The Biology of Tendon Injury; Prof Malcolm Collins - Cape Town

Acute and chronic (overuse) tendon injuries are common as a result of participating in sports and occupational related physical activities. Although the risk factors associated with these injuries have been extensively investigated, the biological mechanisms that cause these injuries are poorly understood.  This has resulted in multiple treatment modalities being proposed and used by clinicians to treat tendinopathies.  This presentation will discuss the biology and molecular mechanisms underlying tendon injuries. Recent developments in the identification of genetic risk factors for tendon injuries will also be reviewed.  Understanding the genetic risk factors of tendon injuries will provide additional insights into the molecular mechanisms that underpin these injuries and could also be included in multifactorial models that will assist in the clinical management of ‘high-risk’ athletes and workers.

 Imaging for Tendon Injuries; Dr Andrew Van Den Heever - Cape Town

This talk will contain many images to illustrate the radiological assessment of tendon pathology using mainly ultrasound and MRI techniques. Radiology plays an important role in the diagnosis of Acute tendon tears which may be full thickness, partial thickness or involve the myotendinous junction. Injury to superficial tendons (eg Achilles) are easily assessed with ultrasound. Full thickness tears are also easily appreciated with MRI. Chronic repetitive microtrauma may result in tendonosis. Tendonosis is manifest by tendon swelling, increased T2 signal on MRI and decreased echogenicity on ultrasound.  This presentation will demonstrate how acurate radiology can play an important role in sports medicine when defining the precise tendon injury and planning clinical management.

 Soft Tissue Tendon Management Protocols; Helen Millson - UK

Tendinopathy, although common in athletes, is poorly understood in terms of the underlying pathogenesis. Conservative management remains a challenge because of the deficient tendon repair and incomplete understanding of the pathology.
There are a number of good studies regarding tendon rehabilitation, in particular the use of eccentric exercises. However, there is poor evidence overall regarding the conservative management and the different strategies when dealing with tendinopathy.  This presentation will focus on the alternative treatments such as Electrotherapy, Massage including SSTM, Taping, Heat, Ice, Injections etc. as well as what will not work. The biomechanical assessment is also the cornerstone of any successful treatment protocol and will be discussed as well as the integration of relevant research into useable clinical guidelines.

 Tendon Rehabilitation; One size fits all? Is one rehab approach suitable for all clinical tendinopathies;  Jill Cook - Australia

There is now clear evidence that tendon is responsive to mechanical loading and that exercise stimulates tendon healing. Surgical intervention appears to stimulate tendon repair by initiating the triphasic response of inflammation, proliferation and repair. The conservative treatment recorded in the literature of tendinopathy includes combinations of rest and exercise – especially eccentric exercise. Different conservative treatments may have a cumulative effect and investigations often include more than one aspect to the intervention as well as other activity and treatments, making it difficult to delineate the most effective part of the treatment.  As the literature has shifted from an inflammatory model, studies of the treatment of tendinopathy have focused on exercise, and most of the new studies include an exercise based treatment regimen.

 Conservative management of Tendinopathies: From stem cells to shock waves. Prof Wayne Derman – Cape Town

Chronic tendon injuries remain a difficult therapeutic challenge. This is due to the fact that the exact pathophysiology is largely unknown, but thought to be a failure of the normal healing process. Furthermore it is also unknown where the pain in most tendinopathies is originating from. Yet, through a sound approach to available therapeutic interventions, up to 75% of chronic degenerative tendinopathies can be resolved without surgery. This talk will review the clinical pathophysiology of the lower limb tendinopathies and focus on the various clinical interventions that are know to be helpful in this condition. These include the Correction of risk factors, Massage, Night splint, NSAID's, Corticosteroid Injections, Eccentric Exercise, Gyceryl Trinitrate Patches, Electrotherapy (microwave and microcurrent), Extra Corporeal Shock Wave Therapy, Sclerosing agents, Prolotherapy and Blood and platelet rich plasma injections. In the final part of this talk a therapeutic algorithm is presented which puts these interventions into perspective.

 Tendon Injury Management - An Orthopedic Overview; Dr Willem Van Der Merwe - Cape Town

More to follow.....

 The Role of Injection and Minimally - Invasive Surgery for Tendinopathies; Prof Hakan Alfredson - Sweden

Recent research at the Sports Medicine Unit in Umeå, Sweden, using ultrasound (US) together with Doppler, and immunohistochemical analyses of tendon tissue specimens, have opened up possibilities for new treatment strategies for lower limb tendinopathies. The findings of increased vascularity in the painful region of the tendon and sensory, as well as sympathetic nerves, in close relation to the vessels, is the background to the new treatment methods sclerosing Polidocanol injections and US+Doppler-guided mini-invasive surgical approaches. Interestingly, it seems that finally the site for pain has been localized. Treatment is instituted outside the tendon, without intra-tendinous invasive procedures. Using sclerosing Polidocanol injections, targeting the area with neovessels and nerves outside the ventral Achilles midportion, 80 % of the patients with chronic midportion tendinosis have been shown to be able to go back to their previous activity level after a mean of 2 injection treatments with 6-8 weeks in between. For insertional Achilles disorders, about 65-70% of the patients are satisfied after a mean of 3 treatments. There are very few complications. Two-year follow-ups, show that in successfully treated patients the tendon thickness is significantly reduced, and the structure is more normal, indicating a possible remodelling potential in these tendons. Further evaluations of these procedures are needed, but it seems to be possible to cure chronic Achilles tendon pain with treatments instituted outside the tendon, without need for immobilisation and long periods of rehabilitation.