. Although multiple imaging modalities can be used, this review focuses on MR imaging, which is the most common and, often, the only modality used.
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Affiliation(s)
- Mohamed Jarraya
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 32 Fruit Street YAW 6044, Boston, MA 02114, USA.
| | - Frank W Roemer
- Department of Radiology, Boston University School of Medicine, 820 Harrison Avenue, FGH Building 3rd Floor, Boston, MA 02118, USA; Department of Radiology, Friedrich-Alexander University Erlangen-Nürnberg (FAU) and University Hospital Erlangen, Maximiliansplatz 391054 Erlangen, Germany
| | - Daichi Hayashi
- Department of Radiology, Stony Brook University, 101 Nichols Road, HSc Level 4, Room 120, Dept of Radiology, Stony Brook, NY 11790, USA
| | - Michel D Crema
- Institut d'Imagerie du Sport, Institut National du Sport, de l'Expertise et de la Performance (INSEP), 11 Avenue du Tremblay, 75012 Paris, France
| | - Ali Guermazi
- Department of Radiology, Boston University School of Medicine, 820 Harrison Avenue, FGH Building 3rd Floor, Boston, MA 02118, USA; Department of Radiology, VA Boston Healthcare System, 1400 VFW Parkway, 1B105 West Roxbury, MA 02132, USA
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8
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Molina-Payá FJ, Ríos-Díaz J, Carrasco-Martínez F, Martínez-Payá JJ. Infrared Thermography, Intratendon Vascular Resistance, and Echotexture in Athletes with Patellar Tendinopathy: A Cross-Sectional Study. ULTRASONIC IMAGING 2023; 45:47-61. [PMID: 36779568 DOI: 10.1177/01617346231153581] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Ultrasonographic signs of tendinopathies are an increase in thickness, loss of alignment in collagen fibers and the presence of neovascularization. Nevertheless, analysis of intratendinous vascular resistance (IVR) can be more useful for understanding the physiological state of the tissue. To show thermal, echotextural, and Doppler signal differences in athletes with patellar tendinopathy and controls. Twenty-six athletes with patellar tendinopathy (PT) participants (30.1 years; SD = 9.0 years) and 27 asymptomatic athletes (23.3 years; SD = 5.38 years) were evaluated with thermographic and Doppler ultrasonography (DS). Area of Doppler signals (DS), echotextural parameters (echointensity and echovariation) and IVR were determined by image analysis. The statistical analysis was performed by Bayesian methods and the results were showed by Bayes Factor (BF10: probability of alternative hypothesis over null hypothesis), and Credibility intervals (CrI) of the effect. The absolute differences of temperature (TD) were clearly greater (BF10 = 19) in the tendinopathy group (patients) than in controls. Regarding temperature differences between the affected and healthy limb, strong evidence was found (BF10 = 14) for a higher temperature (effect = 0.53°C; 95% CrI = 0.15°C-0.95°C) and very strong for reduced IVR compared (BF10 = 71) (effect = -0.67; 95% CrI = -1.10 to 0.25). The differences in area of DS (BF10 = 266) and EV (BF10 = 266) were higher in tendinopathy group. TD showed a moderate positive correlation with VISA-P scores (tau-B = .29; 95% CrI = .04-.51) and strong correlation with IVR (r = -.553; 95%CrI = -.75 to .18). Athletes with patellar tendinopathy showed a more pronounced thermal difference, a larger area of Doppler signal, a lower IVR and a moderately higher echovariaton than controls. The correlation between temperature changes and IVR might be related with the coexistence of degenerative and inflammatory process in PT.
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Affiliation(s)
| | - José Ríos-Díaz
- Universidad Pontificia Comillas Escuela Universitaria de Enfermería y Fisioterapia San Juan de Dios, Madrid, Spain
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Sharif F, Ahmad A, Gilani SA, Bacha R, Hanif A, Arif MA. Efficacy of ultrasound guided dry needling as an adjunct to conventional physical therapy for patients with jumper’s knee: A randomized controlled trial. Front Surg 2022; 9:1023902. [PMID: 36406368 PMCID: PMC9672502 DOI: 10.3389/fsurg.2022.1023902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022] Open
Abstract
Background Jumper’s knee is a degenerative condition among athletes, and it has been treated with conventional physical therapy (CPT). Ultrasound guided dry needling (USG-DN) is a relatively new technique to explore clinical outcomes in patients with tendinopathy. Methods This parallel group, single-blinded randomized controlled trial was carried out involving 94 athletes with clinically diagnosed jumper’s knee, divided into an intervention group (USG-DN + CPT, n = 47) and a control group (CPT, n = 47). Participants received a 4-week programme; the intervention group received ultrasound guided patellar tendon dry needling (DN) in conjunction with CPT. The control group received only CPT. The visual analog scale (VAS), Victorian institute of sports assessment-Patellar tendinopathy (VISA-P) questionnaire, Lysholm scale, Knee injury and osteoarthritis outcome score (KOOS) and ultrasonographic features of patellar tendinopathy were evaluated at baseline,1 week, 2 weeks, and 4 weeks. The data were analyzed through SPSS-26. Results The study found statistically significant differences (P < 0.05) regarding VAS, Lysholm, VISA-P, and KOOS scales at baseline, 1st, 2nd, and 4th week post-intervention. Within-group differences also showed statistically significant results after the intervention. There were significant results observed in ultrasonographic outcomes between both groups at 1 month post-intervention (all P < 0.05). Conclusion The results of the current study suggest, ultrasound guided DN of patellar tendon in combination with CPT reduced pain, improved function, and showed a tendency to decrease tendon thickness in patients with patellar tendinopathy. Clinical Trial Registration Number (IRCT20210409050913N1). Dated: 17.04.2021. https://www.irct.ir/user/trial/55607/view.
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Affiliation(s)
- Faiza Sharif
- University Institute of Physical Therapy, The University of Lahore, Lahore, Pakistan
- Correspondence: Faiza Sharif Ashfaq Ahmad
| | - Ashfaq Ahmad
- Faculty of Allied Health Sciences, The University of Lahore, Lahore, Pakistan
- Correspondence: Faiza Sharif Ashfaq Ahmad
| | - Syed Amir Gilani
- Faculty of Allied Health Sciences, The University of Lahore, Lahore, Pakistan
| | - Raham Bacha
- University Institute of Radiological Sciences and Medical Imaging Technology, University of Lahore, Lahore, Pakistan
| | - Asif Hanif
- University Institute of Public Health, Faculty of Allied Health Sciences, University of Lahore, Lahore, Pakistan
| | - Muhammad Asim Arif
- University Institute of Physical Therapy, The University of Lahore, Lahore, Pakistan
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10
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Sprague AL, Couppé C, Pohlig RT, Cortes DC, Silbernagel KG. Relationships between tendon structure and clinical impairments in patients with patellar tendinopathy. J Orthop Res 2022; 40:2320-2329. [PMID: 34996130 PMCID: PMC9259765 DOI: 10.1002/jor.25262] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 12/17/2021] [Accepted: 01/05/2022] [Indexed: 02/04/2023]
Abstract
The clinical relevance of altered tendon structure in patellar tendinopathy is contested since structural change persists after symptom resolution. The purpose of this study was to explore the relationships between tendon structure and clinical impairments in patellar tendinopathy. In this retrospective, secondary analysis of individuals with patellar tendinopathy (n = 41), tendon structure (thickness, cross-sectional area [CSA], shear modulus, and viscosity), symptom severity, lower extremity function (counter-movement jump [CMJ] height), and quadriceps muscle performance (knee extension force and central activation ratio [CAR]) were recorded for the symptomatic limb. Relationships among structure, symptom severity, lower extremity function, and quadriceps muscle performance were examined using sequential regression models. Adjusting for age, sex, body mass index, and pain levels, there were significant positive relationships for thickness (p < 0.001, β = 0.718) and viscosity (p = 0.006, β = 0.496) with CMJ height. There were significant negative relationships between CSA with both CMJ height (p = 0.001, β = -0.538) and CAR (p = 0.04, β = -0.517). This is the first study to demonstrate relationships between tendon structure and lower extremity function or quadriceps muscle performance in patients with patellar tendinopathy. Clinical significance: Since structural changes persist after symptom resolution, addressing these changes may assist in restoring lower extremity function and quadriceps muscle performance.
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Affiliation(s)
- Andrew L. Sprague
- Department of Physical Therapy, University of Delaware,
Newark, DE, USA
- Department of Biomechanics and Movement Science, University
of Delaware, Newark, DE, USA
- Department of Physical Therapy, University of Pittsburgh,
Pittsburgh, PA, USA
| | - Christian Couppé
- Department of Orthopaedic Surgery M, Faculty of Health and
Medical Sciences, Institute of Sports Medicine Copenhagen, Bispebjerg Hospital and
Center for Healthy Aging, University of Copenhagen, Copenhagen, DK
- Department of Physical and Occupational Therapy, Bispebjerg
Hospital, Copenhagen, DK
- IOC Research Center Copenhagen Center for Injury Prevention
and Protection of Athlete Health, Bispebjerg Hospital, Copenhagen, DK
| | - Ryan T. Pohlig
- Biostatistic Core Facility, College of Health Sciences,
University of Delaware, Newark, DE, USA
| | - Daniel C. Cortes
- Department of Mechanical Engineering, Penn State
University, State College, PA, USA
| | - Karin Grävare Silbernagel
- Department of Physical Therapy, University of Delaware,
Newark, DE, USA
- Department of Biomechanics and Movement Science, University
of Delaware, Newark, DE, USA
- Department of Biomedical Engineering, University of
Delaware, Newark, DE, USA
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11
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Cushman DM, Petrin Z, Cummings K, Eby SF, English J, Teramoto M. Sonographic Screening of Distance Runners for the Development of Future Achilles and Patellar Tendon Pain. Clin J Sport Med 2022; 32:493-500. [PMID: 34759186 PMCID: PMC9085961 DOI: 10.1097/jsm.0000000000000984] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 09/30/2021] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The 2 primary aims of this study were to identify ultrasonographic tendon abnormalities in asymptomatic runners and to examine the likelihood of developing pain in runners with ultrasound abnormalities compared with those without abnormalities. DESIGN Longitudinal, prospective cohort study. SETTING 2019 Salt Lake City Marathon. PARTICIPANTS Recreational half-marathon and full-marathon runners. ASSESSMENT OF RISK FACTORS The Achilles and patellar tendons of asymptomatic runners were examined with ultrasound imaging before a running event. Runners were monitored for self-reported outcomes of pain in the examined tendons at 1, 3, 6, and 12 months after the event. MAIN OUTCOME MEASURES Development of pain based on the presence of asymptomatic tendon abnormalities. RESULTS One hundred thirty-eight runners (36.2 ± 12.0 years, 49.3% men, and 31.2% full-marathon runners) were included. Ultrasound abnormalities of the Achilles and patellar tendons were identified in 24.6% and 39.1% of the runners before the race, respectively. Ultrasound abnormalities were significantly associated with approximately a 3-fold increase [hazard ratio (HR) = 2.55, P = 0.004] in the hazard of developing pain in the Achilles tendon and patellar tendon (HR = 1.67, P = 0.042) over the year after the race. Positive and negative predictive values of developing pain over the year were 34.1% and 87.2%, respectively, for abnormal findings in the Achilles tendon, and 22.9% and 85.0%, respectively, for the patellar tendon. CONCLUSIONS The presence of ultrasonographic abnormalities is associated with increased development of pain in the Achilles and patellar tendons within 1 year of a marathon or half marathon.
