Strickland, J W
In this five-part series, we have attempted to review our current understanding of flexor tendon anatomy, physiology, biomechanics, healing and adhesion formation around a repaired tendon. The methods of acute flexor tendon repair, conventional free tendon grafting, staged flexor tendon reconstruction and pulley restoration have been discussed as well as flexor tenolysis, rehabilitation and results. From these articles it may be seen that flexor tendon surgery is a complex and difficult art which requires a thorough appreciation of the normal flexor tendon system, the exact status of that system following injury and a strong understanding of the techniques which may be best utilized to restore flexor tendon function. The procedures described require both technical skill and experience and postoperative therapy programs must be carefully instituted based on the unique status of each patient. With the important advances occurring in many areas of flexor tendon surgery, it is realistic to believe that in the near future the techniques described in these articles may be substantially altered and modified. Results will continue to improve until the patient and surgeon can realistically expect to return most digits to nearly full function after flexor tendon interruption.
King, Elizabeth A; Lien, John R
Closed pulley ruptures are rare in the general population but occur more frequently in rock climbers due to biomechanical demands on the hand. Injuries present with pain and swelling over the affected pulley, and patients may feel or hear a pop at the time of injury. Sequential pulley ruptures are required for clinical bowstringing of the flexor tendons. Ultrasound confirms diagnosis of pulley rupture and evaluates degree of displacement of the flexor tendons. Isolated pulley ruptures frequently are treated conservatively with early functional rehabilitation. Sequential pulley ruptures require surgical reconstruction. Most climbers are able to return to their previous activity level.
Griffin, M; Hindocha, S; Jordan, D; Saleh, M; Khan, W
Flexor tendon injuries still remain a challenging condition to manage to ensure optimal outcome for the patient. Since the first flexor tendon repair was described by Kirchmayr in 1917, several approaches to flexor tendon injury have enabled successful repairs rates of 70-90%. Primary surgical repair results in better functional outcome compared to secondary repair or tendon graft surgery. Flexor tendon injury repair has been extensively researched and the literature demonstrates successful repair requires minimal gapping at the repair site or interference with tendon vascularity, secure suture knots, smooth junction of tendon end and having sufficient strength for healing. However, the exact surgical approach to achieve success being currently used among surgeons is still controversial. Therefore, this review aims to discuss the results of studies demonstrating the current knowledge regarding the optimal approach for flexor tendon repair. Post-operative rehabilitation for flexor tendon surgery is another area, which has caused extensive debate in hand surgery. The trend to more active mobilisation protocols seems to be favoured but further study in this area is needed to find the protocol, which achieves function and gliding but avoids rupture of the tendons. Lastly despite success following surgery complications commonly still occur post surgery, including adhesion formation, tendon rupture and stiffness of the joints. Therefore, this review aims to discuss the appropriate management of these difficulties post surgery. New techniques in management of flexor tendon will also be discussed including external laser devices, addition of growth factors and cytokines. PMID:22431948
Chinchalkar, Shrikant J; Pipicelli, Joey G; Agur, Anne; Athwal, George S
In this manuscript, these authors have utilized years of clinical experience to suggest rehabilitation modifications for Zone III flexor tendon injuries. - VictoriaPriganc, PhD, OTR, CHT, CLT, Practice Forum Editor.
Kotwal, Prakash P; Ansari, Mohammed Tahir
Flexor tendon injuries are seen commonly yet the management protocols are still widely debated. The advances in suture techniques, better understanding of the tendon morphology and its biomechanics have resulted in better outcomes. There has been a trend toward the active mobilization protocols with development of multistrand core suture techniques. Zone 2 injuries remain an enigma for the hand surgeons even today but the outcome results have definitely improved. Biomolecular modulation of tendon repair and tissue engineering are now the upcoming fields for future research. This review article focuses on the current concepts in the management of flexor tendon injuries in zone 2. PMID:23325961
In the reconstruction of hand flexor tendon injuries it is fundamental to select the best suture technique, which makes possible early, active postoperative mobilization and achievement of the best results. The author reviews the development of suture techniques of the flexor tendon injuries during the last fifteen years, and discusses experimental tendon reconstruction results as well as clinical outcomes. The author describes the importance of different tendon suture materials, the significance of the pulley system of the fingers, the stretching between the sutured tendon ends by tendon sutures and, finally, the importance of the moving course in the reconstructed tendon. He states, that the wide-range adoption of the discussed modern tendon sutures would be necessary for better postoperative results.
Dovelle, S; Heeter, P K
This article describes the use of the "Washington Regimen" of early controlled motion in the rehabilitation of flexor tendon injuries of the hand. This regimen is derived from a combination of Kleinert's controlled active extension with rubber-hand passive flexion, Duran's controlled passive techniques, and the modification of the Kleinert orthosis that uses a palmar pulley system. Based on results of clinical investigations, this regimen of early controlled motion appears effective in inhibiting peritendinous scarring, joint contractures, and other complications that commonly occur secondary to flexor tendon repairs. A six-week staged regimen of postoperative rehabilitation is presented. Splint design, exercise regimen, and rationale for treatment are reviewed.
Jacobsen, Else; Dart, Andrew J.; Mondori, Takamitsu; Horadogoda, Neil; Jeffcott, Leo B.; Little, Christopher B.; Smith, Margaret M.
It is not known how extensively a localised flexor tendon injury affects the entire tendon. This study examined the extent of and relationship between histopathologic and gene expression changes in equine superficial digital flexor tendon after a surgical injury. One forelimb tendon was hemi-transected in six horses, and in three other horses, one tendon underwent a sham operation. After euthanasia at six weeks, transected and control (sham and non-operated contralateral) tendons were regionally sampled (medial and lateral halves each divided into six 3cm regions) for histologic (scoring and immunohistochemistry) and gene expression (real time PCR) analysis of extracellular matrix changes. The histopathology score was significantly higher in transected tendons compared to control tendons in all regions except for the most distal (P ≤ 0.03) with no differences between overstressed (medial) and stress-deprived (lateral) tendon halves. Proteoglycan scores were increased by transection in all but the most proximal region (P < 0.02), with increased immunostaining for aggrecan, biglycan and versican. After correcting for location within the tendon, gene expression for aggrecan, versican, biglycan, lumican, collagen types I, II and III, MMP14 and TIMP1 was increased in transected tendons compared with control tendons (P < 0.02) and decreased for ADAMTS4, MMP3 and TIMP3 (P < 0.001). Aggrecan, biglycan, fibromodulin, and collagen types I and III expression positively correlated with all histopathology scores (P < 0.001), whereas lumican, ADAMTS4 and MMP14 expression positively correlated only with collagen fiber malalignment (P < 0.001). In summary, histologic and associated gene expression changes were significant and widespread six weeks after injury to the equine SDFT, suggesting rapid and active development of tendinopathy throughout the entire length of the tendon. These extensive changes distant to the focal injury may contribute to poor functional outcomes and re-injury
Jacobson, Else; Jacobsen, Else; Dart, Andrew J; Mondori, Takamitsu; Horadogoda, Neil; Jeffcott, Leo B; Little, Christopher B; Smith, Margaret M
It is not known how extensively a localised flexor tendon injury affects the entire tendon. This study examined the extent of and relationship between histopathologic and gene expression changes in equine superficial digital flexor tendon after a surgical injury. One forelimb tendon was hemi-transected in six horses, and in three other horses, one tendon underwent a sham operation. After euthanasia at six weeks, transected and control (sham and non-operated contralateral) tendons were regionally sampled (medial and lateral halves each divided into six 3 cm regions) for histologic (scoring and immunohistochemistry) and gene expression (real time PCR) analysis of extracellular matrix changes. The histopathology score was significantly higher in transected tendons compared to control tendons in all regions except for the most distal (P ≤ 0.03) with no differences between overstressed (medial) and stress-deprived (lateral) tendon halves. Proteoglycan scores were increased by transection in all but the most proximal region (P < 0.02), with increased immunostaining for aggrecan, biglycan and versican. After correcting for location within the tendon, gene expression for aggrecan, versican, biglycan, lumican, collagen types I, II and III, MMP14 and TIMP1 was increased in transected tendons compared with control tendons (P < 0.02) and decreased for ADAMTS4, MMP3 and TIMP3 (P < 0.001). Aggrecan, biglycan, fibromodulin, and collagen types I and III expression positively correlated with all histopathology scores (P < 0.001), whereas lumican, ADAMTS4 and MMP14 expression positively correlated only with collagen fiber malalignment (P < 0.001). In summary, histologic and associated gene expression changes were significant and widespread six weeks after injury to the equine SDFT, suggesting rapid and active development of tendinopathy throughout the entire length of the tendon. These extensive changes distant to the focal injury may contribute to poor functional outcomes and re-injury
Oki, H; Miyake, T; Kasashima, Y; Sasaki, Y
The superficial digital flexor tendon (SDFT) injury causes considerable wastage of racing Thoroughbreds. In this study, the heritability of SDFT injury of the forelimbs was estimated in the Thoroughbred racehorses based on the Bayesian analysis with Gibbs sampling using threshold animal models. New horse patients of SDFT injury at the age of 2-5 years accommodated in the training centers in 2005 were used for the analyses. Based on clinical data of 8198 horses, heritability of SDFT was estimated to be the order of 0.17 (posterior mode) to 0.19 +/- 0.05 (posterior mean +/- posterior SD).
Sade, Ilgin; İnanir, Murat; Şen, Suzan; Çakmak, Esra; Kablanoğlu, Serkan; Selçuk, Barin; Dursun, Nigar
[Purpose] The primary aim of this study was to assess rehabilitation outcomes for early and two-stage repair of hand flexor tendon injuries. The secondary purpose of this study was to compare the findings between treatment groups. [Subjects and Methods] Twenty-three patients were included in this study. Early repair (n=14) and two-stage repair (n=9) groups were included in a rehabilitation program that used hand splints. This retrospective evaluated patients according to their demographic characteristics, including age, gender, injured hand, dominant hand, cause of injury, zone of injury, number of affected fingers, and accompanying injuries. Pain, range of motion, and grip strength were evaluated using a visual analog scale, goniometer, and dynamometer, respectively. [Results] Both groups showed significant improvements in pain and finger flexion after treatment compared with baseline measurements. However, no significant differences were observed between the two treatment groups. Similar results were obtained for grip strength and pinch grip, whereas gross grip was better in the early tendon repair group. [Conclusion] Early and two-stage reconstruction of patients with flexor tendon injuries can be performed with similarly favorable responses and effective rehabilitation programs. PMID:27630400
Duci, Shkelzen B; Arifi, Hysni M; Ahmeti, Hasan R; Manxhuka-Kerliu, Suzana; Neziri, Burim; Mekaj, Agon Y; Lajqi, Shpetim; Shahini, Labinot
Background: The main goals of flexor tendon surgery are to restore digital motion by providing tendon healing and to preserve tendon gliding. Our purpose was to investigate the effects of 5-fluorouracil (5-FU) on tendon adhesions in partially divided profundus flexor tendons (flexor digitorum profundus [FDPs]) following surgical repair and in partially divided FDPs without surgical repair, and to compare the results of the repair versus the nonrepair of zone two injuries via macroscopic and biomechanical evaluations of tendon adhesions. Methods: We used 32 adult male European rabbits (Oryctolagus cunniculus) weighing from 2.5 to 3.5 kg. The study was performed on the deep flexor tendons of the second and third digits of the right hind paws of the rabbits; thus, a total of 64 tendons were examined in this study. Results: Based on the results achieved in our experimental study, the load (N) significantly increased in subgroup 1a in which the tendons were surgically repaired and were not treated with 5-FU compared with subgroup 2a in which tendons were surgically repaired and treated with 5-FU. Conclusions: The load (N) significantly increased in subgroup 1a in which the tendons were surgically repaired and were not treated with 5-FU compared to subgroup 2a in which the tendons were surgically repaired and treated with 5-FU. Therefore, these results revealed a decrease in adhesion formation in the subgroup that was treated with 5-FU due to increased resistance to tendon adhesions during their excursion through the tendon sheath, which in this case required greater traction force. PMID:26063369
Al-Qattan, Mohammad M
There is a paucity of the literature on the outcome of zone III flexor tendon injuries. In this paper, we report on the results of zone III flexor tendon repair in 35 consecutive adult patients with clean cut lacerations of both flexor tendons in 42 fingers. There were 25 men and 10 women with an average age of 32 years. Repair of both flexor tendons was performed using 'figure of eight' core sutures and a continuous epitendinous suture. Postoperatively, an immediate active range of motion protocol was applied to ensure full active extension of the interphalangeal joints. The results were assessed using the Strickland-Glogovac grading system. There were no ruptures. One patient with two injured fingers developed complex regional pain syndrome and the final outcome was fair in both fingers. In the remaining 34 patients (40 fingers), 33 patients (38 fingers) had an excellent outcome and the remaining patient (two fingers) had a good outcome.
Coats, Robert W; Echevarría-Oré, Julio C; Mass, Daniel P
Flexor tendon repair in zone II is still a technically demanding procedure, but the outcomes have become more predictable and satisfying. Of keystone importance for obtaining the goals of normal strength and gliding of repaired flexor tendons are an atraumatic surgical technique, an appropriate suture material, a competent pulley system, and the use of early motion rehabilitation protocols. The overall goal of hand and finger function also implies timely addressing of neurovascular injuries. New devices such as the TenoFix (Ortheon Medical; Winter Park, Florida) have shown adequate strength in the laboratory but are bulky and untested for work of flexion. Insufficient clinical data and high cost may prevent widespread use.
