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com

Warm up

Tendinopathy: no longer a ‘one As a clinically focused journal, BJSM

only publishes animal studies that are of
particular relevance to patients in the short
size fits all’ diagnosis term and the rabbit research in this issue
does shed light on human tendinopathy.
Commonly, individuals have unilateral
Jill Cook symptoms, although often bilateral pathol-
ogy is evident on imaging. This seems
logical in the lower limb, but it also holds
Tendon research has come a long way. So finding from the same group; the possi-
true in the upper limb6 where it makes less
far, in fact, that 120 tendon-interested cli- bility that the Achilles tendon can have
sense. Anderson et al (see page 399) show
nicians and scientists met in Umeå, north superficial tears. Certainly it puts the
that loading one Achilles tendon produced
Sweden, in October 2010 at a conference onus of accurate diagnosis as a key part
pathological changes in the other tendon
called ‘Neuronal and non-neuronal path- of your clinical pathway, as treatments
that was not loaded. Logically, the authors
ways in the tendon pathology contin- can vary greatly. Achilles tendinopathy
propose that there may be some central
uum’. The novel data, vigorous exchanges is no longer an uncomplicated diagnosis
mechanisms involved, and this may clearly
and the generation of new ideas for study with eccentric exercises as the universal
play a role in the bilateral pathology and/
highlighted the buzz in this field. The answer.
or symptoms that present clinically. The
stories of challenging clinical cases under-
‘global response’ of tendons to stimuli is
scored the urgency for improvements in ADVANCES IN TREATMENT also reported when pain is induced experi-
diagnosis and in treatment. In this issue, Although diagnosis is a cornerstone of mentally (see page 393). Here the authors
you will find papers on new surgical tech- clinical practice, advances in treatment describe a decrease in muscle response in
niques (see pages 407 and 411), advances are what most clinicians want to hear not only the calf muscle, but the agonists
in understanding tendon pain (see pages about. Simplistic and unimodal inter- as well, when the tendon was painful.
393 and 429) and updates on injection ventions have produced varied out- So, another raft of new concepts to
therapies (see pages 411 and 424). All comes and this is also evident in this add to your clinical armour. There is
these allow you to manage patients and issue. Platelet-rich plasma,2 one could be no hint that Moses provided tendon
athletes who present with problematical tempted to call a fashionable or funky solutions on a tablet, but tendon injury
tendon symptoms more effectively. treatment for tendons,3 promised to has been recognised as a major clinical
deliver a cocktail of appropriate growth problem and many excellent research
SUBGROUPS, STAGES AND factors to the tendinopathy region and groups throughout the world are sharing
ALGORITHMS improve both pain and tendon healing. their best research via BJSM. Please do
One of the issues arising from all this A randomised trial has shown that it make suggestions as to what you would
research is that the days are well gone was no better than saline for pain,4 and like us to address on BJSM podcasts and
when tendinopathy was an overarching did not improve ultrasound appearance, tell us who you would like to hear from
diagnosis. Subgroups of tendinopathies, a surrogate measure for pathology (see (jill. cook@monash.edu).
different stages of presentation, and risk page 387).
Provenance and peer review Not commissioned;
factors that vary between sexes, ages and Prolotherapy, on the other hand, added not externally peer reviewed.
activities mean that the diagnosis must be a small advantage over eccentric exer-
more specific than just ‘tendinopathy’. cise alone in the short term as shown in Accepted 18 January 2011
This is most clearly described by another randomised trial (see page 421). Br J Sports Med 2011;45:385.
Professor Alfredson (see pages 386 and Similarly in the elbow, although short- doi:10.1136/bjsm.2011.084111
407), who raises the concept of plantaris term effects of glyceryl trinitrate patches
being the root of some failed Achilles ten- have been described,5 the longer-term REFERENCES
dinopathy treatments. Although he sug- outcome is no better than standard treat- 1. Jonsson P, Alfredson H, Sunding K, et al. New
gests a surgical solution (he is a surgeon!) ment (see page 416). These treatments regimen for eccentric calf-muscle training in patients
there are conservative approaches that may be especially beneficial in athletes with chronic insertional Achilles tendinopathy: results
of a pilot study. Br J Sports Med 2008;42:746–9.
may work if applied in the early stages. when quick recovery is an essential part 2. Engebretsen L, Steffen K, Alsousou J, et al. IOC
As he suggests that compression of the of your decision making. Consensus paper on the use of platelet-rich plasma in
plantaris against the Achilles may be a The complexities of making treatment sports medicine. Br J Sports Med 2010;44:1072–81.
3. Cook J. Funky treatments in elite sports people: do
key aetiology, then reducing compression decisions in tendinopathy is enhanced by they just buy rehabilitation time? Br J Sports Med
similar to the approach taken with inser- these well-designed and well run trials. 2010;44:221.
tional Achilles tendon problems can help.1 What we now need to know is the effect 4. de Vos RJ, Weir A, van Schie HT, et al. Platelet-rich
plasma injection for chronic Achilles tendinopathy: a
It may also explain why heel raises help of the diagnostic subgroups mentioned randomized controlled trial. JAMA 2010;303:144–9.
some people with Achilles tendinopathy above; would someone with a plantaris 5. Paoloni JA, Appleyard RC, Nelson J, et al. Topical
and yet do not seem to help others. tendon or a superficial tear be less likely nitric oxide application in the treatment of chronic
On top of building this into your diag- to be responsive to injection therapies? extensor tendinosis at the elbow: a randomized,
double-blinded, placebo-controlled clinical trial.
nostic algorithm, you can add another Every time you think you are getting Am J Sports Med 2003;31:915–20.
close to understanding a simple presenta- 6. Miniaci A, Dowdy PA, Willits KR, et al. Magnetic
tion such as Achilles tendinopathy, more resonance imaging evaluation of the rotator cuff
Correspondence to Dr Jill Cook, Monash University, tendons in the asymptomatic shoulder. Am J Sports
McMahons Road, Frankston, VIC 3199, Australia; information to complicate your clinical Med 1995;23:142–5.
jill.cook@monash.edu processes is published.

Br J Sports Med 2011 April Vol 45 No 5 385

 Downloaded from http://bjsm.bmj.com/ on March 21, 2017 - Published by group.bmj.com

Tendinopathy: no longer a 'one size fits all'

diagnosis
Jill Cook

Br J Sports Med 2011 45: 385

doi: 10.1136/bjsm.2011.084111

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