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Affiliation(s)
- Daniel M Cushman
- Division of Physical Medicine & Rehabilitation, University of Utah, Salt Lake City, Utah
| | - Ziva Petrin
- Department of Physical Medicine & Rehabilitation, Rutgers New Jersey Medical School, Bellevue, Washington
| | - Keith Cummings
- Proliance Orthopaedics & Sports Medicine, Bellevue, Washington; and
| | - Sarah F Eby
- Division of Physical Medicine & Rehabilitation, University of Utah, Salt Lake City, Utah
| | - Joy English
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah
| | - Masaru Teramoto
- Division of Physical Medicine & Rehabilitation, University of Utah, Salt Lake City, Utah
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12
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Götschi T, Hanimann J, Schulz N, Huser S, Held V, Frey WO, Snedeker JG, Spörri J. Patellar Tendon Shear Wave Velocity Is Higher and has Different Regional Patterns in Elite Competitive Alpine Skiers than in Healthy Controls. Front Bioeng Biotechnol 2022; 10:858610. [PMID: 35757800 PMCID: PMC9218688 DOI: 10.3389/fbioe.2022.858610] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/18/2022] [Indexed: 11/13/2022] Open
Abstract
Competitive alpine skiers are exposed to enormous forces acting on their bodies–particularly on the knee joint and hence the patellar tendon - during both the off-season preparation and in-season competition phases. However, factors influencing patellar tendon adaptation and regional pattern differences between alpine skiers and healthy controls are not yet fully understood, but are essential for deriving effective screening approaches and preventative countermeasures. Thirty elite competitive alpine skiers, all members of the Swiss Alpine Ski Team, and 38 healthy age-matched controls were recruited. A set of two-dimensional shear wave elastography measurements of the PT was acquired and projected into three-dimensional space yielding a volumetric representation of the shear wave velocity profile of the patellar tendon. Multivariate linear models served to quantify differences between the two cohorts and effects of other confounding variables with respect to regional shear wave velocity. A significant (p < 0.001) intergroup difference was found between skiers (mean ± SD = 10.4 ± 1.32 m/s) and controls (mean ± SD = 8.9 ± 1.59 m/s). A significant sex difference was found within skiers (p = 0.024), but no such difference was found in the control group (p = 0.842). Regional SWV pattern alterations between skiers and controls were found for the distal region when compared to the mid-portion (p = 0.023). Competitive alpine skiers exhibit higher SWV in all PT regions than healthy controls, potentially caused by long-term adaptations to heavy tendon loading. The presence of sex-specific differences in PT SWV in skiers but not in controls indicates that sex effects have load-dependent dimensions. Alterations in regional SWV patterns between skiers and controls suggest that patellar tendon adaptation is region specific. In addition to the implementation of 3D SWE, deeper insights into long-term tendon adaptation and normative values for the purpose of preventative screening are provided.
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Affiliation(s)
- Tobias Götschi
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.,Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
| | - Jonas Hanimann
- Sports Medical Research Group, Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.,University Centre for Prevention and Sports Medicine, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Nicole Schulz
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.,Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
| | - Simon Huser
- Sports Medical Research Group, Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.,University Centre for Prevention and Sports Medicine, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Victoria Held
- Sports Medical Research Group, Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.,University Centre for Prevention and Sports Medicine, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Walter O Frey
- Sports Medical Research Group, Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.,University Centre for Prevention and Sports Medicine, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Jess G Snedeker
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.,Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
| | - Jörg Spörri
- Sports Medical Research Group, Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.,University Centre for Prevention and Sports Medicine, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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13
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Management of Patellar Tendinopathy Through Monitoring, Load Control, and Therapeutic Exercise: A Systematic Review. J Sport Rehabil 2021; 31:337-350. [PMID: 34942594 DOI: 10.1123/jsr.2021-0117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 09/28/2021] [Accepted: 10/06/2021] [Indexed: 11/18/2022]
Abstract
CONTEXT Patellar tendinopathy presents with persistent tendon pain located in the lower pole of the patella and loss of function related to mechanical load. Although its pathogenesis is not completely clear, conservative treatment including exercise is the main intervention of patellar tendinopathy treatment. OBJECTIVE To describe the efficacy of patellar tendinopathy management through therapeutic exercise, and control and monitoring of loads. EVIDENCE ACQUISITION MEDLINE, WoS, Cochrane Plus, PEDro, and the gray literature were searched from inception to July 2021. Based on the PICO strategy, the inclusion criteria were clinical trials published in English or Spanish; outcomes of function, pain, and strength; patients with patellar tendinopathy with no age or gender limitations; using an active intervention; and at least a methodological quality equal to or greater than 3 points on the Jadad scale. All data were analyzed by 2 independent reviewers (P.N.-M. and D.H.-G.). Studies were qualitatively synthesized using a descriptive synthesis. The methodological quality and risk of bias assessment were performed with the PEDro and Jadad scale, respectively. EVIDENCE SYNTHESIS A total of 136 articles were identified, of which 12 met the eligibility criteria. All of them were regarded as presenting a moderate risk of bias and their methodological quality was considered acceptable to good. Recovering patellar tendinopathy with therapeutic exercise seems to significantly improve function, pain, and strength after intervention and even lasted over time. CONCLUSION A treatment based on load monitoring and physical exercise has proven to be effective in rehabilitating patellar tendinopathy, with positive results in the short and medium term.
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14
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Houston A, Fong DTP, Bennett AN, Walters V, Barker-Davies RM. Biomechanical differences between military patients with patellar tendinopathy and asymptomatic controls during single-leg squatting and gait - A statistical parametric mapping study. Clin Biomech (Bristol, Avon) 2021; 90:105514. [PMID: 34757256 DOI: 10.1016/j.clinbiomech.2021.105514] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 09/07/2021] [Accepted: 10/22/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Prior identification of biomechanical differences between patients with patellar tendinopathy and healthy controls has utilised time-discrete analysis which is susceptible to type I error when multiple comparisons are uncorrected. We employ statistical parametric mapping to minimise the risk of such error, enabling more appropriate clinical decision-making. METHODS Lower-limb biomechanics of 21 patients with patellar tendinopathy and 22 controls were captured during walking and three types of squats. A statistical parametric mapping two-sample t-test was used to identify kinematic and kinetic differences between groups for each joint. Paired t-tests were used to compare pain before and after tasks, in patients with patellar tendinopathy. FINDINGS During walking, cases demonstrated reduced knee joint power during initial contact and hip joint power during terminal stance. In squatting, cases demonstrated increased knee abduction angles at various time points of the small knee bend and single-leg squat. Cases demonstrated reduced knee internal rotation moment during the deepest portion of the single-leg squat and single-leg decline squat. INTERPRETATION Gait appears unaffected by patellar tendinopathy, likely due to low task difficulty. Elevated knee abductions angles during squatting were confirmed as a key difference in patients with patellar tendinopathy. Reduced knee internal rotation moments in patients were attributed to a potential reduction in hip external rotator strength and possible pain avoidance strategy; however further evidence is required to substantiate these claims. Findings provide a clear rationale for rehabilitation programs to focus on knee stabilisation and strengthening of the muscles surrounding the hip.
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Affiliation(s)
- Andrew Houston
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Stanford Hall, Loughborough, UK
| | - Daniel T P Fong
- National Centre for Sport and Exercise Medicine, School of Sport Exercise and Health Sciences, Loughborough University, UK
| | - Alexander N Bennett
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Stanford Hall, Loughborough, UK; National Centre for Sport and Exercise Medicine, School of Sport Exercise and Health Sciences, Loughborough University, UK
| | - Vanessa Walters
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Stanford Hall, Loughborough, UK; Versus Arthritis Centre for Sport, Exercise and Osteoarthritis Research, University of Bath, Bath, UK
| | - Robert M Barker-Davies
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre, Stanford Hall, Loughborough, UK; National Centre for Sport and Exercise Medicine, School of Sport Exercise and Health Sciences, Loughborough University, UK.
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15
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Cushman DM, Petrin Z, Eby S, Clements ND, Haight P, Snitily B, Teramoto M. Ultrasound evaluation of the patellar tendon and Achilles tendon and its association with future pain in distance runners. PHYSICIAN SPORTSMED 2021; 49:410-419. [PMID: 33153352 PMCID: PMC8648045 DOI: 10.1080/00913847.2020.1847004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Objectives: To examine whether asymptomatic ultrasonographic abnormalities in the Achilles and patellar tendons in runners are associated with an increased risk of pain development.Methods: This is a longitudinal, prospective cohort study with 139 runners recruited at a half and full marathon race. Ultrasound examination of the Achilles and patellar tendons was performed bilaterally the day prior to the race. Self-reported injury data were collected at 1, 3, 6 and 12 months. 104 (74.8%) runners were included in the data analysis.Results: Ultrasonographic tendon abnormalities were found in 24.1% of the Achilles and in 23.1% of the patellar tendons prior to the race. Runners with tendon abnormality were 2-3 times more likely to develop pain within 12 months than those without (relative risk = 3.14, p = 0.010 for Achilles; relative risk = 2.52, p = 0.008 for patellar tendon). After adjusting for gender, age, years of running, average miles per week of running over a year, and pre-race pain, runners with ultrasound abnormality were about 3 times (hazard ratio = 2.89, p = 0.039 for Achilles; hazard ratio = 2.73, p = 0.030 for patellar tendon) more likely to develop pain after the race. Tendon delamination was most strongly associated with pain in both the Achilles (relative risk = 6.00; p = 0.001) and patellar tendons (relative risk = 3.81; p = 0.001).Conclusions: Structural changes in asymptomatic tendons were found in almost 25% of runners. Presence of structural changes was associated with increased development of Achilles and patellar tendon pain within one year.
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Affiliation(s)
- Daniel M Cushman
- University of Utah Division of Physical Medicine & Rehabilitation
| | - Ziva Petrin
- Rutgers New Jersey Medical School, Department of Physical Medicine & Rehabilitation
| | - Sarah Eby
- University of Utah Division of Physical Medicine & Rehabilitation
| | - Nathan D. Clements
- University of Texas, San Antonio, Department of Physical Medicine & Rehabilitation
| | | | | | - Masaru Teramoto
- University of Utah Division of Physical Medicine & Rehabilitation
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16
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Bennett K, Vincent T, Sakthi-Velavan S. The patellar ligament: A comprehensive review. Clin Anat 2021; 35:52-64. [PMID: 34554600 DOI: 10.1002/ca.23791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 09/15/2021] [Accepted: 09/17/2021] [Indexed: 01/25/2023]
Abstract
The patellar ligament (PL) is an epiphyseal ligament and is part of the extensor complex of the knee. The ligament has gained attention due to its clinical relevance to autograft and tendinopathy. A variety of anatomical variations of the PL such as aplasia, numerical variations, and vascularity are being reported recently by clinicians and anatomists. The aim of this literature was to review the available literature to provide a consensus regarding anatomic variations of the PL, neurovasculature surrounding the PL, histology of the PL, and various aspects of PL measurements with relevance to the surgical considerations and sex and age-related differences. A narrative review of the patellar ligament was performed by conducting a detailed literature search and review of relevant articles. A total of 90 articles on the patellar ligament were included and were categorized into studies based on anatomical variations, neurovasculature, morphometrics, microanatomy, sex and age-related difference, and ACL reconstruction. The anatomical variations and morphometrics of the PL were found to correlate with the frequency of strain injuries, tendinopathy, and efficacy of the PL autograft in anterior cruciate ligament reconstruction. The sex differences in PL measurements and the effect of estrogen on collagen synthesis explained a higher incidence of patellar tendinopathy in women. An awareness of its variations enables careful selection of surgical incisions, thereby avoiding complications related to nerve injury. Accurate knowledge of the PL microanatomy assists in understanding the mechanism of ligament degeneration, rupture, autograft harvesting, and ligamentization results.