Yeh, Peter C; Shin, Steven S
Mallet injuries are the most common closed tendon injury in the athlete. Flexor digitorum profundus ruptures are rare in baseball, but are common injuries in contact sports. The diagnosis for each condition is based on clinical examination, although radiographs should be evaluated for a possible bony component. Treatment for mallet injury depends on the athlete's goals of competition and understanding of the consequences of any treatment chosen. Gripping, throwing, and catching would be restricted or impossible with the injured finger immobilized. Treatment of FDP ruptures is almost always surgical and requires reattachment of the torn tendon to the distal phalanx.
Wong, Jason K.F.; Lui, Yin H.; Kapacee, Zoher; Kadler, Karl E.; Ferguson, Mark W. J.; McGrouther, Duncan A.
Intrasynovial flexor tendon injuries of the hand can frequently be complicated by tendon adhesions to the surrounding sheath, limiting finger function. We have developed a new tendon injury model in the mouse to investigate the three-dimensional cellular biology of intrasynovial flexor tendon healing and adhesion formation. We investigated the cell biology using markers for inflammation, proliferation, collagen synthesis, apoptosis, and vascularization/myofibroblasts. Quantitative immunohistochemical image analysis and three-dimensional reconstruction with cell mapping was performed on labeled serial sections. Flexor tendon adhesions were also assessed 21 days after wounding using transmission electron microscopy to examine the cell phenotypes in the wound. When the tendon has been immobilized, the mouse can form tendon adhesions in the flexor tendon sheath. The cell biology of tendon healing follows the classic wound healing response of inflammation, proliferation, synthesis, and apoptosis, but the greater activity occurs in the surrounding tissue. Cells that have multiple “fibripositors” and cells with cytoplasmic protrusions that contain multiple large and small diameter fibrils can be found in the wound during collagen synthesis. In conclusion, adhesion formation occurs due to scarring between two damaged surfaces. The mouse model for flexor tendon injury represents a new platform to study adhesion formation that is genetically tractable. PMID:19834058
Marr, C M
Microwave thermographs were recorded from 77 normal horses. In 51% the lowest temperature was recorded in the mid-metacarpal region, and in 41% it was in the distal metacarpal region. The mean temperature of the normal limbs ranged from 25.04 to 37.4 degrees C. Maximum temperature differences between symmetrical points in both forelimbs ranged from 0 to 5.33 degrees C and differences in mean limb temperatures between both forelimbs ranged from 0 to 2.91 degrees C. In 48 horses with acute (less than 4 weeks' duration) injury of the superficial digital flexor tendon (SDFT) (36 unilateral, 12 bilateral) and 12 horses with acute injury of the soft tissues of the palmar metacarpal region other than the SDFT (all unilateral) 66% of forelimbs had acute SDFT injury, and 50% of those with other soft tissue injuries, had elevations of the temperature in the mid- or distal metacarpal region. Abnormal values for mean limb temperature, difference in mean limb temperature and maximum temperature difference between locations in opposite forelimbs were detected in 75% of the horses with SDFT injury and in only 16% of the horses with other soft tissue injury. The sensitivity of microwave thermography for the detection of SDFT injury was 81% and the specificity 74%. When 30 horses in National Hunt training were examined weekly for 5 weeks, 2 horses sustained SDFT injury during that period. The microwave thermographs recorded from these 2 horses, at 1 and 2 weeks before the onset of clinical signs, were abnormal. However, 16 horses which did not develop tendon injury also displayed thermographic abnormalities.
Crowley, Timothy P
Rock climbing has increased in popularity over the past two decades. Closed traumatic rupture of the finger flexor tendon pulleys is rare among the general population but is seen much more commonly in rock climbers. This article reviews the anatomy and biomechanics of the finger flexor tendon pulleys, how they may be injured in rock climbing and how these injuries are best diagnosed and managed.
Welsh, Claire E; Lewis, Thomas W; Blott, Sarah C; Mellor, Dominic J; Stirk, Anthony J; Parkin, Timothy D H
A retrospective cohort study of distal limb fracture and superficial digital flexor tendon (SDFT) injury in Thoroughbred racehorses was conducted using health records generated by the British Horseracing Authority (BHA) between 2000 and 2010. After excluding records of horses that had both flat and jump racing starts, repeated records were reduced to a single binary record per horse (n = 66,507, 2982 sires), and the heritability of each condition was estimated using residual maximum likelihood (REML) with animal logistic regression models. Similarly, the heritability of each condition was estimated for the flat racing and jump racing populations separately. Bivariate mixed models were used to generate estimates of genetic correlations between SDFT injury and distal limb fracture. The heritability of distal limb fracture ranged from 0.21 to 0.37. The heritability of SDFT injury ranged from 0.31 to 0.34. SDFT injury and distal limb fracture were positively genetically correlated. These findings suggest that reductions in the risk of the conditions studied could be attempted using targeted breeding strategies.
Schöffl, Volker; Heid, Andreas; Küpper, Thomas
Tendon injuries are the second most common injuries of the hand and therefore an important topic in trauma and orthopedic patients. Most injuries are open injuries to the flexor or extensor tendons, but less frequent injuries, e.g., damage to the functional system tendon sheath and pulley or dull avulsions, also need to be considered. After clinical examination, ultrasound and magnetic resonance imaging have proved to be important diagnostic tools. Tendon injuries mostly require surgical repair, dull avulsions of the distal phalanges extensor tendon can receive conservative therapy. Injuries of the flexor tendon sheath or single pulley injuries are treated conservatively and multiple pulley injuries receive surgical repair. In the postoperative course of flexor tendon injuries, the principle of early passive movement is important to trigger an “intrinsic” tendon healing to guarantee a good outcome. Many substances were evaluated to see if they improved tendon healing; however, little evidence was found. Nevertheless, hyaluronic acid may improve intrinsic tendon healing. PMID:22720265
Miranda, B. H.; Cerovac, S.
Background Spontaneous flexor tendon rupture is considered to be invariably associated with previous hand/wrist injury or systemic disease such as rheumatoid arthritis. Case Description A 54-year-old man presented with a 4-month history of mild ulnar wrist pain and spontaneous left little finger flexion loss in the absence of distant/recent trauma and systemic arthropathy. Surgical exploration confirmed a zone IV left little finger flexor digitorum profundus (FDP5) attritional rupture (100%), ring finger flexor digitorum profundus (FDP4) attenuation (40%) and a disrupted lunotriquetral ligament and volar-ulnar wrist capsule. Volar subluxation of the narrowed carpal tunnel resulted in flexor tendon attrition against the hamate hook. A side-to-side tendon transfer was performed along with a lunotriquetral ligament repair and temporary Kirschner wire fixation. At 6 months the patient had full active, synchronous flexion of the ring and little fingers and reduced wrist pain. Literature Review Traumatic flexor tendon ruptures have been reported following distal radius/hamate hook fractures, from carpal bone osteophytes, accessory carpal bones and intraosseous ganglia. Attritional ruptures caused by chronic, degenerative carpal pathology are less common. Clinical Relevance This case highlights an unusual cause of flexor tendon rupture due to chronic carpal instability. PMID:25032080
Fedorczyk, Jane M; Barr, Ann E; Rani, Shobha; Gao, Helen G; Amin, Mamta; Amin, Shreya; Litvin, Judith; Barbe, Mary F
Upper extremity tendinopathies are associated with performance of forceful repetitive tasks. We used our rat model of repetitive strain injury to study changes induced in forelimb flexor digitorum tendons. Rats were trained to perform a high repetition high force (HRHF) handle-pulling task (12 reaches/min at 60 +/- 5% maximum pulling force [MPF]), or a low repetition negligible force (LRNF) reaching and food retrieval task (three reaches/min at 5 +/- 5% MPF), for 2 h/day in 30 min sessions, 3 days/week for 3-12 weeks. Forelimb grip strength was tested. Flexor digitorum tendons were examined at midtendon at the level of the carpal tunnel for interleukin (IL)-1beta, neutrophil, and macrophage influx, Substance P, connective tissue growth factor (CTGF), and periostin-like factor (PLF) immunoexpression, and histopathological changes. In HRHF rats, grip strength progressively decreased, while IL-1beta levels progressively increased in the flexor digitorum peritendon (para- and epitendon combined) and endotendon with task performance. Macrophage invasion was evident in week 6 and 12 HRHF peritendon but not endotendon. Also in HRHF rats, Substance P immunoexpression increased in week 12 peritendon as did CTGF- and PLF-immunopositive fibroblasts, the increased fibroblasts contributing greatly to peritendon thickening. Endotendon collagen disorganization was evident in week 12 HRHF tendons. LRNF tendons did not differ from controls, even at 12 weeks. Thus, we observed exposure-dependent changes in flexor digitorum tendons within the carpal tunnel, including increased inflammation, nociceptor-related neuropeptide immunoexpression, and fibrotic histopathology, changes associated with grip strength decline.
Wu, Y F; Mao, W F; Zhou, Y L; Wang, X T; Liu, P Y; Tang, J B
Adhesion formation after digital flexor tendon injury greatly affects gliding function of the tendon, which is a major clinical complication after hand surgery. Transforming growth factor beta 1 (TGF-β1) has a critical role in adhesion formation during tendon healing. Persistent regulation of TGF-β1 through application of microRNA (miRNA) specifically inhibiting the function of TGF-β1 (TGF-β1-miRNA) holds promise for treatment of such a complication. Adeno-associated virus (AAV) was used to transfer TGF-β1-miRNA to the chicken digital flexor tendons, which had been injured and surgically repaired. Four doses of AAV2-TGF-β1-miRNA (2 × 10¹¹, 2 × 10¹⁰, 2 × 10⁹ and 2 × 10⁸ vector genomes (vg)) were used to determine the transfection efficiency. At postoperative 3 weeks, we found a positive correlation between the administered AAV2-TGF-β1-miRNA doses and transfection efficiency. The transfection rate ranged from 10% to 77% as the doses increased. Production of TGF-β1 protein in the tendons decreased on increasing vector dosage. When 2 × 10¹¹ and 2 × 10¹⁰) vg were injected into the tendon, gliding excursion of the repaired tendon and work of flexion of chicken toes were significantly increased and adhesion score decreased 6 and 8 weeks later, indicating the improvement of tendon gliding and decreases in adhesion formations. However, the ultimate strength of the tendons transfected at the dose of 2 × 10¹⁰ vg was 12-24% lower than that of the control tendons. The results of this study demonstrate that application of TGF-β1-miRNA had a mixed impact on tendon healing: adhesion around the tendon is reduced but strength of the tendon healing is adversely affected. Future studies should aim at maintaining the beneficial effects of reducing tendon adhesions, while eliminating the adverse effects of decreasing the healing strength.
Fischer, Lauren H; Abzug, Joshua M; Osterman, A Lee; Stern, Peter J; Chang, James
Orthopaedic and hand surgeons frequently treat disorders of the flexor and extensor tendon systems. Common conditions, such as trigger finger, de Quervain tenosynovitis, extensor tendon injury, and zone II flexor tendon injury, can be challenging to treat. Complications that limit normal hand function still occur despite advances in surgical techniques and therapy protocols. It is helpful to be aware of the complications related to the treatment of these hand disorders and understand surgical techniques to minimize their frequency.
Flexor tendon pulley has been very early noticed and described. Terminology usually accepted recognizes 6 arcifom pulleys (A0 to A5) and 3 cruciform pulleys (C1 to C3). Anatomy and physiology of this flexor tendon gliding and reflection system at the level of the digital sheet are exposed. The integrity necessity of this system became obvious regarding the flexor tendons repair. Four main pathologies may be concerned: the trigger finger congenital or progressive, due to a chondroid metaplasia of the A1 pulley; tenosynovial ganglions arising at the weak point between A1 and A2 pulley; lesions of the flexor tendon sheet during traumatic lacerations or surgical repairs; quite experimental lesions creating isolated ruptures of one or several pulleys which occur during sport practice, especially high level rock climbing. The repair techniques are exposed to allow to graduate and hierarchy the reparation technique regarding the pathology. A2 and A4 repair is always indicated. The best reconstruction material is an extensor retinaculum graft. But its poor surface available often draws to use conventional palmaris longus free graft.
Damkat-Thomas, L; Black, CE; Herbert, K
An unusual case of fibromatosis of the dominant left flexor pollicus longus (FPL) in a thirteen year old schoolboy. Initially presenting with pain in the thenar eminence and difficulty flexing the metacarpal phalangeal joint (MPJ), other symptoms include locking, triggering and difficulty writing. MRI showed a 4cm segment of thickened abnormal tendon. Intra-operatively three 1cm nodules were excised from the FPL while preserving the tendon. Histopathology reported the nodules as fibromatosis. A literature search revealed that this has not previously been reported although symptomatic tendon sheath fibromas have. Our patient achieved a good result following surgical intervention and the two year review has shown no complications. PMID:24946359
... Hand Safety Fireworks Safety Lawnmower Safety Snowblower safety Pumpkin Carving Gardening Safety Turkey Carving Removing a Ring ... Hand Safety Fireworks Safety Lawnmower Safety Snowblower safety Pumpkin Carving Gardening Safety Turkey Carving Removing a Ring ...
