Many athletes do not realize that tendons are at least as important as muscles in athletic performance. Tendons provide essential stiff mechanical characteristics that make actions like running, jumping, and climbing possible. Thus much of athletic training should focus on strengthening the tendons even more than the muscles, but tendons can be slower to adapt. In many cases of injury or overuse, tendons can fall into a rut of inflammation known as tendonitis. Even if this inflammatory process resolves, an even more chronic degradation phase can occur, known as "tendinopathy" or "tendinosis." Tendonitis is like a train that is sparking down the tracks and about to derail, whereas tendinopathy is like a train that has already derailed. As you can imagine, trying to steer a derailed train back onto the train tracks is a difficult task-- the collagen fibrils in the tendon simply struggle to self-organize and grab hold of each other for cross-linking like they normally should, hence the tendon is not able to rebuild and restrengthen itself.
Any tendon attachment point can get tendinopathy, and with image-guidance we can treat any of these sites at the source of injury. We have seen a wide variety of tendon pathologies, with the most common tendinopathy locations being:
- Tennis elbow
- Golfer’s elbow
- Rotator cuff tendonitis (swimmer's/pitcher's shoulder)
- Patellar tendonitis (jumper’s knee)
- Plantar fasciitis
- Achilles tendonitis
- Hip flexor tendonitis
- Gluteus medius/minimus tendonitis.
Understanding the molecular synthesis of collagen is essential for understanding this pathophysiology of tendinopathies (see the nutrition page for more details), but in the final stages of collagen maturation, reactive aldol groups on hydroxylysine react non-enzymatically with sugar to create covalent glycosylated cross-links ("advanced glycation end-products") between fibrils that can add further strength to collagen fibers, but interestingly under states of cell death and inflammation the fibrils can become over-glycated by release of sugar and other contents from localized dying cells, which appears to impair the ability of newly-synthesized collagen fibers to bind to older fibers and thus impairs proper tendon regeneration, and this may explain the dramatic efficacy of treatments like shockwave therapy, PRF repair, peptide therapy, and new injectable investigational medications, which is an area of active ongoing research at AAMI (1) (2) (3) (4).
On the microscopic histology scale, tendinopathy is seen as disorganized collagen fibrils, increase in mucoid ground substance, changes in collagen subtype expression, random neovascularization, focal necrosis, fibrocartilaginous metaplasia, calcification, and interstitial tearing. Some of these features like the neovascularization likely represent failed attempts at tissue repair and persistence of either inflammatory, ischemic, or degenerative conditions of the injured tissue. Evidence suggests that a variety of different mechanisms are involved in tendinosis, which can vary in each patient. This can involve specific subtypes of inflammatory and immunologic signaling mechanisms, and several types of autoimmune disease are also known to weaken tendon attachments. Furthermore, tendinopathies may involve a response to microscopic injuries and tears within the tendon, and there seems to be a distinct neurovascular injury component to some tendinopathies. In both acute and chronic degenerative conditions, this may involve specific sub-types of inflammatory signaling, including Substance P, Tachykinins, and macrophage activation.
The degenerative tendinopathy process can sometimes be ameliorated in the acute phase, but once in full swing it can sometimes take years to recover if left untreated. In these chronic cases of tendinopathy, I have seen that in many cases there is also an associated tendon or ligament tear that has gone undiagnosed. On ultrasound these injuries can appear as a partial-thickness tear or intrasubstance tear, thickened heterogenous tendon with nodular hypoechoic areas, interstitial splits, hyperechoic calcifications (calcific tendinosis), tendon sheath tears or effusions, increased flow on color doppler and power doppler, dilated vascularity, nerve impingement and swelling, and sometimes the entire elbow joint synovium and capsule can become inflammed.
Fortunately there are now new and powerful tools to treat tendonitis and tendinopathies that can speed recovery and maximize tendon strength. Many of these therapies can be done concurrently, giving the best chance of rapid recovery, or the treatment options can be spaced out one at a time to test out their individual efficacy. The following new and ground-breaking therapies have shown the greatest efficacy:
The therapies listed below can be done individually or combined for maximal accelerated tissue repair. For example, the minimally-invasive image-guided PRF tendon repair procedures can be combined with shockwave ultrasound therapy and regenerative peptides targeted around the injury site to further stimulate tissue remodeling and repair. This distinguishes our approach from other approaches like TENEX, which is a procedure that uses a form of ultrasound therapy to treat tendinopathy but which is more expensive and more invasive without the multifaceted regenerative approach.
1) Platelet-Rich Fibrin (PRF) - this cutting-edge therapy provides numerous growth factors, biochemical activators, and scaffolding matrix support that have been shown to enhance regeneration of muscle, tendon, ligament, and joints. The activated fibrin matrix gives a scaffolding on which to build new tissue and which releases helpful growth factors and peptides over time. White blood cells also influence the early differentiation of bone and tendon progenitor cells, and specific PRF protocols can activate white blood cells (especially the monocytes and platelets in the leukocyte-rich matrix) to secrete endogenous growth signaling factors like BMP-2, BMP-7, FGF, VEGF, PDGF, TGF-Beta, and Thrombospondin, which are released locally over the next few days to weeks to accelerate and strengthen tissue repair, and these can further activate recruitment and differentiation of Mesenchymal Stem Cells (MSCs) as well as expression of several tissue remodeling genes. Furthermore, to our knowledge, the Alpine Athletic Medicine clinic was the first clinic to perform PRF repairs under direct ultrasound-guided visualization in order to maximize repair at the injury site and minimize any needle damage in healthy tissue. For tissue and joint regeneration, PRF has the advantage that it causes platelet binding to fibrin, which initiates biochemical activation of certain cells, platelets, and growth factors and also provides an organized scaffolding matrix and fibrin glue to bind and support collagen fibers of tendon and ligament. Dr. McMurtrey originally developed image-guided PRF repair techniques for his own injuries after working with Dr. Joseph Choukroun who conducted the first research on PRF isolation, activation, and injection in France. See the PRF page for more information and extensive list of scientific literature that has been published on this therapy.