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Affiliation(s)
- Karis Bennett
- Division of Biomedical Sciences, Marian University College of Osteopathic Medicine, Indianapolis, Indiana, USA
| | - Tanner Vincent
- Division of Biomedical Sciences, Marian University College of Osteopathic Medicine, Indianapolis, Indiana, USA
| | - Sumathilatha Sakthi-Velavan
- Division of Biomedical Sciences, Marian University College of Osteopathic Medicine, Indianapolis, Indiana, USA
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17
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Chartier C, ElHawary H, Baradaran A, Vorstenbosch J, Xu L, Efanov JI. Tendon: Principles of Healing and Repair. Semin Plast Surg 2021; 35:211-215. [PMID: 34526870 DOI: 10.1055/s-0041-1731632] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Tendon stores, releases, and dissipates energy to efficiently transmit contractile forces from muscle to bone. Tendon injury is exceedingly common, with the spectrum ranging from chronic tendinopathy to acute tendon rupture. Tendon generally develops according to three main steps: collagen fibrillogenesis, linear growth, and lateral growth. In the setting of injury, it also repairs and regenerates in three overlapping steps (inflammation, proliferation, and remodeling) with tendon-specific durations. Acute injury to the flexor and extensor tendons of the hand are of particular clinical importance to plastic surgeons, with tendon-specific treatment guided by the general principle of minimum protective immobilization followed by hand therapy to overcome potential adhesions. Thorough knowledge of the underlying biomechanical principles of tendon healing is required to provide optimal care to patients presenting with tendon injury.
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Affiliation(s)
| | - Hassan ElHawary
- Division of Plastic and Reconstructive Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Aslan Baradaran
- Division of Plastic and Reconstructive Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Joshua Vorstenbosch
- Division of Plastic and Reconstructive Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Liqin Xu
- Division of Plastic and Reconstructive Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Johnny Ionut Efanov
- Division of Plastic and Reconstructive Surgery, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
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18
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Abstract
Utilization of musculoskeletal ultrasound, in particular for sports medicine, has dramatically increased in recent years. Ultrasound is an important adjunct tool to physical examination and other imaging methods in the evaluation and management of the injured athlete. It offers unique advantages in specific clinical scenarios. Dedicated training and a standardized scanning technique are important to overcome the inherent operator dependence and avoid diagnostic pitfalls. Ultrasound guidance can also improve accuracy in targeted percutaneous injection therapies. This article reviews the general ultrasound appearance of muscle, tendon, ligament, and nerve abnormalities in the athlete with a focus on sport-specific injuries.
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19
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Breda SJ, de Vos RJ, Poot DHJ, Krestin GP, Hernandez-Tamames JA, Oei EHG. Association Between T 2 * Relaxation Times Derived From Ultrashort Echo Time MRI and Symptoms During Exercise Therapy for Patellar Tendinopathy: A Large Prospective Study. J Magn Reson Imaging 2021; 54:1596-1605. [PMID: 34056788 PMCID: PMC8596625 DOI: 10.1002/jmri.27751] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/12/2021] [Accepted: 05/13/2021] [Indexed: 12/30/2022] Open
Abstract
Background Exercise therapy is considered preferential treatment for patellar tendinopathy (PT). However, there is conflicting evidence for structural patellar tendon adaptation in response to exercise therapy and its association with symptoms is weak. Purpose To assess the association between 1) T2* relaxation times and symptom severity; 2) baseline T2* and clinical outcome; and 3) longitudinal T2* changes and clinical outcome in athletes with PT performing exercise therapy. Study Type Randomized controlled clinical trial. Subjects Seventy‐six athletes (18–35 years) with clinically diagnosed and ultrasound‐confirmed PT. Field strength/Sequence 3D gradient echo sequence (3.0 T). Assessment Patients were enrolled in a randomized trial of progressive tendon‐loading exercises (PTLE) versus eccentric exercise therapy (EET). Symptoms were assessed using the Victorian Institute of Sports Assessment (VISA‐P) questionnaire. 3D‐Ultrashort echo time (UTE)‐MRI was acquired at baseline, 12 and 24 weeks. Voxel‐wise T2* relaxation times were quantified using mono‐exponential and bi‐exponential models. T2* analysis was performed in three patellar tendon tissue compartments representing: aligned collagen, degenerative tissue, and interface. Statistical Tests Adjusted general linear, mixed‐linear models, and generalized estimating equations. Results We included 76 patients with PT (58 men, mean age 24 ± 4 years); 38 in the PTLE‐group and 38 in the EET‐group, of which 57 subjects remained eligible for analysis. T2* relaxation times were significantly associated with VISA‐P in degenerative and interface tissues of the patellar tendon. No association was found between baseline T2* and VISA‐P after 24 weeks (P > 0.29). The estimated mean T2* in degenerative tissue decreased from 14 msec (95%CI: 12–16) at baseline to 13 msec (95%CI: 11–15) at 12 weeks and to 13 msec (95%CI: 10–15) at 24 weeks. The significant decrease in T2* from baseline to 24 weeks was associated with improved clinical outcome. Data Conclusion Tissue‐specific T2* relaxation times, identified with 3D‐UTE‐MRI, decreased significantly in athletes with patellar tendinopathy performing exercise therapy and this decrease was associated with improved clinical outcome. Evidence Level 1 Technical Efficacy Stage 4
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Affiliation(s)
- Stephan J Breda
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands.,Department of Orthopedics & Sports Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Robert-Jan de Vos
- Department of Orthopedics & Sports Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Dirk H J Poot
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Gabriel P Krestin
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Juan A Hernandez-Tamames
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Edwin H G Oei
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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20
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Physical Activity and Investigation With Magnetic Resonance Imaging Partly Explain Variability in the Prevalence of Patellar Tendon Abnormalities: A Systematic Review With Meta-analysis of Imaging Studies in Asymptomatic Individuals. J Orthop Sports Phys Ther 2021; 51:216-231. [PMID: 33779217 DOI: 10.2519/jospt.2021.10054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To estimate the pooled prevalence of, and factors associated with, the presence of patellar tendon abnormalities observed on imaging in people without symptoms. DESIGN Systematic review with stratified meta-analysis and meta-regression. LITERATURE SEARCH We searched Embase, Scopus, MEDLINE, CINAHL, SPORTDiscus, and Web of Science from 1980 to August 2020. STUDY SELECTION CRITERIA We included studies that reported the prevalence of asymptomatic patellar tendon abnormalities on imaging. We excluded studies of participants with current tendon pain, a history of tendon pain, or other systemic conditions. DATA SYNTHESIS Stratification and meta-regression of studies based on study-level descriptive statistics (mean age, body mass index, proportion of female participants, physical activity participation, imaging modality) were performed using a random-effects model to account for between-study heterogeneity. Risk of bias was assessed using the modified Newcastle-Ottawa scale. RESULTS Meta-analysis of 64 studies (7125 limbs from 4616 participants) found significant between-study heterogeneity (I2≥90%, P<.01), which precluded a summary prevalence estimate. Heterogeneity was partially explained by studies that included participants who were physically active and studies that assessed tendon abnormalities using magnetic resonance imaging compared to ultrasound (P<.05). Mean age, body mass index, proportion of female participants, and sample size did not explain the remaining heterogeneity. CONCLUSION There was substantial variability in the reported prevalence of asymptomatic patellar tendon abnormalities. A clear and valid method is needed to assess and report the presence of patellar tendon abnormalities to increase research capacity and establish the clinical value of imaging the patellar tendon. J Orthop Sports Phys Ther 2021;51(5):216-231. Epub 28 Mar 2021. doi:10.2519/jospt.2021.10054.
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21
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Delorme JP, Jibri Z. The association of patellar tendinosis with patellar maltracking and Hoffa's fat pad impingement: A case-control MRI study. Clin Imaging 2021; 76:180-188. [PMID: 33957384 DOI: 10.1016/j.clinimag.2021.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/05/2021] [Accepted: 04/18/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To assess whether proximal or distal patellar tendinosis is associated with patellar maltracking parameters and superolateral Hoffa's fat pad impingement. METHODS Institutional radiology database was reviewed for knee MRI scans performed over a 7-year period identifying cases of unequivocal patellar tendinosis, which were separated into 2 groups: proximal and distal tendinosis. For each group of proximal and distal patellar tendinosis, a control group of age and gender matched subjects was assigned. The scans were evaluated for patellar maltracking parameters including patellar alta, tibial tuberosity lateralization, trochlear dysplasia and lateral patellar tilt and for presence of superolateral Hoffa's fat pad edema. These parameters were compared between the case and control groups. RESULTS Out of 9852 MRI scans, 94 patellar tendinosis cases were included (65 proximal and 29 distal tendinosis) and matched with equal numbers of controls. In the proximal patellar tendinosis group, more subjects had patella alta (22 versus 6, p = 0.0006), lateralization of tibial tuberosity (16 versus 7, p = 0.0495) and superolateral Hoffa's fat pad edema (16 versus 4, p = 0.0073) compared to the control group. In the distal patellar tendinosis group, there was no significant difference in the prevalence of any maltracking indicator or superolateral Hoffa's fat pad edema compared to the control group. CONCLUSION Proximal patellar tendinosis was associated with patellar maltracking parameters including patella alta, lateralized tibial tuberosity and superolateral Hoffa's fat pad impingement. No association was demonstrated between distal patellar tendinosis and patellar maltracking indicators or superolateral Hoffa's fat pad impingement.
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Affiliation(s)
- Jean-Philippe Delorme
- Department of Radiology, University of Ottawa, Department of Medical Imaging, The Ottawa Hospital, Ottawa, Ontario K1H 8L6, Canada
| | - Zaid Jibri
- Department of Radiology, University of Ottawa, Department of Medical Imaging, The Ottawa Hospital, Ottawa, Ontario K1H 8L6, Canada.
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22
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Zhang C, Svensson RB, Montagna C, Carstensen H, Buhl R, Schoof EM, Kjaer M, Magnusson SP, Yeung CYC. Comparison of Tenocyte Populations from the Core and Periphery of Equine Tendons. J Proteome Res 2020; 19:4137-4144. [PMID: 32822197 DOI: 10.1021/acs.jproteome.0c00591] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Tendon is a highly organized, dense connective tissue that has been demonstrated to have very little turnover. In spite of the low turnover, tendon can grow in response to loading, which may take place primarily at the periphery. Tendon injuries and recurrence of injuries are common in both humans and animals in sports. It is unclear why some areas of the tendon are more susceptible to such injuries and whether this is due to intrinsic regional differences in extracellular matrix (ECM) production or tissue turnover. This study aimed to compare populations of tenocytes derived from the tendon core and periphery. Tenocytes were isolated from equine superficial digital flexor tendons (SDFTs), and the proliferation capacity was determined. ECM production was characterized by immuno- and histological staining and by liquid chromatography-mass spectrometry-based proteomics. Core and periphery SDFT cultures exhibited comparable proliferation rates and had very similar proteome profiles, but showed biological variation in collagen type I deposition. In conclusion, the intrinsic properties of tenocytes from different regions of the tendon are very similar, and other factors in the tissue may contribute to how specific areas respond to loading or injury.