Berglund, M E; Hart, D A; Reno, C; Wiig, M
The purpose of the study was to contribute to the mapping of molecular events during flexor tendon healing, in particular the growth factors insulin-like growth factor-1 (IGF-1), vascular endothelial growth factor (VEGF) and nerve growth factor (NGF), matrix metalloproteinases (MMP-3 and MMP-13) and their inhibitors (tissue inhibitors of metalloproteinases, TIMP-1 and TIMP-3, and the protease cathepsin K. In a rabbit model of flexor tendon injury, the mRNA expression for the growth factors, MMPs and TIMPs were measured in tendon and tendon sheath tissue at several time points (3, 6, 21, and 42 days) representing different phases of the healing process. We found that MMP-13 remained increased during the study period, whereas MMP-3 returned to normal levels within the first week after injury. TIMP-3 was down-regulated in the tendon sheaths. Cathepsin K was up-regulated in tendons and sheaths after injury. NGF was present in both tendons and sheaths, but unaltered. IGF-1 exhibited a late increase in the tendons, while VEGF was down-regulated at the later time points. In conclusion, we have demonstrated the presence of NGF in flexor tendons. MMP-13 expression appears to play a more protracted role in flexor tendon healing than MMP-3. The relatively low levels of endogenous IGF-1 and VEGF mRNA following injury support their potential beneficial role as exogenous modulators to optimize tendon healing and strength without increasing adhesion formation.
Sasi, P. Kiran; Mahapatra, Swagath; Raj Pallapati, Samuel C.; Thomas, Binu P.
Traumatic musculotendinous junction avulsions are rare injuries except in avulsion amputations. They pose a significant challenge to the treating surgeon. We present a 24-year-old male who sustained an open musculotendinous avulsion of the flexor pollicis longus tendon. He was treated with primary tendon transfer using the flexor digitorum superficialis of ring finger, in flexor zone 3. The functional result at 10 months following surgery was excellent. PMID:27019757
Rymer, Ben; Theobald, Peter; Thomas, Peter B.M.
Historically, the surgical treatment of flexor tendon injuries has always been associated with controversy. It was not until 1967, when the paper entitled Primary repair of flexor tendons in no man’s land was presented at the American Society of Hand Surgery, which reported excellent results and catalyzed the implementation of this technique into worldwide practice. We present an up to date literature review using PubMed and Google Scholar where the terms flexor tendon, repair and rehabilitation were used. Topics covered included functional anatomy, nutrition, biome-chanics, suture repair, repair site gapping, and rehabilitation. This article aims to provide a comprehensive and complete overview of flexor tendon repairs. PMID:26793293
Griffin, M; Hindocha, S; Jordan, D; Saleh, M; Khan, W
Extensor tendon injuries are very common injuries, which inappropriately treated can cause severe lasting impairment for the patient. Assessment and management of flexor tendon injuries has been widely reviewed, unlike extensor injuries. It is clear from the literature that extensor tendon repair should be undertaken immediately but the exact approach depends on the extensor zone. Zone I injuries otherwise known as mallet injuries are often closed and treated with immobilisaton and conservative management where possible. Zone II injuries are again conservatively managed with splinting. Closed Zone III or ‘boutonniere’ injuries are managed conservatively unless there is evidence of displaced avulsion fractures at the base of the middle phalanx, axial and lateral instability of the PIPJ associated with loss of active or passive extension of the joint or failed non-operative treatment. Open zone III injuries are often treated surgically unless splinting enable the tendons to come together. Zone V injuries, are human bites until proven otherwise requires primary tendon repair after irrigation. Zone VI injuries are close to the thin paratendon and thin subcutaneous tissue which strong core type sutures and then splinting should be placed in extension for 4-6 weeks. Complete lacerations to zone IV and VII involve surgical primary repair followed by 6 weeks of splinting in extension. Zone VIII require multiple figure of eight sutures to repair the muscle bellies and static immobilisation of the wrist in 45 degrees of extension. To date there is little literature documenting the quality of repairing extensor tendon injuries however loss of flexion due to extensor tendon shortening, loss of flexion and extension resulting from adhesions and weakened grip can occur after surgery. This review aims to provide a systematic examination method for assessing extensor injuries, presentation and management of all type of extensor tendon injuries as well as guidance on
Ferreira, Aline M; Tanaka, Denise M; Barbosa, Rafael I; Marcolino, Alexandre M; Elui, Valeria MC; Mazzer, Nilton
Objective: To evaluate the activity of wrist extensor muscle, correlating with wrist motion during gripping after flexor tendon repair. Design: Cross-sectional clinical measurement study. Setting: Laboratory for biomechanics and rehabilitation. Subjects: A total of 11 patients submitted to rehabilitation by early passive motion of the fingers with wrist flexion position were evaluated after 8 weeks of fingers flexor tendon repair and 11 healthy volunteers, all ranging from 20 to 37 years of age. Intervention: Volunteers performed an isometric standardized gripping task. Main measures: We used electrogoniometry to analyze wrist range of motion and surface electromyography, considering 100% maximum voluntary contraction to represent the amplitude of electromyographic activity of the extensor carpi radialis and flexor digitorum superficialis. Results: Patients with flexor tendon repair showed co-activation deficit between wrist extensor (extensor carpi radialis) and flexor finger muscles (flexor digitorum superficialis) during gripping in the intermediate phase of rehabilitation, despite some recovering mobility for wrist extension (p ≤ 0.05). A moderate correlation between range of motion and extensor carpi radialis was present only for injured group (r = 0.32). Total active motion score, which represents finger active excursion, was regular or poor in 65% of cases, all with nerve repair associated. Conclusion: Wrist extensors have an important synergist role at handgrip, although some imbalance can be present after flexor tendon repair. These preliminary findings suggest that emphasis could be directed to add synergistic wrist motion in rehabilitation protocols after flexor tendon repair. Future studies with early active rehabilitation are necessary. PMID:26770674
Marr, C M; Love, S; Boyd, J S; McKellar, Q
Ultrasonographic examination was used to define the severity of injuries to the superficial digital flexor tendon in 73 National Hunt or point-to-point racehorses and the factors influencing the outcome of the cases were examined. Thirty-four of the horses (46 per cent) returned to work with an average time out of training of 13.5 months. The rate of recurrence of the injury was 35 per cent. The severity of the lesions was related to the outcome; all the mildly affected horses returned to work, with 63 per cent of them racing and an average time out of training of 10.2 months; 50 per cent of the moderately affected horses returned to work, and 30 per cent raced with an average time out of training of 11.3 months; 30 per cent of the severely affected horses worked, and 23 per cent raced with an average time out of training of 18.3 months. The differences in outcome between unilateral and bilateral injuries within each severity group were not statistically significant. Seventy-six per cent of horses treated with polysulphated glycosaminoglycans returned to work, compared with 46 per cent of conservatively managed horses and 50 per cent of horses treated with laser therapy. However, these differences were not statistically significant and the rate of recurrence of the injury in the horses treated with polysulphated glycosaminoglycans was 50 per cent compared with only 31 per cent in the conservatively managed horses. Seventy per cent of the mares and 47 per cent of the geldings were retired from racing.
Sun, L-Q; Zhao, G; Gao, S-H; Chen, C
We report a new method of flexor tendon repair in zone II using a standard modified Kessler technique combined with a vascularized dorsal fascial flap from the finger pedicled on a dorsal cutaneous branch of the proper digital artery, which is placed as a mechanical barrier between the flexor digitorum superficialis and profundus tendons. The functional outcomes of 14 patients (Group A) with flexor tendon repairs in zone II by this new technique were compared with those of 32 patients (Group B) with flexor tendon repairs in zone II using a standard modified Kessler technique only. Patients in Group A had a higher proportion of excellent results (on the modified Strickland system) and more movement in the distal interphalangeal joint than the patients in Group B.
Cooper, Maureen A; Laverty, Peter H; Soiderer, Emily E
Two cats presented with bilateral flexor tendon contracture following onychectomy. This previously unreported complication proved to be painful and debilitating. Deep digital flexor tenectomy successfully resolved the problem. Twelve months after surgery, the first cat remains free of complications. The second cat recovered full limb function, but died of unrelated causes.
Abstract Two cats presented with bilateral flexor tendon contracture following onychectomy. This previously unreported complication proved to be painful and debilitating. Deep digital flexor tenectomy successfully resolved the problem. Twelve months after surgery, the first cat remains free of complications. The second cat recovered full limb function, but died of unrelated causes. PMID:15884646
Cavadas, P C; Pérez-García, A; Thione, A; Lorca-García, C
The reconstruction of finger flexor tendons with vascularized flexor digitorum superficialis (FDS) tendon grafts (flaps) based on the ulnar vessels as a single stage is not a popular technique. We reviewed 40 flexor tendon reconstructions (four flexor pollicis longus and 36 finger flexors) with vascularized FDS tendon grafts in 38 consecutive patients. The donor tendons were transferred based on the ulnar vessels as a single-stage procedure (37 pedicled flaps, three free flaps). Four patients required composite tendon and skin island transfer. Minimum follow-up was 12 months, and functional results were evaluated using a total active range of motion score. Multiple linear regression analysis was performed to evaluate the factors that could be associated with the postoperative total active range of motion. The average postoperative total active range of motion (excluding the thumbs) was 178.05° (SD 50°). The total active range of motion was significantly lower for patients who were reconstructed with free flaps and for those who required composite tendon and skin island flap. Age, right or left hand, donor/motor tendon and pulley reconstruction had no linear effect on total active range of motion. Overall results were comparable with a published series on staged tendon grafting but with a lower complication rate. Vascularized pedicled tendon grafts/flaps are useful in the reconstruction of defects of finger flexor tendons in a single stage, although its role in the reconstructive armamentarium remains to be clearly established.
Chen, Qiang; Lu, Hui; Yang, Hu
Chitosan has been demonstrated to exert potent anti-adhesive activity during tendon repair; however, the underlying molecular mechanisms remain unclear. The present study aimed to investigate the preventive effects of chitosan on adhesion in rabbit tendon repair, and to investigate the role of the sirtuin (SIRT)1 signaling pathway in this process. A total of 30 rabbits were divided randomly into three equal groups: Group 1, saline treatment; group 2, chitosan treatment; and group 3, chitosan + nicotinamide treatment. The flexor tendon of each of the rabbits was injured, and subsequently each rabbit was injected with the one of the reagents. Six weeks post‑surgery, all of the rabbits were sacrificed and their flexor tendons were harvested for subsequent evaluation of adhesion. Western blotting was used to determine the protein expression levels of specific signaling molecules. An MTT assay was conducted to evaluate the viability of human tenocytes and flow cytometry was used to analyze the apoptotic rate of the cells. The present study demonstrated that treatment with chitosan relieved adhesion in the rabbits with flexor tendon injuries. In addition, chitosan treatment increased SIRT1 expression, and reduced acetylated p65 and p53 expression in the tendons. The effects of chitosan on the tendons were attenuated by treatment with nicotinamide (a SIRT1 inhibitor). In the human tenocytes, pretreatment with chitosan resulted in an inhibition of interleukin (IL)‑1β‑induced apoptosis. Furthermore, chitosan reversed the IL‑1β‑induced downregulation of SIRT1 and upregulation of acetylated p65 and p53. Furthermore, downregulation of Sirt1 by RNA interference abrogated the effects of chitosan on the levels of p65 and p53 acetylation, and the rate of tenocyte apoptosis. In conclusion, chitosan treatment prevented adhesion via the SIRT1 signaling pathway during rabbit flexor tendon repair. These results indicate that SIRT1 may be targeted for therapeutic
Elliot, David; Giesen, Thomas
Repair of the divided flexor tendon to achieve normal, or near normal, function is an unsolved problem, with each result still uncertain. The authors believe the way forward in primary flexor tendon surgery clinically is by use of strengthened but simpler sutures, appropriate venting of the pulley system, and maintaining early rehabilitation. However, there needs also be consideration of patient factors and other aspects. Research needs to continue more widely, in both the laboratory and the clinical environment, to find ways of better modifying adhesions after surgical repair of the tendon.
Kociolek, Aaron M; Tat, Jimmy; Keir, Peter J
Pathological changes in carpal tunnel syndrome patients include fibrosis and thickening of the subsynovial connective tissue (SSCT) adjacent to the flexor tendons in the carpal tunnel. These clinical findings suggest an etiology of excessive shear-strain force between the tendon and SSCT, underscoring the need to assess tendon gliding characteristics representative of repetitive and forceful work. A mechanical actuator moved the middle finger flexor digitorum superficialis tendon proximally and distally in eight fresh frozen cadaver arms. Eighteen experimental conditions tested the effects of three well-established biomechanical predictors of injury, including a combination of two wrist postures (0° and 30° flexion), three tendon velocities (50, 100, 150mm/sec), and three forces (10, 20, 40N). Tendon gliding resistance was determined with two light-weight load cells, and integrated over tendon displacement to represent tendon frictional work. During proximal tendon displacement, frictional work increased with tendon velocity (58.0% from 50-150mm/sec). There was a significant interaction between wrist posture and tendon force. In wrist flexion, frictional work increased 93.0% between tendon forces of 10 and 40N. In the neutral wrist posture, frictional work only increased 33.5% (from 10-40N). During distal tendon displacement, there was a similar multiplicative interaction on tendon frictional work. Concurrent exposure to multiple biomechanical work factors markedly increased tendon frictional work, thus providing a plausible link to the pathogenesis of work-related carpal tunnel syndrome. Additionally, our study provides the conceptual basis to evaluate injury risk, including the multiplicative repercussions of combined physical exposures.
