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Painful, overuse tendon conditions have a non-inflammatory pathology
Tendinitis such as that of the Achilles, lateral
elbow, and rotator cuff tendons is a common presentation to family
practitioners and various medical specialists.1 Most
currently practising general practitioners were taught, and many still
believe, that patients who present with overuse tendinitis have a
largely inflammatory condition and will benefit from anti-inflammatory
medication. Unfortunately this dogma is deeply entrenched. Ten of 11 readily available sports medicine texts specifically recommend
non-steroidal anti-inflammatory drugs for treating painful conditions
like Achilles and patellar tendinitis despite the lack of a biological
rationale or clinical evidence for this approach.
2 3
Instead of adhering to the myths above, physicians should acknowledge
that painful overuse tendon conditions have a non-inflammatory pathology. Light microscopy of patients operated on for tendon pain
reveals collagen separation4-6thin, frayed, and fragile tendon fibrils, separated from each other lengthwise and disrupted in
cross section. There is an apparent increase in tenocytes with myofibroblastic differentiation (tendon repair cells) and classic inflammatory cells are usually absent.4 This is tendinosis and it was first described 25 years ago,6 but this
fundamental of musculoskeletal medicine has not yet replaced the
tendinitis myth. Tendinosis is not merely a long term corollary of
short term tendinitis. Animal studies show that within two to three weeks of tendon insult tendinosis is present and inflammatory cells are
absent.7
A critical review of the role of various anti-inflammatory medications
in soft tissue conditions found limited evidence of short term pain
relief and no evidence of their effectiveness in providing even medium
term clinical resolution of clearly diagnosed tendon
disorders.2 Laboratory studies have not shown a
therapeutic role for these medications. Corticosteroid injections
provide mixed results in relieving the pain of
tendinopathy.
8 9
If general practitioners, orthopaedic surgeons, and other
members of the healthcare professions treating tendon disorders made a
quantum shift from previous flawed teaching about overuse tendinitis
and adopted these data there would be immediate ramifications. Nomenclature for the clinical presentation of tendon disorders would
reflect the true histopathological basis underlying clinical presentation.10 The term tendinitis would rarely cross
doctors' lips. Numerous authorities
2 10
recommend the
term tendinopathy (for example, Achilles tendinopathy) as this
acknowledges that the condition is not tendinitis. We favour this term
for clinical diagnosis. Most importantly, we must acknowledge, at least
till contrary data appear, that anti-inflammatory pharmacotherapy does not provide significant long term benefit in
tendinopathy.
2 11
Nevertheless, high quality randomised
controlled trials are urgently needed to examine the long term effects
of these medications on tendinopathy.
If general practitioners treating musculoskeletal conditions
embraced the tendinopathy paradigm, it would provide patients with an
accurate description of their condition. It would avoid inappropriate
pharmacotherapy with its attendant costs and comorbidity. Furthermore,
by accepting need to allow time for collagen turnover and remodelling
inherent in the pathology of tendinosis, doctors would be free to
provide patients with a realistic prognosis that better reflects the
finding of prospective clinical studies.12 These
conditions take months rather than weeks to resolve.
Some pockets of the sports medicine, orthopaedics, and
rheumatology specialties have adopted this
paradigm,
2-4 10
but it must no longer remain within that
cabal. It is time for medical educators to accept the irrefutable
evidence that the term tendonitis must be abandoned to highlight a new
perspective on tendon disorders. Adopting the tendinopathy paradigm is
essential if general practitioners are to practise evidence based
medicine. However, there remain many unanswered questions, particularly
with respect to treatment.
Department of Family Practice, University of British Columbia,
Vancouver, Canada V6T 1Z3 School of Physiotherapy, LaTrobe University, Bundoora,
Australia 3083 Department of Surgery, Tampere University Medical School and
University and UKK Institute, Tampere, Finland 33501 Department of Trauma and Orthopaedic Surgery, Keele University
School of Medicine, North Staffordshire Hospital, Stoke on Trent,
ST4 7QB Douglass Hanly Moir Pathology, Sydney, Australia 2113
J L Cook
P Kannus
N Maffulli
S F Bonar
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