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Affiliation(s)
- Cheng Zhang
- Institute of Sports Medicine Copenhagen, Bispebjerg Hospital and Center for Healthy Aging, University of Copenhagen, 2400 Copenhagen, Denmark
| | - Rene B Svensson
- Institute of Sports Medicine Copenhagen, Bispebjerg Hospital and Center for Healthy Aging, University of Copenhagen, 2400 Copenhagen, Denmark
| | - Costanza Montagna
- Institute of Sports Medicine Copenhagen, Bispebjerg Hospital and Center for Healthy Aging, University of Copenhagen, 2400 Copenhagen, Denmark
| | - Helena Carstensen
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2630 Taastrup, Denmark
| | - Rikke Buhl
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, 2630 Taastrup, Denmark
| | - Erwin M Schoof
- Proteomics Core, Technical University of Denmark, 2800 Kongens Lyngby, Denmark
| | - Michael Kjaer
- Institute of Sports Medicine Copenhagen, Bispebjerg Hospital and Center for Healthy Aging, University of Copenhagen, 2400 Copenhagen, Denmark
| | - S Peter Magnusson
- Institute of Sports Medicine Copenhagen, Bispebjerg Hospital and Center for Healthy Aging, University of Copenhagen, 2400 Copenhagen, Denmark.,Department of Physical and Occupational Therapy, Bispebjerg Hospital, 2400 Copenhagen, Denmark
| | - Ching-Yan Chloé Yeung
- Institute of Sports Medicine Copenhagen, Bispebjerg Hospital and Center for Healthy Aging, University of Copenhagen, 2400 Copenhagen, Denmark
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23
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Little RD, Smith SE, Cicuttini FM, Tanamas SK, Wluka AE, Hussain SM, Urquhart DM, Jones G, Wang Y. Association between increased signal intensity at the proximal patellar tendon and patellofemoral geometry in community-based asymptomatic middle-aged adults: a cross-sectional study. BMC Musculoskelet Disord 2020; 21:571. [PMID: 32828128 PMCID: PMC7443287 DOI: 10.1186/s12891-020-03589-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 08/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Histological and epidemiological data suggest that increased signal intensity at the proximal patellar tendon on magnetic resonance imaging is a response to tendon loading. As patellofemoral geometry is a mediator of loading, we examined the association between patellofemoral geometry and the prevalence of increased signal intensity at the patellar tendon in community-based middle-aged adults. METHODS Two hundred-one adults aged 25-60 years in a study of obesity and musculoskeletal health had the patellar tendon assessed from magnetic resonance imaging. Increased signal intensity at the proximal patellar tendon was defined as hyper-intense regions of characteristic pattern, size and distribution on both T1- and T2-weighted sequences. Indices of patellofemoral geometry, including Insall-Salvati ratio, patellofemoral congruence angle, sulcus angle, and lateral condyle-patella angle, were measured from magnetic resonance imaging using validated methods. Binary logistic regression was used to examine the association between patellofemoral geometrical indices and the prevalence of increased signal intensity at the patellar tendon. RESULTS The prevalence of increased signal intensity at the patellar tendon was 37.3%. A greater Insall-Salvati ratio (odds ratio 0.80, 95% confidence interval 0.66-0.97 per 0.1 change in the ratio, p = 0.02), indicative of a higher-riding patella, and a larger patellofemoral congruence angle (odds ratio 0.91, 95% confidence interval 0.85-0.98 per 5 degree change in the angle, p = 0.01), indicating a more laterally placed patella, were associated with reduced odds of increased signal intensity at the patellar tendon. Sulcus angle and lateral condyle-patella angle were not significantly associated with the odds of increased signal intensity at the patellar tendon. CONCLUSIONS In community-based asymptomatic middle-aged adults, increased signal intensity at the patellar tendon was common and associated with Insall-Salvati ratio and patellofemoral congruence angle, suggesting a biomechanical mechanism. Such work is likely to inform tissue engineering and cell regeneration approaches to improving outcomes in those with tendon pathology.
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Affiliation(s)
- Robert D Little
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Samuel E Smith
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Flavia M Cicuttini
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Stephanie K Tanamas
- Institute of Vector-Borne Disease, Monash University, Clayton, VIC, 3800, Australia
| | - Anita E Wluka
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Sultana Monira Hussain
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Donna M Urquhart
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Graeme Jones
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, 7000, Australia
| | - Yuanyuan Wang
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia.
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Zhang C, Couppé C, Scheijen JLJM, Schalkwijk CG, Kjaer M, Magnusson SP, Svensson RB. Regional collagen turnover and composition of the human patellar tendon. J Appl Physiol (1985) 2020; 128:884-891. [PMID: 32163333 DOI: 10.1152/japplphysiol.00030.2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Tendon pathology (tendinopathy) typically occurs in specific regions of a tendon, and growth in response to exercise also appears to be more pronounced in specific regions. In a previous study in animals we found evidence of regional differences in tendon turnover, but whether the turnover of human patellar tendon differs in different regions still remains unknown. Patellar tendons were obtained from cadavers of healthy men and women (body donation program, n = 5 donors, >60 yr of age). Samples were taken from 10 different regions along the length, width, and thickness of the tendon. Turnover was measured by 14C bomb pulse dating and also estimated from the accumulation of advanced glycation end products (AGEs) by fluorescence (340/460 nm) in addition to measurement of specific AGEs by mass spectrometry. Composition in terms of collagen, glycosaminoglycans (GAGs), and DNA was also assessed in each region. 14C results showed that all tendon regions had a similar 14C concentration, which was equal to the average atmospheric 14C concentration during the first 15 yr of the person's life. Fluorescence normalized to dry weight did not differ between regions, nor did specific AGEs. Higher GAG content was observed in the proximal and near the distal insertion of the tendon. In conclusion, healthy human patellar tendon displays no regional differences in collagen turnover throughout life.NEW & NOTEWORTHY Tendon injuries and tendinopathies typically occur in specific regions of the tendon, but the reason for this specificity is not well understood. A potential factor in injury susceptibility is tissue turnover, and previous work suggests that the tendon core has practically no turnover during adult life; however, it is not known whether this is true for other regions of the tendon. Our present results on healthy human patellar tendon clearly demonstrate that turnover does not differ between regions and thereby cannot explain differences in injury susceptibility. The findings also indicate that all regions of the tendon are formed simultaneously during skeletal maturation and do not turn over appreciably during adulthood. This is an important finding because little is known about tendon growth during maturation in humans.
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Affiliation(s)
- Cheng Zhang
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg Hospital, Copenhagen, Denmark.,Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
| | - Christian Couppé
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg Hospital, Copenhagen, Denmark.,Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark.,Department of Physical and Occupational Therapy, Bispebjerg Hospital, Copenhagen, Denmark
| | - Jean L J M Scheijen
- CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Casper G Schalkwijk
- CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Michael Kjaer
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg Hospital, Copenhagen, Denmark.,Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
| | - S Peter Magnusson
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg Hospital, Copenhagen, Denmark.,Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark.,Department of Physical and Occupational Therapy, Bispebjerg Hospital, Copenhagen, Denmark
| | - Rene B Svensson
- Institute of Sports Medicine Copenhagen, Department of Orthopedic Surgery, Bispebjerg Hospital, Copenhagen, Denmark.,Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
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Histopathological changes in patellar tendon enthesis of rabbit induced by electrical stimulation intensity. J Orthop Sci 2020; 25:344-348. [PMID: 31101414 DOI: 10.1016/j.jos.2019.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 04/06/2019] [Accepted: 04/09/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Enthesis injury is a common problem in athletes and workers, which is considered closely related to overuse. However, the early pathophysiologic changes of osteotendinous junction are not well understood, and moreover, few studies investigated the relationship between intensity and pathological changes. The purpose of this study was to evaluate microstructural changes induced by different loading intensities and to find out the threshold intensity. METHODS Forty-eight New Zealand White rabbits were randomly divided into six groups. One control group, the others were electrically stimulated to contract repetitively for 2 h per day, three days a week. 30% of peak tetanic force (7.06 N) was adopted to stimulate the rabbits in the 100% cyclic loading group. Other groups were stimulated with 20%, 40%, 60% and 80% of this force. After four weeks, prepared samples were stained with hematoxylin and eosin. RESULTS After 4 weeks of cyclic loading, the shape and the distribution of tendon cells in patellar enthesis changed, the arrangement of collagen fibers became disordered and the tidemark had become irregular or even disappeared. Different stimulus intensity caused a significant change of cell density in different groups (F = 10.19, P < 0.001). The cell densities of tendon were 34.3 ± 7.9 cells/100 μm2 (L60), 38.2 ± 5.9 cells/100 μm2 (L80), 43.8 ± 10.3 cells/100 μm2 (L100) respectively, which had significant difference with CON group 22.5 ± 3.5 cells/100 μm2. The thickness of fibrocartilage zone had no significant difference among the groups. CONCLUSIONS The changes of histomorphology with the increasing exercise intensity elucidated that the degree of enthesis microdamage was directly related to the intensity of exercises. The findings demonstrated that 18% (used in L60 group) of peak tetanic force was the threshold intensity which could induce pathological changes in enthesis in four weeks.
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A systematic review of inflammatory cells and markers in human tendinopathy. BMC Musculoskelet Disord 2020; 21:78. [PMID: 32028937 PMCID: PMC7006114 DOI: 10.1186/s12891-020-3094-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 01/24/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND This article systematically reviews the current evidence regarding inflammation in Tendinopathy with the aim to increase understanding of a potential common pathophysiology. METHODS Following the PRISMA statements, the terms: (tendinopathy OR (tendons AND rupture)) AND (inflammation OR (inflammation AND cells) OR immune system OR inflammation mediators OR bacteria) were used. One thousand four hundred thirty-one articles were identified which was screened down to 53. RESULTS 39/53 studies mentioned inflammatory cells but had contradicting conclusions. Macrophages were the most common cell type and inflammatory markers were detectable in all the articles which measure them. CONCLUSIONS The included studies show different conclusions, but this heterogeneity is not unexpected since the clinical criteria of 'tendinopathy' encompass a huge clinical spectrum. Different 'tendinopathy' conditions may have different pathophysiology, and even the same clinical condition may be at different disease stages during sampling, which can alter the histological and biochemical picture. Control specimen sampling was suboptimal since the healthy areas of the pathological-tendon may actually be sub-clinically diseased, as could the contralateral tendon in the same subject. Detection of inflammatory cells is most sensitive using immunohistochemistry targeting the cluster of differentiation markers, especially when compared to the conventional haematoxylin and eosin staining methods. The identified inflammatory cell types favour a chronic inflammatory process; which suggests a persistent stimulus. This means NSAID and glucocorticoids may be useful since they suppress inflammation, but it is noted that they may hinder tendon healing and cause long term problems. This systematic review demonstrates a diversity of data and conclusions in regard to inflammation as part of the pathogenesis of Tendinopathy, ranging from ongoing or chronic inflammation to non-inflammatory degeneration and chronic infection. Whilst various inflammatory markers are present in two thirds of the reviewed articles, the heterogenicity of data and lack of comparable studies means we cannot conclude a common pathophysiology from this systematic review.