Farhat, Youssef M.; Al-Maliki, Alaa A.; Easa, Anas; O’Keefe, Regis J.; Schwarz, Edward M.; Awad, Hani A.
Flexor tendon injuries caused by deep lacerations to the hands are a challenging problem as they often result in debilitating adhesions that prevent the movement of the afflicted fingers. Evidence exists that tendon adhesions as well as scarring throughout the body are largely precipitated by the pleiotropic growth factor, TGF-β1, but the effects of TGF-β1 are poorly understood in tendon healing. Using an in vitro model of tendon healing, we previously found that TGF-β1 causes gene expression changes in tenocytes that are consistent with scar tissue and adhesion formation, including upregulation of the anti-fibrinolytic protein, PAI-1. Therefore, we hypothesized that TGF-β1 contributes to scarring and adhesions by reducing the activity of proteases responsible for ECM degradation and remodeling, such as plasmin and MMPs, via upregulation of PAI-1. To test our hypothesis, we examined the effects of TGF-β1 on the protease activity of tendon cells. We found that flexor tendon tenocytes treated with TGF-β1 had significantly reduced levels of active MMP-2 and plasmin. Interestingly, the effects of TGF-β1 on protease activity were completely abolished in tendon cells from homozygous PAI-1 KO mice, which are unable to express PAI-1. Our findings support the hypothesis that TGF-β1 induces PAI-1, which suppresses plasmin and plasmin-mediated MMP activity, and provide evidence that PAI-1 may be a novel therapeutic target for preventing adhesions and promoting a scarless, regenerative repair of flexor tendon injuries. PMID:24962629
Thorfinn, J; Angelidis, I K; Gigliello, L; Pham, H M; Lindsey, D; Chang, J
Tissue-engineered rabbit flexor tendons reseeded with cells are stronger in vitro after culture in a bioreactor. It is not known whether this effect persists in vivo. Tenocytes from New Zealand white rabbits were seeded onto rabbit rear paw flexor tendons that were deprived of cells and exposed to cyclic strain in a bioreactor. Reseeded constructs that were kept unloaded in a medium for 5 days were used as controls. The tendons were implanted to bridge a zone II defect in the rabbit. After explantation 4 weeks later, the ultimate tensile strength (UTS) and elastic modulus (EM) were determined. Tendon constructs that were exposed to cyclic strain had significantly improved UTS and EM. Histology showed that cellularity was increased in the bioreactor tendons.
Bottagisio, Marta; Lovati, Arianna B
Tendon is a connective tissue mainly composed of collagen fibers with peculiar mechanical properties essential to functional movements. The increasing incidence of tendon traumatic injuries and ruptures-associated or not with the loss of tissue-falls on the growing interest in the field of tissue engineering and regenerative medicine. The use of animal models is mandatory to deepen the knowledge of the tendon healing response to severe damages or acute transections. Thus, the selection of preclinical models is crucial to ensure a successful translation of effective and safe innovative treatments to the clinical practice. The current review is focused on animal models of tendon ruptures and lacerations or defective injuries with large tissue loss that require surgical approaches or grafting procedures. Data published between 2000 and 2016 were examined. The analyzed articles were compiled from Pub Med-NCBI using search terms, including animal model(s) AND tendon augmentation OR tendon substitute(s) OR tendon substitution OR tendon replacement OR tendon graft(s) OR tendon defect(s) OR tendon rupture(s). This article presents the existing preclinical models - considering their advantages and disadvantages-in which translational progresses have been made by using bioactive sutures or tissue engineering that combines biomaterials with cells and growth factors to efficiently treat transections or large defects of Achilles and flexor tendons.
Al-Thunayan, Turki A.; Al-Zahrani, Mohammed T.; Hakeem, Ahmad A.; Al-Zahrani, Fahad M.; Al-Qattan, Mohammad M.
Objectives: To investigate the tensile strength of repaired flexor profundus tendons in young lambs, which would be equivalent to repairs in children older than 2 years of age. Methods: A comparative in-vitro experimental study conducted at King Saud University, Riyadh, Kingdom of Saudi Arabia from October 2014 to December 2015. We utilized 30 flexor profundus tendons of young lambs with a width of 4 mm. All tendons were repaired with a 4-strand repair technique using 4/0 polypropylene core sutures. In group I (n=10 tendons), 2 separate figure-of-eight sutures were applied. In group II (n=10 tendons), simple locking sutures were added to the corners of 2 separate figure-of-eight sutures. In group III (n=10 tendons), the locked cruciate repair was used. All tendon repairs were tested to single-cycle tensile failure. Results: There was no significant difference between groups II and III with regards to gap and breaking forces; and all forces of these 2 groups were significantly higher than the forces in group I. Conclusion: It was concluded that 4 mm-wide pediatric flexor tendons allow a 4-strand repair and the use of 4/0 sutures. The use of locking sutures increases the tensile strength to values that may allow protective mobilization in children. PMID:27570850
Newmeyer, William L; Manske, Paul R
New surgical procedures, novel concepts, and/or the presentation of very good results with an apparently discredited technique meet varying degrees of resistance among the establishment of any profession. In hand surgery this phenomenon was exemplified in a striking fashion with the presentation of a controversial report entitled, "Primary repair of flexor tendons in no man's land" by Kleinert, Kutz, Ashbell, and Martinez of Louisville, KY, at the 1967 American Society for Surgery of the Hand (ASSH) annual meeting. The discussant, Joseph Boyes, expressed such skepticism that a special ASSH committee was appointed to go to Louisville and review the results to determine if they were as good as claimed. They were, and today primary flexor tendon repair is the procedure of choice for most flexor tendon lacerations.
Summary: The Saint John Protocol describes a rehabilitation program of up to half a fist of protected true active finger flexion beginning 3 to 5 days after flexor tendon repair. We no longer use full fist place and hold. We illustrate with film and text the reasons for these changes. PMID:27975032
Savage, Robert; Tang, Jin Bo
Multistrand core suture repairs have become the mainstay of digital flexor tendon repair in recent decades. Here we briefly describe the history of the development of these multistrand repair methods and their correct nomenclature. A historical account, their evolution, the correct use of nomenclature, and some technical points are reviewed.
Bartle, B K; Telepun, G M; Goldberg, N H
Reconstruction or replacement of the damaged pulley is a difficult surgical problem because of the need to find suitable biological material, the bulkiness of the repair, and adhesion formation between the pulley and flexor tendons. Therefore, a method was developed to reconstruct the fibro-osseous pulleys with polytetrafluoroethylene (PTFE) membrane. Twenty White Leghorn chickens had the A3 pulley of the long digit excised; this was followed by a standard injury to the flexor profundus tendon. The A3 pulley was then reconstructed with PTFE membrane. In the opposite foot, the A3 pulley was transected laterally, the tendon injured in the same manner, and the native pulley sutured. Seven control chickens had a PTFE pulley reconstruction without tendon injury in one foot and the opposite foot did not undergo surgery. At postoperative days 0, 21, and 35, the animals were killed to evaluate the effectiveness of the PTFE pulleys. Flexor tendon function was assessed by determining the active range of motion of the digit. There was no significant difference between the PTFE pulleys and suture repair of the native pulleys at postoperative days 21 and 35. This indicates that the PTFE pulleys were capable of preventing tendon bow-stringing and did not significantly impair tendon gliding. The breaking strength of the PTFE pulley was less than that of the normal A3 pulleys, but it was sufficient to allow immediate mobilization of the digits postoperatively without fear of pulley rupture. The synthetic PTFE pulley appears to have the potential to function as an effective immediate replacement for the fibro-osseous pulleys.
Gabra, Joseph N; Gordon, Joshua L; Marquardt, Tamara L; Li, Zong-Ming
The transverse carpal ligament (TCL) is a component of the flexor pulley system of the wrist, keeping the flexor tendons in place by resisting their volar displacement. The purpose of this study was to investigate the in vivo biomechanical interaction between the TCL and flexor tendons in response to tendon tensioning with the wrist at various postures. In eight healthy subjects, the flexor digitorum superficialis and profundus tendons were tensioned by isometrically applying loads (5, 10, and 15N) to the index finger while the wrist posture was at 20° extension, neutral, 20° flexion, and 40° flexion. The TCL and flexor tendons were imaged at the distal carpal tunnel cross section using ultrasound. The volar-dorsal positions of the tendons, TCL arch height, and TCL-tendon distances were calculated. With increasing wrist flexion, the flexor tendons moved volarly, the TCL arch height increased, and the TCL-tendon distances decreased, indicating that the flexor tendons contacted the TCL and pushed it volarly. The TCL-tendon interaction was amplified by the combination of finger loading and wrist flexion. This study provides in vivo evidence of the biomechanical interaction between the TCL and flexor tendons. Repetitive TCL-tendon interactions may implicate the interacting tissues and the median nerve resulting in tissue maladaptation and nerve compression.
Thomopoulos, Stavros; Zampiakis, Emmanouil; Das, Rosalina; Silva, Matthew J; Gelberman, Richard H
Previous tendon and ligament studies have demonstrated a role for mechanical loading in tissue homeostasis and healing. In uninjured musculoskeletal tissues, increased loading leads to an increase in mechanical properties, whereas decreased loading leads to a decrease in mechanical properties. The role of loading on healing tissues is less clear. We studied tendon-to-bone healing in a canine flexor tendon-to-bone injury and repair model. To examine the effect of muscle loading on tendon-to-bone healing, repaired tendons were either cut proximally (unloaded group) to remove all load from the distal phalanx repair site or left intact proximally (loaded group). All paws were casted postoperatively and subjected to daily passive motion rehabilitation. Specimens were tested to determine functional properties, biomechanical properties, repair-site gapping, and bone mineral density. Loading across the repair site led to improved functional and biomechanical properties (e.g., stiffness for the loaded group was 8.2 +/- 3.9 versus 5.1 +/- 2.5 N/mm for the unloaded group). Loading did not affect bone mineral density or gapping. The formation of a gap between the healing tendon and bone correlated with failure properties. Using a clinically relevant model of flexor tendon injury and repair, we found that muscle loading was beneficial to healing. Complete removal of load by proximal transection resulted in tendon-to-bone repairs with less range of motion and lower biomechanical properties compared to repairs in which the muscle-tendon-bone unit was left intact.
Nunley, J A; Levin, L S; Devito, D; Goldner, R D; Urbaniak, J R
Between 1976 and 1986, 38 consecutive acute isolated flexor pollicis longus lacerations were repaired. This study excluded all replanted or mutilated digits and all lacerations with associated fracture. Average follow-up was 26 months. Tendon rehabilitation was standardized. Range of motion and pinch strength were measured postoperatively. Seventy-four percent (28/38) of the flexor pollicis longus injuries occurred in zone II. Neurovascular injury occurred in 82% of the lacerations, and this correlated with the zone of tendon injury. In 21% of the patients (8/38) both digital nerves and arteries were transected. Postoperative thumb interphalangeal motion averaged 35 degrees and key pinch strength was 81% that of the uninjured thumb. One rupture occurred in a child. Laceration of the flexor pollicis longus is likely to involve damage to neurovascular structures, and repair may be necessary. Direct end-to-end repairs within the pulley system do at least as well as delayed tendon reconstruction and do not require additional procedures.
Ayad, K. E.; El Gohary, H. M.; Abd Elrahman, M.; Abd El Mejeed, S. F.; Bekheet, A. B.
Flexor tendon injury is a common problem requiring suturing repair followed by early postoperative mobilization. Muscle atrophy, joint stiffness, osteoarthritis, infection, skin necrosis, ulceration of joint cartilage and tendocutaneous adhesion are familiar complications produced by prolonged immobilization of surgically repaired tendon ruptures. The purpose of this study was to clarify the importance of low level laser therapy after hand flexor tendon repair in zone II. Thirty patients aging between 20 and 40 years were divided into two groups. Patients in group A (n = 15) received a conventional therapeutic exercise program while patients in group B (n = 15) received low level laser therapy combined with the same therapeutic exercise program. The results showed a statistically significant increase in total active motion of the proximal and distal interphalangeal joints as well as maximum hand grip strength at three weeks and three months postoperative, but improvement was more significant in group B. It was concluded that the combination of low level laser therapy and early therapeutic exercises was more effective than therapeutic exercises alone in improving total active motion of proximal and distal interphalangeal joints and hand grip strength after hand flexor tendon repair.
Ayad, K. E.; Abd El Mejeed, S. F.; El Gohary, H. M.; Abd Elrahman, M.; Bekheet, A. B.