2) Peptide Therapy - tenocytes (tendon cells) can be pharmacologically stimulated to lay down new layers of collagen. This new ground-breaking approach has already demonstrated extraordinary improvement in recovery times of tendinopathies, and can be combined with PRF above. At the Alpine Athletic Medicine clinic, powerful peptides may be injected directly along the surface of the tendon or directly into an injury site under ultrasound guidance to stimulate tendon reorganization and repair (e.g., BPC-157, etc., and we have also started seeing interesting results with injectable glycosaminoglycans as well). In addition, certain peptides can be used to stimulate the release of natural hormones in your body (like injectable Sermorelin/Glycine or Ipamorelin/CJC-1295 to synergistically stimulate the release of your own natural Growth Hormone). In certain cases (like RED-Syndrome, etc.), hormones can also be used to restore natural balance, stimulate new collagen production, and optimize healing status. See the peptides page for more information.
3) Hyaluronic Acid Hydrogel - also known as "SportVis," this substance is injected along the tendon or ligaments (similar to PRF, PRP, or Stem Cells). It has been used for epicondylitis, ankle sprains, and osteoarthritis with good clinical evidence supporting efficacy in pain relief and recovery, but unlike the other agents it is a fairly inert lubricant substance by itself.
4) Stem Cells - along with PRF, preliminary evidence suggests autologous mesenchymal stem cell therapy may provide an enhanced stimulus of growth factors for tendon repair. The addition of PRF can provides additional factors that drives stem cells towards mesenchymal tissue repair and support the microenvironment. Although this work is in the early stages, stem cells have already been shown to kickstart tendon repair (6). See the stem cells page for more information.
5) Shockwave Therapy - continuing the analogy above, shock wave treatment is like using machinery to get a derailed train back onto the tracks. Electromagnetic energy is converted into pulsed waves of mechanical energy that impact and absorb into the stiff tendon tissue where the shockwaves disrupt inefficient degraded collagen fiber associations and also stimulate new tighter collagen fiber deposition and organization (5). This mechanical stimulation also stimulates cells to release growth factors, tensed muscle fibers to release, blood vessels to calm down (calming the reactive hyperemia), and more healing factors to be delivered to the injured area under normal vascular perfusion pressures. See the shockwave page for more information.
6) Myofascial Release / Scraping / Dry-Needling / Acupuncture / Soft-Tissue Mobilization / Active Release Technique / Trigger-Point Release / Instrument-Assisted Massage / Rolling / Percutaneous Needle Tenotomy - these again are various methods of stimulating connective tissue healing, uncoupling inappropriate binding of muscle fibers, breaking down inefficient collagen organization, mechanically disrupting pathological processes, stimulating tissue growth, and causing microvasculature hemorrhages that help stimulate tissue repair. Though less invasive and less effective than shockwave, PRF, or peptides, these can still be useful in providing additional tools for tissue healing. See the myofascial page for more information.
7) IV Infusions & Proper Nutrition - another essential component of tendon repair is ensuring that you are consuming all essential nutrients, vitamins, precursors, co-factors, and building blocks for robust collagen production and cross-linking... see our nutrition and infusion pages for more details. There is also some evidence that certain medications may be beneficial in repair of tendon, ligament, cartilage, and other collagen connective tissues.
8) Physical Therapy Exercises - this is an additional important tool for proper tissue healing, with a particular focus on doing eccentric exercises that stimulate tendon repair without overstraining the tendon, stretching overworked muscles that may have undergone adaptive muscle shortening, maintaining tissue loading and movement, and training antagonist muscles where necessary.
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*Disclaimer: The information presented here is for informational use and cites the ongoing cutting-edge research and medical advancements on these relevant topics. There are many treatments, interventions, and protocols routinely practiced in medicine and surgery which the FDA has not studied nor formally approved yet which have demonstrated overwhelming evidence of efficacy and clinical benefit. The FDA does not regulate the practice of medicine but rather regulates medical marketing of devices and drugs. The FDA does not conduct clinical trials or attempt to discover new treatments, but rather requires companies or other entities to fund marketing approvals. Breakthrough technologies typically require years to decades of research work to optimize the technology and collect enough data to prove efficacy and superiority, which in some cases can optionally be submitted to the FDA if there is sufficient financial backing to market a specific product or drug. Thus the FDA has not yet studied, evaluated, or formally approved many regenerative therapies currently practiced by many of the top physicians and surgeons in the United States and around the world. Some therapies, products, or interventions may still be considered investigational or "off-label" even with substantial evidence of efficacy, and many different applications of regenerative therapies continue to be researched by our institute and other top institutions around the world. We seek to always provide the highest-quality evidence-based care to our patients, which may include FDA-approved therapies as well as additional investigational or alternative therapies. We always discuss potential risks and benefits of all these options. The rapid evolution and advancement of medicine demands that physicians continually update their knowledge and practice techniques to adapt to future improvements and advancing technologies. These statements have not been evaluated by the FDA, and the treatments and products presented here are for informational purposes and not intended or guaranteed to diagnose, treat, cure, or prevent any specific disease or condition. All injuries and conditions should be formally evaluated by a knowledgeable medical professional whereby standard treatments and/or additional therapeutic interventions may be considered with the diagnosis and treatment plan.