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Abstract
Members of the International Skeletal Society compiled a glossary of terms for musculoskeletal radiology. The authors also represent national radiology or pathology societies in Asia, Australia, Europe, and the USA. We provide brief descriptions of musculoskeletal structures, disease processes, and syndromes and address their imaging features. Given the abundance of musculoskeletal disorders and derangements, we chose to omit most terms relating to neoplasm, spine, intervention, and pediatrics. Consensus agreement was obtained from 19 musculoskeletal radiology societies worldwide.
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Abstract
BACKGROUND Patellar tendinopathy is an overuse condition that commonly affects athletes. Surgery is usually offered if medical and physical therapies fail to treat it effectively. There is variation in the type of surgery performed for the condition. OBJECTIVES To assess the benefits and harms of surgery for patellar tendinopathy in adults. SEARCH METHODS We searched the following databases, to 17 July 2018: the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Library, OVID MEDLINE, OVID Embase, clinical trial registries (www.ClinicalTrials.gov) and the WHO trials portal (www.who.int/ictrp/en/). SELECTION CRITERIA We included all randomised controlled trials (RCTs) that compared surgical techniques (open or arthroscopic) with non-operative treatment (including placebo surgery, exercise or other non-surgical modalities) in adults with patellar tendinopathy.Major outcomes assessed were knee pain, function, quality of life, participant global assessment of success, withdrawal rate, proportion with adverse events and proportion with tendon rupture. DATA COLLECTION AND ANALYSIS Two review authors selected studies for inclusion, extracted trial characteristics and outcome data, assessed the risk of bias and assessed the quality of the evidence using GRADE. MAIN RESULTS Two trials (92 participants) met our inclusion criteria. Participants in both trials were followed for 12 months. Neither trial compared surgery to placebo surgery. One trial (40 randomised participants) compared open surgical excision with eccentric exercises, and the other compared arthroscopic surgery with sclerosing injections (52 randomised participants). Due to the nature of the interventions, neither the participants or the investigators were blinded to the group allocation, resulting in the potential for performance and detection bias. Some outcomes were selectively not recorded, leading to reporting bias. Overall, the certainty of the evidence from these studies was low for all outcomes due to the potential for bias, and imprecision due to small sample sizes.Compared with eccentric exercises, low-certainty evidence indicates that open surgical excision provides no clinically important benefits with respect to knee pain, function or global assessment of success. At 12 months, mean knee pain - measured by pain with standing jump on a 10-point scale (lower scores indicating less pain) - was 1.7 points (standard deviation (SD) 1.6) in the eccentric training group and 1.3 (SD 0.8) in the surgical group (one trial, 40 participants). This equates to an absolute pain reduction of 4% (ranging from 4% worse to 12% better, the minimal clinically important difference being 15%) and a relative reduction in pain of 10% better (ranging from 30% better to 10% worse) in the treatment group. At 12 months, function on the zero- to 100-point Victorian Institute of Sport Assessment (VISA) scale was 65.7 (SD 23.8) in the eccentric training group and 72.9 (SD 11.7) in the surgical group (one trial, 40 participants). This equates to an absolute change of 7% better function (ranging from 4% worse to 19% better) and relative change of 25% better (ranging from 15% worse to 65% better, the minimal clinically important difference being 13%). Participant global assessment of success was measured by the number of people with no pain at 12 months: 7/20 participants in the eccentric training group reported no pain, compared with 5/20 in the open surgical group (risk ratio (RR) 0.71 (95% CI 0.27 to 1.88); one trial, 40 participants). There were no withdrawals, but five out of 20 people from the eccentric exercise group crossed over to open surgical excision. Quality of life, adverse events and tendon ruptures were not measured.Compared with sclerosing injection, low-certainty evidence indicates that arthroscopic surgery may provide a reduction in pain and improvement in participant global assessment of success, however further studies are likely to change these results. At 12 months, mean pain with activities, measured on a 100-point scale (lower scores indicating less pain), was 41.1 (SD 28.5) in the sclerosing injection group and 12.8 (SD 19.3) in the arthroscopic surgery group (one trial, 52 participants). This equates to an absolute pain reduction of 28% better (ranging from 15% to 42% better, the minimal clinically important difference being 15%), and a relative change of 41% better (ranging from 21% to 61% better). At 12 months, the mean participant global assessment of success, measured by satisfaction on a 100-point scale (scale zero to 100, higher scores indicating greater satisfaction), was 52.9 (SD 32.6) in the sclerosing injection group and 86.8 (SD 20.8) in the arthroscopic surgery group (one trial, 52 participants). This equates to an absolute improvement of 34% (ranging from 19% to 49%). In both groups, one participant (4%) withdrew from the study. Functional outcome scores, including the VISA score, were not reported. Quality-of-life assessment, adverse events, and specifically the proportion with a tendon rupture, were not reported.We did not perform subgroup analysis to assess differences in outcome between arthroscopic or open surgical excision, as we did not identify more than one study with a common comparator. AUTHORS' CONCLUSIONS We are uncertain if surgery is beneficial over other therapeutic interventions, namely eccentric exercises or injectables. Low-certainty evidence shows that surgery for patellar tendinopathy may not provide clinically important benefits over eccentric exercise in terms of pain, function or participant-reported treatment success, but may provide clinically meaningful pain reduction and treatment success when compared with sclerosing injections. However, further research is likely to change these results. The evidence was downgraded two levels due to the small sample sizes and susceptibility to bias. We are uncertain if there are additional risks associated with surgery as study authors failed to report adverse events. Surgery seems to be embedded in clinical practice for late-stage patella tendinopathy, due to exhaustion of other therapeutic methods rather than evidence of benefit.
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Affiliation(s)
- Michael Dan
- University of New South WalesLiverpoolAustralia
| | - Alfred Phillips
- University of New South WalesHunter New England Health DistrictLiveroolNSWAustralia2170
| | - Renea V Johnston
- Monash UniversityMonash Department of Clinical Epidemiology, Cabrini Institute and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive MedicineMelbourneAustralia
| | - Ian A Harris
- South Western Sydney Clinical School, University of New South WalesIngham Institute for Applied Medical ResearchElizabeth StreetLiverpoolNew South WalesAustralia2170
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Clinical Improvements Are Not Explained by Changes in Tendon Structure on Ultrasound Tissue Characterization After an Exercise Program for Patellar Tendinopathy. Am J Phys Med Rehabil 2019; 97:708-714. [PMID: 29649012 DOI: 10.1097/phm.0000000000000951] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the effects of a 4-wk in-season exercise program of isometric or isotonic exercises on tendon structure and dimensions as quantified by ultrasound tissue characterization (UTC). DESIGN This was a randomized clinical trial. Volleyball and basketball players (16-31 yrs, n = 29) with clinically diagnosed patellar tendinopathy were randomized to a 4-wk isometric or isotonic exercise program. The programs were designed to decrease patellar tendon pain. A baseline and 4-wk UTC scan was used to evaluate change in tendon structure. RESULTS No significant change in tendon structure or dimensions on UTC was detected after the exercise program despite patellar tendinopathy symptoms improving. The percentage and mean cross-sectional area of aligned fibrillar structure (echo types I + II) (Z = -0.414, P = 0.679) as well as disorganized structure (echo types III + IV) (Z = -0.370, P = 0.711) did not change over the 4-wk exercise program. Change in tendon structure and dimensions on UTC did not differ significantly between the groups. CONCLUSION Structural properties and dimensions of the patellar tendon on UTC did not change after a 4-wk isometric or isotonic exercise program for athletes with patellar tendinopathy in-season, despite an improvement in symptoms. It seems that structural improvements are not required for a positive clinical outcome.
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Mersmann F, Pentidis N, Tsai MS, Schroll A, Arampatzis A. Patellar Tendon Strain Associates to Tendon Structural Abnormalities in Adolescent Athletes. Front Physiol 2019; 10:963. [PMID: 31427983 PMCID: PMC6687848 DOI: 10.3389/fphys.2019.00963] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 07/11/2019] [Indexed: 12/28/2022] Open
Abstract
High mechanical strain is thought to be one of the main factors for the risk of tendon injury, as it determines the mechanical demand placed upon the tendon by the working muscle. The present study investigates the association of tendon mechanical properties including force, stress and strain, and measures of tendon micromorphology and neovascularization, which are thought to be indicative of tendinopathy in an adolescent high-risk group for overuse injury. In 16 adolescent elite basketball athletes (14–15 years of age) we determined the mechanical properties of the patellar tendon by combining inverse dynamics with magnetic resonance and ultrasound imaging. Tendon micromorphology was determined based on a spatial frequency analysis of sagittal plane ultrasound images and neovascularization was quantified as color Doppler area. There was a significant inverse relationship between tendon strain and peak spatial frequency (PSF) in the proximal tendon region (r = −0.652, p = 0.006), indicating locally disorganized collagen fascicles in tendons that are subjected to high strain. No such associations were present at the distal tendon site and no significant correlations were observed between tendon force or stress and tendon PSF as well as between tendon loading and vascularity. Our results suggest that high levels of tendon strain might associate to a micromorphological deterioration of the collagenous network in the proximal patellar tendon, which is also the most frequent site affected by tendinopathy. Neovascularization of the tendon on the other hand seems not to be directly related to the magnitude of tendon loading and might be a physiological response to a high frequency of training in this group. Those findings have important implications for our understanding of the etiology of tendinopathy and for the development of diagnostical tools for the assessment of injury risk.
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Affiliation(s)
- Falk Mersmann
- Department of Training and Movement Sciences, Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin School of Movement Science, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Nikolaos Pentidis
- Department of Training and Movement Sciences, Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin School of Movement Science, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Meng-Shiuan Tsai
- Department of Training and Movement Sciences, Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin School of Movement Science, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Arno Schroll
- Department of Training and Movement Sciences, Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin School of Movement Science, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Adamantios Arampatzis
- Department of Training and Movement Sciences, Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin School of Movement Science, Humboldt-Universität zu Berlin, Berlin, Germany
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Bojsen-Møller J, Magnusson SP. Mechanical properties, physiological behavior, and function of aponeurosis and tendon. J Appl Physiol (1985) 2019; 126:1800-1807. [DOI: 10.1152/japplphysiol.00671.2018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
During human movement, the muscle and tendinous structures interact as a mechanical system in which forces are generated and transmitted to the bone and energy is stored and released to optimize function and economy of movement and/or to reduce risk of injury. The present review addresses certain aspects of how the anatomical design and mechanical and material properties of the force-transmitting tissues contribute to the function of the muscle-tendon unit and thus overall human function. The force-bearing tissues are examined from a structural macroscopic point of view down to the nanoscale level of the collagen fibril. In recent years, the understanding of in vivo mechanical function of the force-bearing tissues has increased, and it has become clear that these tissues adapt to loading and unloading and furthermore that force transmission mechanics is more complex than previously thought. Future investigations of the force-transmitting tissues in three dimensions will enable a greater understanding of the complex functional interplay between muscle and tendon, with relevance for performance, injury mechanisms, and rehabilitation strategies.