Flexor tendon injury is a common problem requiring suturing repair followed by early postoperative mobilization. Muscle atrophy, joint stiffness, osteoarthritis, infection, skin necrosis, ulceration of joint cartilage and tendocutaneous adhesion are familiar complications produced by prolonged immobilization of surgically repaired tendon ruptures. The purpose of this study was to clarify the importance of low level laser therapy after hand flexor tendon repair in zone II. Thirty patients aging between 20 and 40 years were divided into two groups. Patients in group A (n = 15) received a conventional therapeutic exercise program while patients in group B (n = 15) received low level laser therapy combined with the same therapeutic exercise program. The results showed a statistically significant increase in total active motion of the proximal and distal interphalangeal joints as well as maximum hand grip strength at three weeks and three months postoperative, but improvement was more significant in group B. It was concluded that the combination of low level laser therapy and early therapeutic exercises was more effective than therapeutic exercises alone in improving total active motion of proximal and distal interphalangeal joints and hand grip strength after hand flexor tendon repair.
Thomopoulos, Stavros; Zampiakis, Emmanouil; Das, Rosalina; Silva, Matthew J.; Gelberman, Richard H.
SUMMARY Previous tendon and ligament studies demonstrated a role for mechanical loading in tissue homeostasis and healing. In uninjured musculoskeletal tissues, increased loading leads to an increase in mechanical properties, while decreased loading leads to a decrease in properties. The role of loading on healing tissues is less clear. We studied tendon-to-bone healing in a canine flexor tendon-to-bone injury and repair model. To examine the effect of muscle loading on healing, repaired tendons were either cut proximally to remove all load from the distal phalanx repair site (unloaded group) or left intact proximally (loaded group). All paws were cast post-operatively and subjected to daily passive motion rehabilitation. Specimens were tested to determine functional properties, biomechanical properties, repair-site gapping, and bone mineral density. Loading across the repair site led to improved functional and biomechanical properties (e.g., stiffness for the loaded group was 8.2 ± 3.9 vs. 5.1 ± 2.5 N/mm for the unloaded group). Loading did not affect bone mineral density or gapping. The formation of a gap between the healing tendon and bone correlated with failure properties. Using a clinically relevant model of flexor tendon injury and repair, we found that muscle loading was beneficial to healing. Complete removal of load by proximal transection resulted in tendon-to-bone repairs with less range of motion and lower biomechanical properties compared to repairs in which the muscle-tendon-bone unit was left intact. PMID:18524009
Yamazaki, H; Kato, H; Hata, Y; Nakatsuchi, Y; Tsuchikane, A
We analysed 21 patients with closed rupture of the flexor tendons caused by carpal bone and joint disorders. The tendon that ruptured depended on the location of the bone perforation into the carpal tunnel. Radiocarpal arthrography was performed in 13 patients and capsular perforation was demonstrated by contrast medium leakage into the carpal canal in 11 patients. This proved a useful diagnostic test. The flexor tendon(s) were reconstructed with free tendon graft in 17 patients, cross-over transfer of flexor tendons from adjacent digits in two and buddying to an adjacent flexor tendon in one patient. Postoperative total active range of motion in the fingers after 13 free tendon graft reconstructions averaged 213 degrees (range 170-265 degrees ). The active range of motion of the thumb-interphalangeal joint after free tendon graft reconstruction in three cases improved from 0 degrees to 33 degrees on average (range 10 degrees -40 degrees ).
Felder, Jerrod J; Guseila, Loredana M; Saranathan, Archana; Shary, Timothy J; Lippitt, Steven B; Elias, John J
The current study was performed to determine the strength and rigidity of the intact flexor digitorum profundus (FDP) tendon attachment and compare the rigidity at the attachment site to the rigidity within a more proximal part of the tendon. Eight cadaveric index fingers were tested to failure of the FDP tendon. Lines were drawn on each tendon with India ink stain at the position of the attachment to bone and 5 mm and 10 mm proximally. Each test was recorded using a high resolution video camera. A minimum of six images per test were used for analysis of tissue deformation. The centroid of each line was computationally identified to characterize the deformation of the tendon between the lines. Force vs. deformation curves were generated for the 5 mm region representing the tendon attachment and the 5 mm region adjacent to the attachment. Stiffness measurements were generated for each curve, and normalized by the initial length to determine the rigidity. The failure strength ranged from 263 N to 548 N, with rigidity values ranging from 2201 N/(mm/mm) to 8714 N/(mm/mm) and from 3459 N/(mm/mm) to 6414 N/(mm/mm) for the attachment and the tendon proximal to the attachment, respectively. The rigidity did not vary significantly between the attachment and proximal tendon based on a Wilcoxon signed rank test (p = 0.2). The measured strength and rigidity establish biomechanical properties for the FDP tendon attachment to bone.
Ostric, Srdjan Andrei; Russell, Robert C; Petrungaro, Jason
Zone III flexor tendon injuries are relatively rare in comparison to other flexor tendon injuries in zones I, II, IV, and V. Often, these are open injuries resulting from an electrical device like a saw; however, closed injures are even rarer, and those mid-substance ruptures resulting from bowling with no evidence of underlying tendinopathy from diseases like gout are highly unusual. The principles underlying tendon repair remain the same regardless of the etiology. In this case, we delineate some of the options and stress the guiding principles of the various methods available in this interesting and unusual case.
Tat, Jimmy; Kociolek, Aaron M; Keir, Peter J
Non-inflammatory fibrosis and thickening of the subsynovial connective tissue (SSCT) are characteristic in carpal tunnel syndrome (CTS) patients. These pathological changes have been linked to repetitive hand tasks that create shear forces between the flexor tendons and SSCT. We measured the relative motion of the flexor digitorum superficialis tendon and SSCT during two repetitive finger tasks using color Doppler ultrasound. Twelve participants performed flexion-extension cycles for 30 min with the long finger alone (differential movement) and with all four fingers together (concurrent movement). Shear strain index (SSI, a relative measure of excursion in flexion and extension) and maximum velocity ratio (MVR, the ratio of SSCT versus tendon during flexion and extension) were used to represent shear. A linear effect of exertion time was significant and corresponded with larger tendon shear in differential motion. The flexion SSI increased 20.4% from the first to the 30th minute, while MVR decreased 8.9% in flexion and 8.7% in extension. No significant changes were found during concurrent motion. These results suggest that exposure to repetitive differential finger tasks may increase the risk of shear injury in the carpal tunnel.
Two-thirds of Achilles tendon injuries in competitive athletes are paratenonitis and one-fifth are insertional complaints (bursitis and insertion tendinitis). The remaining afflictions consist of pain syndromes of the myotendineal junction and tendinopathies. The majority of Achilles tendon injuries from sport occur in males, mainly because of their higher rates of participation in sport, but also with tendinopathies a gender difference is probably indicated. Athletes in running sports have a high incidence of Achilles tendon overuse injuries. About 75% of total and the majority of partial tendon ruptures are related to sports activities usually involving abrupt repetitive jumping and sprinting movements. Mechanical factors and a sedentary lifestyle play a role in the pathology of these injuries. Achilles tendon overuse injuries occur at a higher rate in older athletes than most other typical overuse injuries. Recreational athletes with a complete Achilles tendon rupture are about 15 years younger than those with other spontaneous tendon ruptures. Following surgery, about 70 to 90% of athletes have a successful comeback after Achilles tendon injury. Surgery is required in about 25% of athletes with Achilles tendon overuse injuries and the frequency of surgery increases with patient age and duration of symptoms as well as occurrence of tendinopathic changes. However, about 20% of injured athletes require a re-operation for Achilles tendon overuse injuries, and about 3 to 5% are compelled to abandon their sports career because of these injuries. Myotendineal junction pain should be treated conservatively. Partial Achilles tendon ruptures are primarily treated conservatively, although the best treatment method of chronic partial rupture seems to be surgery. Complete Achilles tendon ruptures of athletes are treated surgically, because this increases the likelihood of athletes reaching preinjury activity levels and minimises the risk of re-ruptures. Marked forefoot
Johnson, M.; Firoozbakhsh, K.; Moniem, M.; Jamshidi, M.
An SC-based multi-objective decision-making method for determining the optimal flexor-tendon repair technique from experimental and clinical survey data, and with variable circumstances, was presented. Results were compared with those from the Taguchi method. Using the Taguchi method results in the need to perform ad-hoc decisions when the outcomes for individual objectives are contradictory to a particular preference or circumstance, whereas the SC-based multi-objective technique provides a rigorous straightforward computational process in which changing preferences and importance of differing objectives are easily accommodated. Also, adding more objectives is straightforward and easily accomplished. The use of fuzzy-set representations of information categories provides insight into their performance throughout the range of their universe of discourse. The ability of the technique to provide a "best" medical decision given a particular physician, hospital, patient, situation, and other criteria was also demonstrated.
Lustgarten, Meghann; Redding, W Rich; Labens, Raphael; Morgan, Michel; Davis, Weston; Seiler, Gabriela S
Tendon and ligament injuries are common causes of impaired performance in equine athletes. Gray-scale ultrasonography is the current standard method for diagnosing and monitoring these injuries, however this modality only provides morphologic information. Elastography is an ultrasound technique that allows detection and measurement of tissue strain, and may provide valuable mechanical information about equine tendon and ligament injuries. The purpose of this study was to determine the feasibility, reproducibility, and repeatability of elastography; and to describe elastographic characteristics of metacarpal tendons in sound horses. Nineteen legs for 17 clinically sound horses without evidence of musculoskeletal pathology were included. Elastographic images of the superficial and deep digital flexor tendons and the branches of the suspensory ligament (tendon of the interosseous muscle) were described quantitatively and qualitatively. There was no statistically significant difference between operators (P = 0.86) nor within operators (P = 0.93). For qualitative assessments, reproducibility (0.46) was moderate and repeatability (0.78) was good. Similar to human Achilles tendons, equine tendons were classified as predominantly hard using elastography. There was no statistically significant difference in stiffness of the flexor tendons (P = 0.96). No significant difference in stiffness was found with altered leg position during standing (P = 0.84) and while nonweight bearing (P = 0.61). The flexor tendons were softer when imaged in longitudinal versus transverse planes (P < 0.01) however, the suspensory branches were not (P = 0.67). Findings supported future clinical application of elastography as a noninvasive "stall-side" imaging modality for evaluation of the tendons and ligaments of the distal forelimb in horses.
Lee, G J; Kwak, S; Kim, H K; Ha, S H; Lee, H J; Baek, G H
Spontaneous flexor tendon rupture is a rare condition and the aetiology is not clear. We report 12 elderly Korean farmers with spontaneous flexor tendon ruptures. We found the rupture in the dominant hand in ten patients. A rupture in the little finger was found in all 12 patients (seven with both flexor tendons ruptured and five with only the profundus ruptured), in the ring finger in four patients (the profundus ruptured in all and both flexor tendons in two patients), and in the middle finger a partial rupture of the profundus in one patient. The tendons were ruptured close to the hook of the hamate. Repetitive friction between the flexor tendons and the hamate hook may cause the ruptures. The hamate hook was excised and the ruptured profundus tendons were reconstructed with tendon transfers with quite favourable functional recovery at follow-up of 1 to 2 years. The ruptured superficialis tendons were not reconstructed. Level of Evidence IV.
Zhao, Chunfeng; Ozasa, Yasuhiro; Shimura, Haruhiko; Reisdorf, Ramona L.; Thoreson, Andrew R.; Jay, Gregory; Moran, Steven L.; An, Kai-Nan; Amadio, Peter C.
The purpose of the study was to test a novel treatment that carbodiimide-derivatized-hyaluronic acid-lubricin (cd-HA-lubricin) combined cell-based therapy in an immobilized flexor tendon repair in a canine model. Seventy-eight flexor tendons from 39 dogs were transected. One tendon was treated with cd-HA-lubricin plus an interpositional graft of 8 × 105 BMSCs and GDF-5. The other tendon was repaired without treatment. After 21 day of immobilization, 19 dogs were sacrificed; the remaining 20 dogs underwent a 21-day rehabilitation protocol before euthanasia. The work of flexion, tendon gliding resistance, and adhesion score in treated tendons were significantly less than the untreated tendons (p < 0.05). The failure strength of the untreated tendons was higher than the treated tendons at 21 and 42 days (p < 0.05). However, there is no significant difference in stiffness between two groups at day 42. Histologic analysis of treated tendons showed a smooth surface and viable transplanted cells 42 days after the repair, whereas untreated tendons showed severe adhesion formation around the repair site. The combination of lubricant and cell treatment resulted in significantly improved digit function, reduced adhesion formation. This novel treatment can address the unmet needs of patients who are unable to commence an early mobilization protocol after flexor tendon repair. PMID:26177854
DiGiovanni, Daria L; Rademacher, Nathalie; Riggs, Laura M; Baumruck, Rebecca A; Gaschen, Lorrie
Palmar/plantar annular desmitis is a common disease that may be associated with adhesions and structures affecting the flexor tendons, which requires tenoscopy to diagnose. The purpose of this descriptive study was to develop a dynamic sonographic technique for evaluating the motion of normal equine flexor tendons in relation to the palmar/plantar annular ligament and to compare findings with horses previously diagnosed with palmar/plantar annular desmitis. Ten healthy adult horses were examined prospectively and the images of four horses diagnosed with palmar/plantar annular desmitis were retrospectively evaluated. Dynamic sonography was performed at the level of the metacarpo/metatarsophalangeal joint by maximally extending and flexing the interphalangeal joints. Palmar/plantar annular ligament thickness (mm), size of any gap between the flexor tendons, and subjectively increased angulation of the long linear echoes of the superficial digital flexor tendon were measured. The presence of gliding motion between the palmar/plantar annular ligament and superficial digital flexor tendon was determined by consensus. Twenty-eight healthy control limbs (16 hind/12 fore) and four with palmar/plantar annular desmitis (3 hind/1 fore) were evaluated. Controls had unrestricted gliding motion between the palmar/plantar annular ligament and flexor tendons and zero to 13° of angulation of the long linear echoes. The four affected horses had restricted gliding motion and between 20-35° angulation of the long linear echoes. Dynamic ultrasound is a feasible technique for detecting restricted flexor tendon and palmar/plantar annular ligament gliding motion, as well as subjectively increased angulation of the long linear echoes of the flexor tendon in affected horses compared with controls and warrants further investigation.