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Affiliation(s)
- Jens Bojsen-Møller
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- Section for Physical Performance, Norwegian School of Sport Sciences, Oslo, Norway
| | - S. Peter Magnusson
- Institute of Sports Medicine, Department of Orthopaedic Surgery M, Bispebjerg Hospital and Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Occupational and Physical Therapy, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
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Ultrasonographic assessment of patellar tendon thickness at 16 clinically relevant measurement sites - A study of intra- and interrater reliability. J Bodyw Mov Ther 2019; 23:344-351. [PMID: 31103118 DOI: 10.1016/j.jbmt.2019.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 02/02/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To determine intra- and interrater reliability of ultrasonographic imaging (USI) measurements of patellar tendon (PT) thickness using 16 measurement sites covering the entire tendon. DESIGN Reliability study. SETTING Physiotherapy outpatient clinic. PARTICIPANTS Twenty healthy and physically active volunteers (9 women). Mean age: 24 years (SD ± 2.73). Mean body mass: 75.8 kg (SD ± 11.8). MAIN OUTCOME MEASURES Intraclass correlation coefficient (ICC) and 95% limits of agreement (LOA) in cm and in percentage relative to the mean PT thickness. RESULTS Intrarater reliability ranged from 0.59 to 0.87 and 0.59 to 0.93 for examiners I and II, respectively. Interrater reliability ranged from 0.37 to 0.89. Measurement precision for examiner I ranged from 0.05 to 0.09 cm (17.5%-26.7%) while ranging from 0.04 to 0.13 cm (13.3%-38.7%) for examiner II. Interrater measurement precision ranged from 0.07 to 0.15 cm (19.1%-42.5%). CONCLUSION In an attempt to replicate daily clinical USI practice, this was the first study extensively assessing reliability throughout the full range of the patellar tendon - revealing a considerable variation in intra- and interrater reliability as well as measurement precision throughout the 16 individual PT sites. In a clinical context, the low interrater reliability and precision found at the proximal tendon insertion site may have implications for USI of the symptomatic PT, as this is the site mainly associated with underlying pathologic changes. Further reliability studies are needed to clarify the region-specific reliability of the full length PT.
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The presence of patellar tendinopathy in the bone-patellar tendon-bone autograft may increase the risk of anterior cruciate ligament graft failure. Knee Surg Sports Traumatol Arthrosc 2019; 27:766-772. [PMID: 30141146 DOI: 10.1007/s00167-018-5066-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 07/12/2018] [Indexed: 12/19/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the influence of patellar tendinopathy on primary anterior cruciate ligament (ACL) reconstruction graft failure when using bone-patellar tendon-bone (BPTB) autograft. METHODS All patients undergoing primary ACL reconstruction using ipsilateral BPTB with preoperative magnetic resonance imaging (MRI) available for review were approached for eligibility. The medical charts of included patients were reviewed to obtain demographic information, anatomical characteristics, injury characteristics, treatment characteristics, length of follow-up, and presence of graft failure. A single, fellowship-trained, knee-specialist and blinded researcher performed preoperative MRI interpretation of patellar tendinopathy. The presence/absence of patellar tendinopathy (none, mild, moderate, or severe changes) was compared between patients with (cases) and without (controls) failure of ACL reconstruction. There were 559 cases with a median (range) clinical follow-up was 8 (4-30) months and an average age of 21.5 years (82% males). RESULTS Of the 559 cases, there were 182 (32.6%) with and 377 (67.4%) without patellar tendinopathy. A total of 32 (5.7%) graft failures occurred. There were a significantly higher failure rate in patients with compared to without patellar tendinopathy (p < 0.001), and in patients with compared to without partial tendon tear (p < 0.001). The odds ratio (95% confidence interval) for graft failure was 5.9 (2.7-13.1), 20.8 (6.8-63.9) and 54.4 (5.5-539.4) in patients with patellar tendinopathy (compared to absence of patellar tendinopathy), moderate or severe patellar tendinopathy (compared to none or mild patellar tendinopathy), or partial tendon tear (compared to absence of tendon tear), respectively. CONCLUSION The presence of patellar tendinopathy increases the risk of BPTB graft failure when used for ACL reconstruction. The use of BPTB autograft is not recommended if patellar tendinopathy is obvious or there are suspicious of partial tendon tear on MRI. In such cases, the surgeon should consider using a different graft. LEVEL OF EVIDENCE Retrospective cohort analysis, Level III.
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Thygesen MM, Jordt I, Kristensen MS, Fisker FY, Kildegaard S, Pfeiffer-Jensen M. High-Intensity Resistance Training Does Not Produce Immediate Ultrasonographic Changes in Muscle Tendons. Orthop J Sports Med 2019; 7:2325967118821604. [PMID: 30729146 PMCID: PMC6350153 DOI: 10.1177/2325967118821604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: Chronic overload injuries to tendons can be visualized using ultrasonography,
with characteristics such as tendon thickening and darkening. Purpose: To investigate whether these characteristics are evident in the patellar and
Achilles tendons immediately after 1 session of high-intensity resistance
training. Study Design: Controlled laboratory study. Methods: A total of 18 volunteers were randomized to an experimental group (n = 10)
and a sham group (n = 8). The experimental group performed 5 circuits at
maximum effort consisting of 5 weighted front squats, 10 box jumps (60/50
cm), and 15 double-under jump-rope jumps. The sham group performed a similar
circuit consisting of 5 weighted shoulder presses, 10 push-ups, and 15
weighted biceps curls. Ultrasonograms were obtained before and after
exercise, for a total of 30 minutes at intervals of 2.5 minutes for the
first 10 minutes and 5 minutes for the remaining time. Tendon thickness and
tendon matrix signals were measured. Statistics were performed using
repeated-measures mixed analysis of variance (ANOVA). Results: Tendon thickness did not increase significantly over 30 minutes after both
circuits. The mean grayscale value for the patellar and Achilles tendons
increased for both the experimental and the sham groups. ANOVA showed that
the experimental group was not a significant explanatory variable; however,
the increased work of both groups was. A post hoc analysis found that the
maximum increase in the tendon signal was a grayscale value of 10.8 for the
patellar tendon (99.4% CI, 3.7-17.9; P = .002). Conclusion: This trial failed to reproduce an earlier study in which tendon thickness
increased after high-intensity training. The tendons produced a hyperechoic
signal after high-intensity resistance training, regardless of loading to
the tendon. Chronic overload characteristics on ultrasonography were not
evident immediately after acute loading of tendons. Clinical Relevance: There is a need for prognostic and diagnostic markers of tendinopathy
especially because of the protracted course of subclinical development of an
injury. This study assessed whether clinical findings for a chronic overload
injury can be detected during acute overloading.
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Affiliation(s)
- Mathias Møller Thygesen
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark.,Comparative Medicine Laboratory, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Ida Jordt
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Filip Yang Fisker
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | - Sofie Kildegaard
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
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Clinical Measures and Their Contribution to Dysfunction in Individuals With Patellar Tendinopathy. J Sport Rehabil 2019; 28:165-170. [PMID: 29140160 DOI: 10.1123/jsr.2017-0196] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
CONTEXT Patellar tendinopathy (PT) is prevalent in physically active populations, and it affects their quality of living, performance of activity, and may contribute to the early cessation of their athletic careers. A number of previous studies have identified contributing factors for PT; however, their contributions to self-reported dysfunction remain unclear. OBJECTIVE The purpose of this investigation was to determine if strength, flexibility, and various lower-extremity static alignments contributed to self-reported function and influence the severity of PT. DESIGN Cross-sectional research design. SETTING University laboratory. PARTICIPANTS A total of 30 participants with PT volunteered for this study (age: 23.4 [3.6] y, height: 1.8 [0.1] m, mass: 80.0 [20.3] kg, body mass index: 25.7 [4.3]). MAIN OUTCOME MEASURES Participants completed 7 different patient-reported outcomes. Isometric knee extension and flexion strength, hamstring flexibility and alignment measures of rearfoot angle, navicular drop, tibial torsion, q-angle, genu recurvatum, pelvic tilt, and leg length differences were assessed. Pearson's correlation coefficients were assessed to determine significantly correlated outcome variables with each of the patient-reported outcomes. The factors with the highest correlations were used to identify factors that contribute the most to pain and dysfunction using backward selection, linear regression models. RESULTS Correlation analysis found significant relationships between questionnaires and body mass index (r = -.35-.46), normalized knee extension (r = .38-.50) and flexion strength (r = -.34-.50), flexibility (r = .32-.38, q-angle (r = .38-.56), and pelvic tilt (r = -.40). Regression models (R2 = .22-.54) identified thigh musculature strength and supine q-angle to have greatest predictability for severity in patient-reported outcomes. CONCLUSIONS These findings put an emphasis of bodyweight management, improving knee extensor and flexor strength, and posterior flexibility in PT patients.
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Tavares Junior WC, Paulino E, Magalhaes MAB, Fonseca ACGG, Rodrigues JBSR, Resende V. MAGNETIC RESONANCE IMAGING PERFUSION TECHNIQUE IN THE EVALUATION OF ACHILLES TENDON INJURY IN RABBITS. ACTA ORTOPEDICA BRASILEIRA 2019; 27:12-15. [PMID: 30774522 PMCID: PMC6362701 DOI: 10.1590/1413-785220192701132230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study aimed to evaluate the dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) in the experimental model of Achilles tendon injury. METHODS Twelve white male adults New Zealand rabbits were divided into two groups, a group with resection of the central portion of the Achilles tendon (n = 8) and a control group (n = 4). Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) was performed 4 weeks after the surgical procedure, followed by histological analysis of the tendons. RESULTS The main finding of this study was the difference (p < 0.001) in peak contrast enhancement on DCE-MRI, which demonstrated that the operated group had greater contrast uptake. The operated tendons showed histological disruption of their architecture, and cluttered appearance of tendinous fibers, with vascular and fibroblast proliferations. CONCLUSION DCE-MRI is a technique with a potential to demonstrate changes in the vascularity pattern of the Achilles tendon before and after operation. DCE-MRI has a potential to be used in studies of tendinosis diagnosis and surgical follow-up. Level of evidence II, Experimental Study .
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Arthroscopic patellar release allows timely return to performance in professional and amateur athletes with chronic patellar tendinopathy. Knee Surg Sports Traumatol Arthrosc 2018; 26:3553-3559. [PMID: 29806056 DOI: 10.1007/s00167-018-4985-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 04/23/2018] [Indexed: 10/14/2022]
Abstract
PURPOSE Return to sports rates in amateur and professional athletes with chronic patellar tendinopathy following arthroscopic patellar release are unpredictable. The present study aims to analyse the effectiveness of arthroscopic patellar release in professional compared to amateur athletes. METHODS A total of 34 amateur and 20 professional athletes with chronic patellar tendinopathy, refractory to conservative treatment, were studied prospectively and underwent arthroscopic tendon release at the inferior patellar pole. Impact of grouped sports on clinical and functional outcome, subjective patient satisfaction and return to sports rates were assessed. Additionally, preoperative MRI-scans of the knee were evaluated and correlated with clinical outcome. RESULTS In 40 patients (74.1%) arthroscopic patellar release resulted in complete recovery and return to preinjury exercise levels. Full return to sports was achieved after a median of 3.0 (range 0.5-12.0) months. Functional outcome measures VISA-P (Victorian Institute of sport assessment for patella) and modified Blazina scores improved significantly from pre- to postoperatively (VISA-P: 48.8 vs. 94.0 pts., respectively, p < 0.0001; Blazina: 4.47 vs. 0.5, respectively, p < 0.0001). CONCLUSION As rapid recovery and timely return to sports are crucial for professional athletes, arthroscopic patellar release should be considered after failed conservative treatment. LEVEL OF EVIDENCE IV.