Lui, Tun Hing
Tenosynovial chondromatosis can occur in the flexor hallucis longus tendon sheath. Complete synovectomy and removal of the loose bodies comprise the treatment of choice. An open procedure requires extensive soft-tissue dissection because the flexor hallucis longus tendon is a deep structure except at the hallux. A tendoscopy approach to synovectomy and removal of loose bodies has the advantage of minimally invasive surgery. This technical note outlines pearls and pitfalls and provides a step-by-step guide to performing this procedure.
Crevier-Denoix, N; Ravary-Plumioën, B; Vergari, C; Camus, M; Holden-Douilly, L; Falala, S; Jerbi, H; Desquilbet, L; Chateau, H; Denoix, J-M; Pourcelot, P
The incidence of superficial digital flexor tendon (SDFT) injuries is one of the highest of all equine musculoskeletal conditions. Horses with SDFT injuries commonly show no improvement of lameness on soft ground, unlike those suffering from distal bone or joint lesions. The aim of this study was to compare the SDFT loading in five horses at the walk and trot on asphalt and sand using a non-invasive ultrasonic tendon force measurement device. Three horses were equipped with the ultrasonic device, whereas the other two horses were equipped with the ultrasonic device and a dynamometric horseshoe (DHS); the DHS was used to calibrate the measured values of tendon speed of sound (SOS) converted to tendon force, while a previously established ground reaction force pattern was used to calibrate SOS measurements for the other three horses. Although the horses tended to be slower on S, maximal tendon force was higher on sand than on asphalt at the trot (+6%); there was no significant difference between the two surfaces at the walk. The duration of tendon loading was longer on S (+5%) and the area under the tendon force-time curve was larger on S (+10%) at both walk and trot. SDFT loading is significantly affected by the ground surface and the observed increase in SDFT loading on sand compared with asphalt is consistent with clinical observations in horses with SDFT injuries.
Endo, Jun; Yamaguchi, Satoshi; Sasho, Takahisa
Intratendinous ganglion cysts are rare lesions of unknown etiology that originate within a tendon. We report the case of a 34-year-old female with an intratendinous ganglion in the plantar portion of the flexor hallucis longus tendon. The intratendinous ganglion recurred after ultrasound-guided needle aspiration. Tendoscopic excision of the intratendinous ganglion cyst achieved a satisfactorily result without recurrence.
Lee, S K; Bae, K W; Choy, W S
It has been suggested that the increased frequency of trigger finger (TF) after carpal tunnel release (CTR) may be caused by the volar migration of the flexor tendons at the wrist altering the tendon biomechanics at the A1 pulley. This hypothesis has not been validated. We performed pre- and post-operative ultrasonography (USG) on the affected wrists of 92 patients who underwent CTR. Pre-operative USG was performed in neutral with no tendon loading; post-operative USG was performed in neutral unloaded and in various positions of wrist flexion whilst loading the flexor tendons with gripping. The mean volar migration of the flexor tendons after CTR was 2.2 (SD 0.4) mm in the unloaded neutral position. It was 1.8 (SD 0.4) mm in patients who did not develop TF and 2.5 (SD 0.5) mm in those who did (p = 0.0067). In loaded wrist flexion, the mean volar migration of flexor tendons after CTR in patients who did not develop TF and those who did was 2.1 and 3.0 mm in 0° flexion; 3.2 and 3.9 mm in 15° flexion; 4.3 and 5.1 mm in 30° flexion; and 4.9 and 5.8 mm in 45° flexion, respectively. There were significant differences between patients with and without TF at each flexion angle. Our data indicate that patients with greater volar migration of the flexor tendons after CTR are more likely to develop TF. This conclusion supports the hypothesis that the occurrence of TF after CTR may be caused by the bowstringing effects of the flexor tendons.
Wong, Jason; Bennett, William; Ferguson, Mark W J; McGrouther, Duncan A
Mice are currently the species of choice for the in vivo study of injury, but few detailed anatomical descriptions have been made of rodent digits, limiting their use for the investigation of intrasynovial tendon healing. In this study a detailed microscopic and histological investigation was performed using C57/BL6 and Tie2 LacZ reporter gene transgenic mice. Serial-sectioned mouse hindpaw digits were characterized using haematoxylin and eosin, Masson's trichrome (collagen), Alcian blue (fibrocartilage), Miller's stain (elastin) and TRITC-phalloidin (cellular cytoskeleton) staining. Digital vasculature was demonstrated using FITC-labelled dextran perfusion studies supplemented with LacZ expression in Tie2 LacZ transgenic mice digits. Imaging of the digit used a combination of brightfield and confocal microscopy with three-dimensional reconstruction. Our findings demonstrated that the mouse hindpaw possesses deep and superficial flexor tendons within a synovial sheath comparable with that found in other mammalian species. The intrasynovial tendons were avascular and had regions of fibrocartilaginous specialization relating to areas of compression. Corresponding vascular networks were demonstrated around the sheath using Tie2 LacZ mice and FITC-perfused hindpaws. Furthermore, there is an area of digit where both deep and superficial tendons reside between two pulleys, similar to zone 2 in the human hand where it would be possible to study intrasynovial tendon injury and adhesion formation. In conclusion, although the dimensions of the mouse digit pose technical challenges for surgical intervention, we have identified a model for the study of flexor tendon injury that will permit future genetic manipulation studies. PMID:17005025
As tendon transfer of the flexor hallucis longus (FHL) and the flexor digitorum longus (FDL) is an established procedure, exact knowledge of the formation of the chiasma plantare is of great interest. Although the quadratus plantae (QP) appears to play a major role, it has been rarely addressed in previous studies. The aim of the present study was to reinvestigate the formation of the chiasma plantare and the composition of the long flexor tendons in order to clarify the inexact and partly contradictory descriptions published from 1865 onward. The chiasma plantare and the long flexor tendons in both feet of 50 formalin-fixed specimens of body donors (25 men and women) were analyzed by gross anatomical dissection. It was composed of one (3%), two (69%) or three layers (28%) which were variably established by the tendinous and muscular fibers of the FHL, the FDL and the QP. In 61% the FHL gave one or more slips to the FDL, and in 39% there was a bidirectional interconnection between the two tendons. The slip from the FHL to the FDL largely reinforces the second (45%), or the second and third tendon (46%). Thus, the FHL is involved in the first tendon in all cases, in the second one in 97% of cases, and in the third tendon in about one half of cases (53%). In all instances, the FDL contributes to the third to fourth, in 98% the second, and in at least 39% to the first tendon. The QP reinforces the second to fourth tendon in nearly all cases, the fifth in about one half of cases, and even the first tendon in 14% of cases. In addition, the individual composition of the five long flexor tendons arising from the chiasma plantare was analyzed in detail. Special emphasis was placed on the evaluation of side and sex differences as well as individual symmetry. Furthermore, biomechanical, developmental and phylogenetic aspects were outlined. In terms of the outcome of this study, the FHL appears to be the better donor for tendon transfer to restore lost function, but
Tamura, N; Kuroda, T; Kotoyori, Y; Fukuda, K; Nukada, T; Kato, T; Kuwano, A; Kasashima, Y
Sonoelastography can assess the inner stiffness of tissues. Sonoelastographic evaluation of injured equine superficial digital flexor tendons (SDFTs) is considered to be useful for assessing the stiffness of a lesion even during late-stage rehabilitation. The purpose of this study was to investigate and compare the sonoelastographic appearance of injured SDFTs over time from the onset of the injury. Eighteen horses were classified into three groups according to the length of time from injury onset: group A, within two weeks after injury; group B, approximately five months after injury; and group C, approximately nine months after injury. Longitudinal and transverse images of all injured SDFTs were obtained using grey-scale ultrasonography and sonoelastography. Grey-scale and sonoelastographic images were evaluated by two observers using echogenicity-grading and colour-grading systems, respectively. The authors evaluated the interobserver agreement and compared the grades among the three groups. The results indicated almost perfect interobserver agreement. Significant differences were found in the sonoelastography among the three groups, whereas no significant difference was found in the grey-scale ultrasonography between groups B and C. Sonoelastography is a feasible and useful modality to evaluate the equine injured SDFTs in vivo and to distinguish between them among the different phases even during the chronic phase.
Senda, Hiroya; Mizutani, Jun; Okamoto, Hideki
Abstract An intratendinous ganglion of the hand is a rare entity, and only one case report of flexor tendon has been published in the English literature. We herein report two cases of an intratendinous ganglion occurring in the extensor digitorum communis and flexor digitorum superficialis tendon, respectively. PMID:28164147
Lee, Kang; Moon, Jeong Seok; Seo, Jeong Gook; Lee, Woo Chun
We present one-stage treatment of deep infection following repair of Achilles tendon rupture using flexor hallucis longus transfer. Flexor hallucis longus was used not only to connect the defect in Achillles tendon, but also to control the soft tissue infection with its abundant blood supply, simultaneously. The clinical results for the two patients in this report were excellent without major complication.
Watanabe, Takafumi; Hosaka, Yoshinao; Yamamoto, Etsuko; Ueda, Hiromi; Tangkawattana, Prasarn; Takehana, Kazushige
The Golgi tendon organ (GTO) is an encapsulated fusiform mechanoreceptor siding in the musculo-tendinous junction of many animal species. Inhibitory function of afferent nerve fibers distributed from nearby motor units, the organ responds to active tension exerted onto the muscle. The morphological features of the equine GTO have not yet been elucidated. Additionally, there is some controversy regarding to the existence of the GTO in the equine superficial digital flexor tendon (SDFT). Therefore, immunohistochemistry and immunoelectron microscopy using alcian blue (pH 2.5) staining and the silver-enhanced colloidal gold method were carried out to determine both the location and characteristics of the GTO at the musculo-tendinous junction of the SDFT. A GTO with a fusiform structure of approximately 3 mm in length was found in the tendinous part. The lumen of the GTO was divided into compartments by septal cells. Each compartment contained collagen fibrils, nerve fibers and Schwann cells. This is the first report of the equine GTO.
Frois Temponi, Eduardo; de Carvalho, Lúcio Honório; da Silva Bernardes, Cláudio Otávio; Presses Teixeira, Bruno
Chronic patellar tendon rupture is a rare disabling injury that is technically difficult to repair. The true prevalence of this injury is unknown. Delayed reconstruction of chronic patellar tendon rupture has yielded suboptimal clinical and functional results. Many different surgical methods for reconstruction of chronic patellar tendon injury have been reported. In this report, we present a case with chronic patellar tendon injury that was addressed using a technique that had not previously been described in the literature, through combining procedures that had been described separately. The reconstruction method presented in this article has the advantages of being easy and reproducible, without a requirement of allografts.
Schöffl, Volker Rainer; Schöffl, Isabelle
Closed traumatic ruptures of finger flexor tendon pulleys began to be recognized specifically over the past several decades. This injury, although rare in the general population, is seen more commonly in rock climbers. This article analyzes this type of injury and the current diagnostic and therapeutic criteria. Ultrasound and magnetic resonance imaging are used to differentiate between a pulley strain, partial rupture, complete rupture, or multiple ruptures. Grade I to III injuries (strains, partial rupture, single ruptures) are treated conservatively with initial immobilization and early functional therapy under pulley protection. Grade IV injuries (multiple ruptures) require surgical repair.
Lui, Tun Hing
Flexor hallucis longus (FHL) tendon transfer is indicated for reconstruction of the Achilles tendon with a gap larger than 5 cm. The tendon can be harvested at zone 2 or zone 3 by minimally invasive techniques with the advantage of minimal soft-tissue dissection. The tendon can be harvested under the sustentaculum tali by zone 2 FHL tendoscopy. It is adequate for FHL transfer to the posterior calcaneal tubercle. If a double-thickness reconstruction of a huge gap of the Achilles tendon is indicated, the tendon can be harvested at the level of the hallux by means of a tendon stripper. However, the interconnection tendon of the master knot of Henry can be split together with the FHL or flexor digitorum longus tendon instead of being cut. Zone 2 FHL tendoscopy can be used to release the split tendon to complete the FHL harvest.
Witvrouw, E; Mahieu, N; Roosen, P; McNair, P
The function of tendons can be classified into two categories: tensile force transmission, and storage and release of elastic energy during locomotion. The action of tendons in storing and releasing energy is mainly seen in sports activities with stretch-shortening cycles (SSCs). The more intense the SSC movements are (jumping-like activities), the more frequently tendon problems are observed. High SSC movements impose high loads on tendons. Consequently, tendons that frequently deal with high SSC motion require a high energy-absorbing capacity to store and release this large amount of elastic energy. As the elasticity of tendon structures is a leading factor in the amount of stored energy, prevention and rehabilitation programmes for tendon injuries should focus on increasing this tendon elasticity in athletes performing high SSC movements. Recently, it has been shown that ballistic stretching can significantly increase tendon elasticity. These findings have important clinical implications for treatment and prevention of tendon injuries.