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Owen DJ, Manley R, Casale SA. Influence of methods of joint inspection during tibial plateau leveling osteotomy on the radiographic appearance of the patellar tendon. Vet Surg 2018; 47:916-922. [PMID: 30180275 DOI: 10.1111/vsu.12942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 06/12/2018] [Accepted: 06/20/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the influence of methods of joint inspection during tibial plateau leveling osteotomy (TPLO) on radiographic appearance of the patellar tendon. STUDY DESIGN Retrospective study. ANIMALS Client-owned dogs (191) treated with TPLO (199). METHODS Data collected from medical records included signalment, weight, duration of anesthesia and surgery, preoperative and postoperative tibial plateau angle (TPA), cranial cruciate ligament status, meniscal status, and meniscal treatment. Method of joint inspection was recorded as (1) arthroscopy (AR), (2) craniomedial parapatellar arthrotomy (CrMA), or (3) caudomedial arthrotomy (CdMA). The radiographic thickness of the patellar tendon (PTT) was measured preoperatively and at 8-12 weeks postoperatively. Radiographic signs of patellar tendonitis were graded as 0-2 on the basis of the severity of changes. RESULTS Thirty-nine dogs (41 stifles) underwent AR, 86 dogs (87 stifles) underwent CrMA, and 70 dogs (71 stifles) underwent CdMA. Durations of surgery (P < .001) and anesthesia (P < .001) were longer when joints were inspected by AR than by arthrotomies. PTT was greater after AR than after CrMA (P = .004) and CdMA (P < .001). The proportion of dogs with grade 1 or grade 2 PTT was greater after AR (78.04%) than after CrMA (52.87%, P = .0065) and CdMA (28.17%, P < .001). CONCLUSION The PTT was thicker 8-12 weeks after TPLO when stifles were inspected arthroscopically rather than via arthrotomies. CLINICAL SIGNIFICANCE The method of stifle exploration during TPLO influences the postoperative radiographic appearance of the patellar tendon and may contribute to patellar tendinopathy.
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Affiliation(s)
- Deandra J Owen
- Department of Surgery, Angell Animal Medical Center, Boston, Massachusetts
| | - Rebecca Manley
- Department of Radiology, Angell Animal Medical Center, Boston, Massachusetts
| | - Sue A Casale
- Department of Surgery, Angell Animal Medical Center, Boston, Massachusetts
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Sikes KJ, Li J, Shen Q, Gao SG, Sandy JD, Plaas A, Wang VM. TGF-b1 or hypoxia enhance glucose metabolism and lactate production via HIF1A signaling in tendon cells. Connect Tissue Res 2018; 59:458-471. [PMID: 29447016 PMCID: PMC6175639 DOI: 10.1080/03008207.2018.1439483] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
UNLABELLED Purpose/Aim of the study: Healthy tendons are maintained in homeostasis through controlled usage of glucose for energy and redox equilibrium. Tendon cell stress imposed by overuse injury or vascular insufficiency is accompanied by activation of wound healing pathways which facilitate an adaptive response and the restoration of homeostasis. To understand this response at the gene expression level we have studied the in vivo effects of injected TGF-β1 in a murine model of tendinopathy, as well as treatment of murine tendon explants with either TGF-β1 or hypoxia in vitro. METHODS AND RESULTS We provide evidence (from expression patterns and immunohistochemistry) that both in vivo and in vitro, the stress response in tendon cells may be metabolically controlled in part by glycolytic reprogramming. A major feature of the response to TGF-β1 or hypoxia is activation of the Warburg pathway which generates lactate from glucose under normoxia and thereby inhibits mitochondrial energy production. CONCLUSIONS We discuss the likely outcome of this major metabolic shift in terms of the potential benefits and damage to tendon and suggest how incorporation of this metabolic response into our understanding of initiation and progression of tendinopathies may offer new opportunities for diagnosis and the monitoring of therapies.
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Affiliation(s)
- Katie J Sikes
- Department of Orthopedic Surgery, Rush University Medical Center, 1611 W. Harrison Street, Suite 510, Chicago, IL 60612,Department of Bioengineering, University of Illinois at Chicago, 851 S. Morgan Street, Chicago, IL 60607
| | - Jun Li
- Department of Internal Medicine (Rheumatology), Rush University Medical Center, 1611 W. Harrison Street, Suite 510, Chicago, IL 60612
| | - Quan Shen
- Department of Internal Medicine (Rheumatology), Rush University Medical Center, 1611 W. Harrison Street, Suite 510, Chicago, IL 60612,Department of Orthopaedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, China 410008
| | - Shu-Guang Gao
- Department of Internal Medicine (Rheumatology), Rush University Medical Center, 1611 W. Harrison Street, Suite 510, Chicago, IL 60612,Department of Orthopaedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, China 410008
| | - John D Sandy
- Department of Internal Medicine (Rheumatology), Rush University Medical Center, 1611 W. Harrison Street, Suite 510, Chicago, IL 60612
| | - Anna Plaas
- Department of Internal Medicine (Rheumatology), Rush University Medical Center, 1611 W. Harrison Street, Suite 510, Chicago, IL 60612
| | - Vincent M Wang
- Department of Biomedical Engineering and Mechanics, Virginia Tech, 339 Kelly Hall, 325 Stanger Street MC 0298, Blacksburg, VA, 24061,Department of Bioengineering, University of Illinois at Chicago, 851 S. Morgan Street, Chicago, IL 60607
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Glait SA, Mahure S, Loomis CA, Cammer M, Pham H, Feldman A, Jazrawi LM, Strauss EJ. Regional histologic differences in the long head of the biceps tendon following subpectoral biceps tenodesis in patients with rotator cuff tears and SLAP lesions. Knee Surg Sports Traumatol Arthrosc 2018; 26:2481-2489. [PMID: 29362860 DOI: 10.1007/s00167-018-4839-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 01/11/2018] [Indexed: 01/02/2023]
Abstract
PURPOSE The purpose of this study was to quantify the regional histology of the long head of the biceps tendon (LHBT) and compare the histopathology present to clinical findings in patients with rotator cuff tears and SLAP lesions. METHODS Prospectively enrolled patients undergoing an open subpectoral LHBT tenodesis in the setting of a rotator cuff (RTC) tear or SLAP lesion. Perioperative data were collected and the excised LHBT was analyzed by a fellowship trained pathologist. Tendons were sectioned into proximal (biceps anchor), middle (bicipital groove), and distal (myotendinous junction) portions. Sections were stained with Movat's pentachrome stain and digitized for analysis. Comparisons were made between the histologic findings present in the setting of a rotator cuff tear with those seen in the setting of a SLAP tear. RESULTS 39 tendons were analyzed: 20 from patients with SLAP lesions (mean age of 44.7 years, range 23-60 years) and 19 from patients with rotator cuff tears (mean age of 58.7 years, range 43-71). Patients with the most pathologic tendons in the bicipital groove were significantly older (59.4 vs. 50.4 years; p < 0.05), reported higher pre-operative VAS scores (6.6 vs. 5.0; p < 0.02), and demonstrated lower pre-operative ASES scores (41.6 vs. 50.7; p < 0.05). The RTC group showed significantly more mucinous degeneration at both the proximal (p < 0.03) and the middle (p < 0.01) tendon portions compared to the SLAP group. In both groups, the portions of proximal tendon showed significantly (p < 0.05) more mucinous degeneration than distal portions. CONCLUSION Regional histologic differences exist in the LHBT. Rotator cuff patients showed the most degenerated tendon in the bicipital groove and these patients tended to be older and have higher VAS and lower ASES scores. Surgeons should consider performing a subpectoral biceps tenodesis as the bicipital groove portion of the tendon may be very degenerated, especially in patients with rotator cuff disease. Additional research is warranted to distinguish whether treating the biceps differently in distinct geographic regions affects patient outcomes. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Sergio A Glait
- Department of Orthopaedic Surgery, NYU Langone Medical Center Hospital for Joint Diseases, 301 E 17th St., New York, NY, 10003, USA.
| | - Siddharth Mahure
- Department of Orthopaedic Surgery, NYU Langone Medical Center Hospital for Joint Diseases, 301 E 17th St., New York, NY, 10003, USA
| | - Cynthia A Loomis
- Department of Pathology, NYU Langone Medical Center, New York, NY, USA
| | - Michael Cammer
- Microscopy Core, Office of Collaborative Science, NYU Langone Medical Center, New York, NY, USA
| | - Hien Pham
- Department of Orthopaedic Surgery, NYU Langone Medical Center Hospital for Joint Diseases, 301 E 17th St., New York, NY, 10003, USA
| | - Andrew Feldman
- Department of Orthopaedic Surgery, NYU Langone Medical Center Hospital for Joint Diseases, 301 E 17th St., New York, NY, 10003, USA
| | - Laith M Jazrawi
- Department of Orthopaedic Surgery, NYU Langone Medical Center Hospital for Joint Diseases, 301 E 17th St., New York, NY, 10003, USA
| | - Eric J Strauss
- Department of Orthopaedic Surgery, NYU Langone Medical Center Hospital for Joint Diseases, 301 E 17th St., New York, NY, 10003, USA
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Meyer NB, Jacobson JA, Kalia V, Kim SM. Musculoskeletal ultrasound: athletic injuries of the lower extremity. Ultrasonography 2018; 37:175-189. [PMID: 29794963 PMCID: PMC6044222 DOI: 10.14366/usg.18013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 04/14/2018] [Indexed: 12/23/2022] Open
Abstract
Athletic injuries of the lower extremities are commonly encountered in clinical practice. While some pathology can be diagnosed on physical exam, others are a clinical dilemma with nonspecific symptomatology. In these situations, ultrasound imaging can be utilized as an exceptional diagnostic tool, offering unique advantages over other imaging modalities. This article will review the imaging characteristics of commonly encountered athletic injuries of the lower extremity.
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Affiliation(s)
- Nathaniel B Meyer
- Department of Radiology, University of Michigan Hospital, Ann Arbor, MI, USA
| | - Jon A Jacobson
- Department of Radiology, University of Michigan Hospital, Ann Arbor, MI, USA
| | - Vivek Kalia
- Department of Radiology, University of Michigan Hospital, Ann Arbor, MI, USA
| | - Sung Moon Kim
- Department of Radiology, University of Michigan Hospital, Ann Arbor, MI, USA
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Sussman WI, Mautner K, Malanga G. The role of rehabilitation after regenerative and orthobiologic procedures for the treatment of tendinopathy: a systematic review. Regen Med 2018. [DOI: 10.2217/rme-2017-0110] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Aim: Significant variability exists in the literature, with no clear consensus to the optimal protocol after a regenerative procedure. Given this uncertainty, the authors systematically reviewed the literature cataloging the different variables that may influence outcomes. Methods: Search was limited to randomized clinical trials and prospective cohort studies of regenerative procedures for the treatment of tendinopathy. Variables were predetermined, and included: cyrotherapy, pre- and post-procedure nonsteroidal anti-inflammatory drugs use, recommendations for alternative pain medications, immobilization and duration of rest. Variables were categorized based on the influence of the intervention on the three phases of healing. Results: 749 studies were assessed for eligibility, and 60 studies were included. Significant variability existed in the literature. Conclusion: Despite the importance of rehabilitation after regenerative procedures, there is a paucity of evidence available to guide clinicians and highlights the need for additional validation.