Gomes Júnior, Nelson Pelozo; Andreoli, Carlos Vicente; Pochini, Alberto de Castro; Raduan, Fernando Cipolini; Ejnisman, Benno; Cohen, Moisés
The presence of accessory tendons in the foot and ankle needs to be recognized, given that depending on their location, they may cause disorders relating either to pain processes or to handling of the surgical findings. We describe the presence of an accessory flexor tendon of the toes, seen in surgical exposure for transferring the long flexor tendon of the hallux to the calcaneus, due to the presence of a disorder of tendinopathy of the insertion of the calcaneal tendon in association with Haglund's syndrome. PMID:26962495
Gomes Júnior, Nelson Pelozo; Andreoli, Carlos Vicente; Pochini, Alberto de Castro; Raduan, Fernando Cipolini; Ejnisman, Benno; Cohen, Moisés
The presence of accessory tendons in the foot and ankle needs to be recognized, given that depending on their location, they may cause disorders relating either to pain processes or to handling of the surgical findings. We describe the presence of an accessory flexor tendon of the toes, seen in surgical exposure for transferring the long flexor tendon of the hallux to the calcaneus, due to the presence of a disorder of tendinopathy of the insertion of the calcaneal tendon in association with Haglund's syndrome.
Zhao, Chunfeng; Ettema, Anke M; Berglund, Lawrence J; An, Kai-Nan; Amadio, Peter C
The purpose of this study was to investigate the effect of carpal tunnel pressure on the gliding characteristics of flexor tendons within the carpal tunnel. Eight fresh human cadaver wrists and hands were used. A balloon was inserted into the carpal tunnel to elevate the pressure. The mean gliding resistance of the middle finger flexor digitorum superficialis tendon was measured with the following six conditions: (1) as a baseline, before balloon insertion; (2) balloon with 0 mmHg pressure; (3) 30 mmHg; (4) 60 mmHg; (5) 90 mmHg; (6) 120 mmHg. The gliding resistance of flexor tendon gradually increased as the carpal tunnel pressure was elevated. At pressures above 60 mmHg, the increase in gliding resistance became significant compared to the baseline condition. This study helps us to understand the relationship between carpal tunnel pressure, which is elevated in the patient with carpal tunnel syndrome (CTS) and tendon gliding resistance, which is a component of the work of flexion. These findings suggest that patients with CTS may have to expend more energy to accomplish specific motions, which may in turn affect symptoms of hand pain, weakness and fatigue, seen commonly in such patients.
Samukawa, Mina; Hattori, Masaki; Sugama, Naoko; Takeda, Naoki
Dynamic stretching is commonly used in warm-up routines for athletic activities. Even though several positive effects of dynamic stretching on athletic performance have been reported, the effects on the muscle-tendon unit (MTU) itself are still unclear. The objective of this study is to determine the effects of dynamic stretching on the ankle plantar flexor muscle-tendon properties by use of ultrasonography. Twenty healthy male subjects participated in the present study. The subjects were asked to engage in dynamic stretching of plantar flexors for 30 s and to repeat for 5 sets. Ankle dorsiflexion ROM was measured before and after the dynamic stretching. Changes in the displacement of the myotendinous junction (MTJ), pennation angle, and fascicle length were also determined by using ultrasonography. Ankle dorsiflexion ROM increased significantly after the dynamic stretching (p < 0.0001). A significant distal displacement of the MTJ was observed until the second stretching set (p < 0.001) with no significant changes thereafter. Pennation angle, and fascicle length were unaffected by the dynamic stretching. Dynamic stretching was shown to be effective in increasing ankle joint flexibility. Outcomes that could have indicated changes in muscle tissue (such as the pennation angle and fascicle length) were unaltered. However, a significant displacement of the MTJ was found, indicating some change in the tendon tissues. Therefore, dynamic stretching of the plantar flexors was considered an effective means of lengthening the tendon tissues.
Lui, Tun Hing
Chronic tendinopathy is characterized by pain in the tendon, generally at the start and completion of exercise. However, tendinosis may lead to decreased blood flow, increased stiffness of the tendon and reduced tensile strength, and predispose to rupture. Operative treatment is indicated to restore the function of the Achilles tendon and alleviate the prerupture heel cord pain. A case of acute Achilles tendon rupture with extensive tendinosis that was successfully treated with minimally invasive flexor hallucis longus transfer is reported.
An original method for A1 retinaculum reconstruction of flexor pollicis longus sheath with extensor pollicis brevis tendon is presented. Reconstructed retinaculum is very strong. Loss of extensor pollicis brevis did not impaired thumb function.
Rodriguez, D; Devos Bevernage, B; Maldague, P; Deleu, P-A; Leemrijse, T
Tarsal tunnel syndrome (TTS) defines an entrapment neuropathy of the posterior tibial nerve or one of its branches, within the tarsal tunnel. Numerous etiologies have been described explaining this entrapment, including trauma, space-occupying lesions, foot deformities, etc. We present an unreported cause of a space-occupying lesion in the etiology of TTS, namely the combination of a hypertrophic long distally extended muscle belly of the flexor hallucis longus and repetitive ankle motion. Surgical debulking of the muscle belly in the posterior ankle compartment resolved all symptoms.
Peterson, W W; Manske, P R; Lesker, P A; Kain, C C; Schaefer, R K
A method was developed to reconstruct the fibro-osseous pulleys with Nitex, a synthetic material. Nitex is a closely woven fabric constructed from monofilament nylon fibers. Six adult monkeys (24 digits) had excision of the A1 and A2 pulleys; this was followed by reconstruction of the A2 pulley with the Nitex synthetic material. The animals were killed, two at a time, at 4, 8, and 12 weeks to evaluate the effectiveness of the Nitex pulleys. Flexor tendon function was assessed by biomechanical methods with a tensile testing machine to measure the tendon excursion and the work of flexion (the area under the force-excursion curve) necessary to fully flex each digit; these parameters revealed that the Nitex pulleys were capable of preventing tendon bow-stringing and did not significantly impair tendon gliding. The breaking strength of the Nitex pulleys was comparable to that of normal A2 pulleys (for monkeys weighing less than 10 kg) and it was sufficient to allow immediate mobilization of the digits postoperatively without fear of pulley rupture. Histologic examination showed minimal foreign body reaction around the Nitex, and the gliding surface of a Nitex pulley was found to be covered with a smooth layer of fibrous tissue with minimal adhesions to the underlying flexor tendon. The synthetic Nitex pulley appears to have the potential to function as an effective fibro-osseous pulley replacement.
Al-Qattan, M M
Over an eight-year period, the author has treated five males (mean age of 31 years) with clean-cut zone 2 lacerations of both flexor tendons of all fingers using the same surgical technique (profundus only repair using three 'figure of eight' core sutures and proximal venting of the pulley system) and the same postoperative mobilization programme (a dorsal blocking splint with immediate active motion that allowed full extension at the interphalangeal joints). There were no ruptures of the repaired 20 fingers. At final follow-up (mean of 22 months after surgery), the outcome was considered excellent in 12 fingers, good in four fingers and fair in the remaining four fingers by the Strickland-Glogovac criteria. The outcome was similar in all four fingers for every patient supporting the hypothesis of previous studies that the outcome of repair of clean-cut flexor tendon lacerations in zone 2 is related to the psychological and biologic characteristics of the patient.
Hennecke, Kathleen; Redeker, Joern; Kuhbier, Joern W.; Strauss, Sarah; Allmeling, Christina; Kasper, Cornelia; Reimers, Kerstin; Vogt, Peter M.
Repair success for injuries to the flexor tendon in the hand is often limited by the in vivo behaviour of the suture used for repair. Common problems associated with the choice of suture material include increased risk of infection, foreign body reactions, and inappropriate mechanical responses, particularly decreases in mechanical properties over time. Improved suture materials are therefore needed. As high-performance materials with excellent tensile strength, spider silk fibres are an extremely promising candidate for use in surgical sutures. However, the mechanical behaviour of sutures comprised of individual silk fibres braided together has not been thoroughly investigated. In the present study, we characterise the maximum tensile strength, stress, strain, elastic modulus, and fatigue response of silk sutures produced using different braiding methods to investigate the influence of braiding on the tensile properties of the sutures. The mechanical properties of conventional surgical sutures are also characterised to assess whether silk offers any advantages over conventional suture materials. The results demonstrate that braiding single spider silk fibres together produces strong sutures with excellent fatigue behaviour; the braided silk sutures exhibited tensile strengths comparable to those of conventional sutures and no loss of strength over 1000 fatigue cycles. In addition, the braiding technique had a significant influence on the tensile properties of the braided silk sutures. These results suggest that braided spider silk could be suitable for use as sutures in flexor tendon repair, providing similar tensile behaviour and improved fatigue properties compared with conventional suture materials. PMID:23613793
Zhao, Chunfeng; Wei, Zhuang; Kirk, Ramona L.; Thoreson, Andrew R.; Jay, Gregory D.; Moran, Steven L.; An, Kai-Nan; Amadio, Peter C.
Background Using allograft is an attractive alternative for flexor tendon reconstruction because of the lack of donor morbidity, and better matching to the intrasynovial environment. The purpose of this study was to use biolubricant molecules to modify the graft surface to decrease adhesions and improve digit function. Methods 28 flexor digitorum profundus (FDP) tendons from the 2nd and 5th digits of 14 dogs were first lacerated and repaired to create a model with repair failure and scar digit for tendon reconstruction. Six weeks after the initial surgery, the tendons were reconstructed with FDP allograft tendons obtained from canine cadavers. One graft tendon in each dog was treated with saline as a control and the other was treated with gelatin, carbodiimide derivatized, hyaluronic acid and lubricin (cd-HA-Lubricin). Six weeks postoperatively, digit function, graft mechanics, and biology were analyzed. Results Allograft tendons treated with cd-HA-Lubricin had decreased adhesions at the proximal tendon/graft repair and within flexor sheath, improved digit function, and increased graft gliding ability. The treatment also reduced the strength at the distal tendon to bone repair, but the distal attachment rupture rate was similar for both graft types. Histology showed that viable cells migrated to the allograft, but these were limited to the tendon surface. Conclusion cd-HA-Lubricin treatment of tendon allograft improves digit functional outcomes after flexor tendon reconstruction. However, delayed bone-tendon healing should be a caution. Furthermore, the cell infiltration into the allograft tendons substance should be a target for future studies, to shorten the allograft self-regeneration period. PMID:24445876
Schweizer, A; Frank, O; Ochsner, P E; Jacob, H A C
A method was developed to indirectly measure friction between the flexor tendons and pulleys of the middle and ring finger in vivo. An isokinetic movement device to determine maximum force of wrist flexion, interphalangeal joint flexion (rolling in and out) and isolated proximal interphalangeal (PIP) joint flexion was built. Eccentric and concentric maximum force of these three different movements where gliding of the flexor tendon sheath was involved differently (least in wrist flexion) was measured and compared. Fifty-one hands in 26 male subjects were evaluated. The greatest difference between eccentric and concentric maximum force (29.9%) was found in flexion of the PIP joint. Differences in the rolling in and out movement (26.8%) and in wrist flexion (14.5%) were significantly smaller. The force of friction between flexor tendons and pulleys can be determined by the greater difference between eccentric and concentric maximum force provided by the same muscles in overcoming an external force during flexion of the interphalangeal joints and suggests the presence of a non-muscular force, such as friction. It constitutes of 9% of the eccentric flexion force in the PIP joint and therefore questions the low friction hypothesis at high loads.
Zhao, Chunfeng; Zobitz, Mark E.; Sun, Yu-Long; Predmore, Kelly S.; Amadio, Peter C.; An, Kai-Nan; Moran, Steven L.
Background: Topical 5-fluorouracil has been reported to reduce adhesions in animal models of tenolysis. The purpose of this study was to investigate the effects of topical 5-fluorouracil on adhesion formation after tendon repairs were subjected to immediate postoperative rehabilitation in a canine model in vivo. Methods: Sixty dogs were randomly assigned to either a 5-fluorouracil treatment (thirty dogs) or a control group (thirty dogs). Each treatment group was then divided into three survival time points: ten days, twenty-one days, and forty-two days. The second and fifth flexor digitorum profundus tendons from each dog were fully lacerated at the zone-II area and then were repaired. Passive motion therapy started at day 5 postoperatively and continued until the dogs were killed. The repaired tendons were evaluated for normalized work of flexion, gliding resistance, repair strength, gene expression for type-I and type-III collagen and transforming growth factor-β1, and histological appearance. Results: The normalized work of flexion of the repaired tendons treated with 5-fluorouracil was significantly lower than that of the repaired tendons without 5-fluorouracil treatment at ten days. However, there was no significant difference between treated and untreated tendons at twenty-one and forty-two days. There was also no significant difference in gliding resistance, repair failure strength, or stiffness between treated and untreated tendons at any time point, or in the gross or histological appearance of adhesions at the time of killing. The expression of types-I and III collagen and transforming growth factor-β1 of the repaired tendon with 5-fluorouracil treatment was significantly lower than that of the tendons without treatment at ten days postoperatively, but not at twenty-one or forty-two days. Conclusions: Although 5-fluorouracil treatment can reduce adhesions in in vivo models of tenolysis, this treatment had only a transient effect in an in vivo model of
Giant cell tumour of tendon sheath with simultaneous two tendon involvement of the foot treated with excision of the tumour and reconstruction of the flexor retinaculum using tibialis posterior tendon in a paediatric patient: A rare case report.