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Affiliation(s)
- Walter I Sussman
- Department of Physical Medicine & Rehabilitation, Tufts University, Boston, MA 02111, USA
- Orthopedic Care Physician Network, N Easton, MA 02356, USA
| | - Ken Mautner
- Department of Physical Medicine & Rehabilitation & Department of Orthopedics, Emory University, Atlanta, GA 30329, USA
| | - Gerard Malanga
- Department of Physical Medicine & Rehabilitation, Rutgers School of Medicine University of Medicine & Density, Newark, NJ 07101, USA
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Tscholl PM, Biedert RM, Wanivenhaus F, Fucentese SF. Patellar tendinopathy with intratendinous alteration on MRI may be related to patellofemoral dysplasia. Scand J Med Sci Sports 2018; 28:1443-1450. [PMID: 29226423 DOI: 10.1111/sms.13033] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2017] [Indexed: 01/17/2023]
Abstract
Patellar tendinopathy (PT) is a frequent overuse injury of the extensor knee apparatus, whereas as up to 30% of the athletes might suffer from persisting symptoms during their entire career. In the present case-control study, 47 patients (30.8 ± 11.4 years) with PT with intratendinous alteration (PTita) of a minimum of ≥25% of the axial surface on MRI and minimum Blazina score of II (pain during without limiting sports activity) were included; MR images were analyzed for trochlear geometry, patellar height/tilt, and tibial tubercle-trochlear groove distance (TT-TG). The control group (CG) comprised 87 age- and gender-matched patients without history of anterior knee pain or lateral patellar instability. It was hypothesized that patients with PT might be related to patellofemoral dysplasia. It was found that the patella was significantly higher in patients with PT compared to the CG (patellotrochlear index [PT-I]: 0.33 vs 0.37, P = .014; Insall-Salvati index [InSa]: 1.18 vs 1.07, P = .004). PT-I was above the cut-off value in 10.6% of PT knees (CG 5.7%, P = .27), and InSa in 42.6% (CG 21.8%, P = .012). TT-TG was significantly higher in patients with PT compared to CG (12.0 mm vs 9.9 mm, P = .002); however, TT-TG was only pathologic (>20 mm) in one patient. The trochlear facet ratio was above the cut-off value in 55.3% of PT patients and 23% of CG (P < .001), and was significantly greater in patients with PT (0.39 ± 0.09) than CG (0.48 ± 0.1, P < .001). Knees with PT have significantly more morphological characteristics of patellofemoral instability, which needs to be considered especially in recurrent or treatment-refractive cases.
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Affiliation(s)
- P M Tscholl
- Department of Orthopaedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.,Division of Orthopedics and Trauma Surgery, Geneva University Hospital, Geneva, Switzerland
| | - R M Biedert
- SportsClinic#1, Wankdorf Center, Bern, Switzerland
| | - F Wanivenhaus
- Department of Orthopaedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - S F Fucentese
- Department of Orthopaedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Novel animal model for Achilles tendinopathy: Controlled experimental study of serial injections of collagenase in rabbits. PLoS One 2018; 13:e0192769. [PMID: 29438431 PMCID: PMC5811024 DOI: 10.1371/journal.pone.0192769] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 01/30/2018] [Indexed: 11/19/2022] Open
Abstract
Our goal was to develop a novel technique for inducing Achilles tendinopathy in animal models which more accurately represents the progressive histological and biomechanical characteristic of chronic Achilles tendinopathy in humans. In this animal research study, forty-five rabbits were randomly assigned to three groups and given bilateral Achilles injections. Low dose (LD group) (n = 18) underwent a novel technique with three low-dose (0.1mg) injections of collagenase that were separated by two weeks, the high dose group (HD) (n = 18) underwent traditional single high-dose (0.3mg) injections, and the third group were controls (n = 9). Six rabbits were sacrificed from each experimental group (LD and HD) at 10, 12 and 16 weeks. Control animals were sacrificed after 16 weeks. Histological and biomechanical properties were then compared in all three groups. At 10 weeks, Bonar score and tendon cross sectional area was highest in HD group, with impaired biomechanical properties compared to LD group. At 12 weeks, Bonar score was higher in LD group, with similar biomechanical findings when compared to HD group. After 16 weeks, Bonar score was significantly increased for both LD group (11,8±2,28) and HD group (5,6±2,51), when compared to controls (2±0,76). LD group showed more pronounced histological and biomechanical findings, including cross sectional area of the tendon, Young’s modulus, yield stress and ultimate tensile strength. In conclusion, Achilles tendinopathy in animal models that were induced by serial injections of low-dose collagenase showed more pronounced histological and biomechanical findings after 16 weeks than traditional techniques, mimicking better the progressive and chronic characteristic of the tendinopathy in humans.
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Mascaró A, Cos MÀ, Morral A, Roig A, Purdam C, Cook J. Load management in tendinopathy: Clinical progression for Achilles and patellar tendinopathy. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/j.apunts.2017.11.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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47
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Herod TW, Veres SP. Development of overuse tendinopathy: A new descriptive model for the initiation of tendon damage during cyclic loading. J Orthop Res 2018; 36:467-476. [PMID: 28598009 DOI: 10.1002/jor.23629] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 06/05/2017] [Indexed: 02/04/2023]
Abstract
Tendinopathic tissue has long been characterized by changes to collagen microstructure. However, initial tendon damage from excessive mechanical loading-a hallmark of tendinopathy development-could occur at the nanoscale level of collagen fibrils. Indeed, it is on this scale that tenocytes interact directly with tendon matrix, and excessive collagen fibril damage not visible at the microscale could trigger a degenerative cascade. In this study, we explored whether initiation of tendon damage during cyclic loading occurs via a longitudinal compression-induced buckling mechanism of collagen fibrils leading to nanoscale kinkband development. Two groups of tendons were cyclically loaded to equivalent peak stresses. In each loading cycle, tendons in one group were unloaded to the zero displacement mark, while those in the other group were unloaded to a nominal level of tension, minimizing the potential for fibril buckling. Tendons that were unloaded to the zero displacement mark ruptured significantly sooner during cyclic loading (1,446 ± 737 vs. 4,069 ± 1,129 cycles), indicating that significant fatigue damage is accrued in the low stress, toe region of the load-deformation response. Ultrastructural analysis using scanning electron microscopy of tendons stopped after 1,000 cycles showed that maintaining a nominal tension slowed the accumulation of kinkbands, supporting a longitudinal compression-induced buckling mechanism as the basis for kinkband development. Based on our results, we present a new descriptive model for the initiation of tendon damage during cyclic loading. The so-called Compression of Unrecovered Elongation or CUE Model may provide useful insight into the development of tendinopathy. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:467-476, 2018.
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Affiliation(s)
- Tyler W Herod
- School of Biomedical Engineering, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Samuel P Veres
- School of Biomedical Engineering, Dalhousie University, Halifax, Nova Scotia, Canada.,Division of Engineering, Saint Mary's University, 923 Robie Street, Halifax, Nova Scotia Canada B3H 3C3
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Heterogeneity of passive elastic properties within the quadriceps femoris muscle–tendon unit. Eur J Appl Physiol 2017; 118:213-221. [DOI: 10.1007/s00421-017-3763-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Accepted: 11/09/2017] [Indexed: 10/18/2022]
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Fernandez-Jaén T, Rey GÁ, Angulo F, Cuesta JA, Loureda RA, España FÁ, Ayala J, Matas RB, Pazos FB, de Dios Beas Jiménez J, Rosell JC, Fernandez CC, del Pilar Doñoro Cuevas M, Ros FE, Colmenero JE, de Prado JF, García Cota JJ, Garrido González JI, de Vega CG, Santander MG, Herrador Munilla MÁ, Ruiz FI, Díaz FJ, Fernandez AM, Marqueta PM, Muñoz Benito JJ, Vilás RO, Pedret C, Teres XP, Amaro JP, Grifell JP, San Roque JP, Parenteu CR, Serna JR, Rodas G, Álvarez MS, Marchori CS, Perez LT, Durán RU, del Valle Soto M, Villalón Alonso JM, García PG. Spanish Consensus Statement: Clinical Management and Treatment of Tendinopathies in Sport. Orthop J Sports Med 2017; 5:2325967117734127. [PMID: 29119124 PMCID: PMC5666520 DOI: 10.1177/2325967117734127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
On October 15, 2016, experts met at Clínica CEMTRO in Madrid, Spain, under the patronage of the Spanish Society for Sports Traumatology (SETRADE), the Spanish Society of Sports Medicine (SEMED), the Spanish Association of Medical Services for Football Clubs (AEMEF), the Spanish Association of Medical Services for Basketball Clubs (AEMB), F.C. Barcelona, and Clínica CEMTRO. The purpose was to consider the most appropriate clinical management and treatment of tendinopathies in sports, based on proven scientific data described in the medical literature as well as on each expert’s experience. Prior to the meeting, each expert received a questionnaire regarding clinical management and treatment of tendinopathies in sports. The present consensus document summarizes the answers to the questionnaire and the resulting discussion and consensus regarding current concepts on tendinopathies in sports.
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Affiliation(s)
| | - Tomas Fernandez-Jaén
- Tomas F. Fernandez-Jaén, MD, PhD, Clínica CEMTRO, Ventisquero de la Condesa 42, Madrid 28035, Spain ()
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Alves TI, Girish G, Kalume Brigido M, Jacobson JA. US of the Knee: Scanning Techniques, Pitfalls, and Pathologic Conditions. Radiographics 2017; 36:1759-1775. [PMID: 27726755 DOI: 10.1148/rg.2016160019] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Pain and other disorders of the knee are a common presenting complaint in the ambulatory setting. Although the cornerstones of imaging evaluation of the knee are radiographs and magnetic resonance (MR) imaging, ultrasonography (US) is less expensive than MR imaging, easily available, and of comparable accuracy in the evaluation of certain pathologic conditions of the knee. The benefits of US include portability, low cost, high spatial resolution, dynamic imaging, and ability to guide percutaneous interventions when indicated. US also allows direct patient contact, facilitating immediate clinical correlation and the ability to compare with the contralateral knee. US evaluation of the knee can be targeted to a specific region on the basis of the complaint or be a comprehensive review. For comprehensive evaluation, the knee is divided into anterior, medial, lateral, and posterior compartments for structured evaluation of the tendons, ligaments, joint space, osseous structures, as well as peripheral nerves and vasculature. US is particularly well suited for evaluating injuries of the quadriceps and patellar tendons, injuries of the medial and lateral collateral ligaments, joint effusions, and fluid collections around the knee. There is additional utility in evaluation of the distal hamstrings tendons, the iliotibial tract, the superficial patellar cortex, the common peroneal nerve, the popliteal vessels, and juxta-articular cystic collections including Baker cyst. In-depth appreciation of relevant sonographic anatomy, common pathologic conditions, knowledge of important pitfalls, and mastery of US technique will allow one to effectively use this powerful bedside tool for the evaluation of a wide variety of knee disorders. ©RSNA, 2016.
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Affiliation(s)
- Timothy I Alves
- From the Department of Radiology, Division of Musculoskeletal Imaging, University of Michigan Health System, 2910 S Taubman Center, SPC 5326, 1500 E Medical Center Dr, Ann Arbor, MI 48109
| | - Gandikota Girish
- From the Department of Radiology, Division of Musculoskeletal Imaging, University of Michigan Health System, 2910 S Taubman Center, SPC 5326, 1500 E Medical Center Dr, Ann Arbor, MI 48109
| | - Monica Kalume Brigido
- From the Department of Radiology, Division of Musculoskeletal Imaging, University of Michigan Health System, 2910 S Taubman Center, SPC 5326, 1500 E Medical Center Dr, Ann Arbor, MI 48109
| | - Jon A Jacobson
- From the Department of Radiology, Division of Musculoskeletal Imaging, University of Michigan Health System, 2910 S Taubman Center, SPC 5326, 1500 E Medical Center Dr, Ann Arbor, MI 48109
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