Tiwari, Vivek; Ansari, Tahir; Mittal, Samarth; Sharma, Pankaj; Nalwa, Aasma
Giant cell tumour of tendon sheath is a benign soft tissue tumour arising from the tendon sheath. The involvement of foot and ankle by such tumours is relatively rare. Children are not commonly afflicted by this condition. All such tumours are reported to arise either from a single tendon sheath or one joint. We report a case of giant cell tumour of tendon sheath in a 12-year-old child, arising simultaneously from the tendon sheaths of tibialis posterior and flexor digitorum longus tendons, as well as extending into the ankle joint. It was treated by complete excision of the mass along with the tendon sheaths with reconstruction of the flexor retinaculum. The location of the tumour, age of the patient, diffuse nature of the tumour and novel technique of reconstruction of the flexor retinaculum make this case extremely rare and the first to be reported in literature.
Zhao, Chunfeng; Ettema, Anke M; Osamura, Naoki; Berglund, Lawrence J; An, Kai-Nan; Amadio, Peter C
The purpose of this study was to investigate the gliding characteristics of flexor tendons within the carpal tunnel with varied wrist positions and tendon motion styles, which may help us to understand the relationship between carpal tunnel syndrome (CTS) and repetitive hand motion. Eight fresh human cadaveric wrists and hands were used. The peak (PGR) and mean (MGR) gliding resistance of the middle finger flexor digitorum superficialis tendon were measured with the wrist in 0, 30, and 60 degrees of flexion and extension. While moving all three fingers together, the PGR at 60 degrees flexion was significantly higher than that at 0, 30, or 60 degrees extension. While moving the middle finger alone, the PGR at 60 and 30 degrees flexion was significantly higher than the PGR at 60 degrees extension. The PGR moving the middle finger FDS alone was significantly greater than that for all three digits moving together in 0, 30, and 60 degrees flexion. Differential finger motion with wrist flexion elevated the tendon gliding resistance in the carpal tunnel, which may be relevant in considering the possible role of wrist position and activity in the etiology of CTS.
Hernández-Cortés, P; Caba, M; Gómez-Sánchez, R; Gómez-Morales, M
The authors report an unusual case of flexor tenosynovitis, severe carpal tunnel syndrome, and triggering at the carpal tunnel as the first manifestation of gout. A 69-year-old man presented with digital flexion contracture and severe carpal tunnel syndrome of his right hand and was treated surgically. A flexor tenosynovectomy and a median nerve neurolysis were performed through an extended carpal tunnel approach. The sublimis and the profundus tendons were involved. Partial ruptures and multiple whitish lesions suggestive of tophacceous infiltration of the flexor tendons were seen. Macroscopically, the removed synovial tissue was involved by multiple whitish nodules that were milimetric in size and was suggestive of monosodium urate crystals deposits. By light microscopy examination, numerous nonnecrotizing granulomas of different sizes were observed that were compounded by large aggregations of acellular nonpolarized material, surrounded by epithelioid histiocytes, mononuclear cells, and foreign body multinucleated giant cells. Postoperatively, the patient recovered with resolution of the median nerve symptoms and a near-to-full range of motion of the affected digits.To the authors' knowledge, this patient is the first case report with flexor tendons tophacceous infiltration as the first clinical sign of gout. Gouty flexor tenosynovitis can occur in the absence of a long history of gout. A high index of suspicion is paramount to the initiation of proper management. Operative treatment of gouty flexor tenosynovitis is mandatory to debulk tophaceous deposits, improve tendon gliding, and decompress nerves. Routine uric acid determination could be helpful in the preoperative evaluation of patients with flexor tenosynovitis.
Mao, Haijiao; Shi, Zengyuan; Xu, Dachuan; Liu, Zhenxin
Neglected Achilles Tendon Ruptures are commonly seen by orthopaedic surgeons. In cases resistant to conservative treatment, a variety of surgical procedures have been utilized in the past. The senior -surgeon at our institution has utilized a technique -employing two turndown fascia flaps fashioned from the proximal Achilles tendon augmented by a tenomyodesis of the flexor hallucis longus and plantaris tendon. The purpose of this study was to assess the clinical outcome of all patients who underwent this procedure. The medical records of 10 cases that underwent this procedure were retrospectively reviewed. We completed data collection sets using the American Orthopaedic Foot and Ankle Society ankle-hind foot scores, isokinetic evaluation, and postoperative magnetic resonance imaging (MRI) at 1 year of follow-up. The mean American Orthopaedic Foot and Ankle Society ankle-hind foot scores improved from 64.4±3.54. Isokinetic testing at 30º/sec and 120º/sec revealed an mean deficits of 24.5%, respectively, in the plantar flexion peak torque of the involved ankle than non-involved ankle. The flexor hallucis longus tendon, gastrocnemius fascia flap and plantaris were well -integrated into the Achilles tendon forming a homogenous tendon, which was confirmed in MRI. Our subjective and objective data indicate that the reconstructive technique using flexor hallucis longus transfer with two turndown gastrocnemius fascia flaps and plantaris tendon is a good option for repairing large gap defect of Achilles tendon.
Kubo, Keitaro; Kanehisa, Hiroaki; Fukunaga, Tetsuo
The purposes of this study were to compare the elasticity of tendon and aponeurosis in human knee extensors and ankle plantar flexors in vivo and to examine whether the maximal strain of tendon was correlated to that of aponeurosis. The elongation of tendon and aponeurosis during isometric knee extension (n = 23) and ankle plantar flexion (n = 22), respectively, were determined using a real-time ultrasonic apparatus, while the participants performed ramp isometric contractions up to voluntary maximum. To calculate the strain values from the measured elongation, we measured the respective length of tendon and aponeurosis. For the knee extensors, the maximal strain of aponeurosis (12.1 +/- 2.8 %) was significantly greater than that of the patella tendon (8.3 +/- 2.4 %), p < 0.001. On the contrary, the maximal strain of Achilles tendon (5.9 +/- 1.4 %) was significantly greater than that of aponeurosis in ankle plantar flexors (2.7 +/- 1.4 %), p < 0.001. Furthermore, for both knee extensors and ankle plantar flexors there was no significant correlation between maximal strain of tendon and aponeurosis. These results would be important for understanding the different roles of tendon and aponeurosis during human movements and for more accurate muscle modeling.
Lu, Hui; Chen, Qiang; Shen, Hui
Abstract Rationale: Gouty tophi is a rare cause of CTS. We first report a unique case of repeated CTS with gouty tophi in flexor tendon. In the previous literature, the symptoms cases of CTS were gradually increased. Patient concerns: We report a 44-year-old male porter presented with mass on his left distal forearm combined a repeated carpal tunnel syndrome for 5 years. He felt numbness in fingers and his left palmar. The CTS symptoms had been eased through rest and dugs medication. It recurred twice. Diagnoses: Monosodium urate crystal deposits were found in surgery. Histologic findings confirmed the diagnosis of gout. Interventions: We removed partial of gouty tophus and retained the integrity of the tendon. Outcomes: Two years after the surgery, the patient had not experienced any symptom recurrence. Lessons: Early diagnosis and control of gout are necessary to avoid irreversible complications. The surgery combined with decreasing trioxypurine treatment can improve the treatment outcome of gouty tophus. PMID:28248892
Al-Qattan, Mohammad M
Previous authors have used either a grasping or a locking technique for flexor tendon repair in zone II. A combined (grasping and locking) 10-strand repair was used by the author in 22 adults (n = 28 fingers) with lacerations of both flexor tendons in zone II. The combined repair is known to be strong (mean tensile strength of 164 N), and the technique was used in selected cases who were thought to be at higher risk of rupture either because of excessive digital oedema (in early tendon repairs) or because of tendon retraction (in late primary tendon repairs). The 10-strand repair was bulky and, hence, only the profundus tendon was repaired; and "venting" of the pulley system was done proximal to the repair site as recommended by other authors. Supervised early active mobilisation was done immediately after the operation. At final follow-up, the outcome was calculated using the original Strickland-Glogovac grading system. There were no ruptures and the final outcome was considered excellent in 19 patients (n = 25 fingers), good in two patients (n = 2 fingers), and fair in the remaining patient (n = 1 finger). It was concluded that the bulky 10-strand repair may be used for zone II finger flexor tendon lacerations as long as a profundus-(?) only repair and "venting" of the pulley system are performed.
Foisneau-Lottin, A; Touillet, A; Paysant, J; Dautel, G
The repair of the finger flexor tendons can be complicated by the appearance of ruptures and peritendinous adhesions. Ruptures are often treated with tendon grafts. Peritendinous adhesions can require tenolysis. Following these two surgical procedures, there is a risk of new adhesions and rupture. Rehabilitation after this secondary surgery consists of a tailored, closely supervised protocol. Protocols used by the team at the Physical Medicine and Rehabilitation Department of the Regional Rehabilitation Institute and the team at the Plastic and Reconstructive Surgery Department of the Emile-Gallé Surgical Center of Nancy (France) are described. A close collaboration between these teams of surgeons and physical therapists is essential. After tendon grafting, protected early motion helps to move the transplant immediately while still protecting it. After tenolysis, immediate (several times a day) and extended rehabilitation ensures that the mobility obtained intraoperatively is maintained. It is performed in a specialized rehabilitation center during the first three postoperative weeks. The goal is to prevent new adhesions from forming while taking into account tendon's fragility.
Lee, Daniel J; Southgate, Richard D; Farhat, Youssef M; Loiselle, Alayna E; Hammert, Warren C; Awad, Hani A; O'Keefe, Regis J
Parathyroid hormone (PTH) 1-34 is known to enhance fracture healing. Tendon repair is analogous to bone healing in its dependence on the proliferation and differentiation of mesenchymal stem cells, matrix formation, and tissue remodeling.(1,2,3) We hypothesized that PTH 1-34 enhances tendon healing in a flexor digitorum longus (FDL) tendon repair model. C57Bl/6J mice were treated with either intraperitoneal PTH 1-34 or vehicle-control (PBS). Tendons were harvested at 3-28 days for histology, gene expression, and biomechanical testing. The metatarsophalangeal joint range of motion was reduced 1.5-2-fold in PTH 1-34 mice compared to control mice. The gliding coefficient, a measure of adhesion formation, was 2-3.5-fold higher in PTH 1-34 mice. At 14 days post-repair, the tensile strength was twofold higher in PTH 1-34 specimens, but at 28 days there were no differences. PTH 1-34 mice had increased fibrous tissue deposition that correlated with elevated expression of collagens and fibronectin as seen on quantitative PCR. PTH 1-34 accelerated the deposition of reparative tissue but increased adhesion formation.
Effects of sodium-hyaluronate and glucosamine-chondroitin sulfate on remodeling stage of tenotomized superficial digital flexor tendon in rabbits: a clinical, histopathological, ultrastructural, and biomechanical study.
Oryan, Ahmad; Moshiri, Ali; Meimandiparizi, Abdul-Hamid
This study was designed to evaluate the effects of sodium-hyaluronate (NaH) combined with glucosamine HCl-chondroitin sulfate (GlcN-CS) on the post-surgical repair of tendon rupture on day 84 post injury. Twenty white New Zealand female rabbits were divided randomly into two equal groups of injured treated and injured untreated. After tenotomy and surgical repair, using the modified Kessler technique and running pattern, the injured legs were casted for 14 days. NaH was injected subcutaneously over the lesion on days 3, 7, and 10 and was followed by daily oral administration of GlcN-CS on days 3 to 23 post injury. The control animals received normal saline injection and oral placebo similarly. The weight of the animals, tendon diameter, clinical manifestations, and radiographic and ultrasonographic evaluations were conducted for 12 weeks. The rabbits were euthanized 84 days post injury and the tendons were evaluated at macroscopic, histopathologic, and ultrastructural level and were assessed for biomechanical and percentage dry-weight parameters. Treatment significantly reduced the tendon diameter and ultimate and yield strain, and increased the echogenicity, dry-weight content, ultimate and yield strength, and stress and stiffness of the injured tendons compared to those of the untreated ones. Treatment also significantly enhanced the maturation rate of the tenoblasts, fibrillogenesis, the diameters of the collagen fibrils, and fibrillar density. These findings suggest that a combined treatment of NaH and GlcN-CS could be effective in restoring the morphological and biomechanical properties of injured superficial digital flexor tendon of rabbits and might be helpful for future clinical trial studies in tendon ruptures.
Todhunter, P G; Schumacher, J; Finn-Bodner, S T
Chronic lameness was determined to be caused by desmitis of the accessory ligament of the deep digital flexor tendon and adhesions associated with these 2 structures. Desmotomy of the accessory ligament, resection of adhesions, and controlled exercise during convalescence resulted in return to normal use without apparent lameness. Images Figure 1. Figure 2. PMID:9332748
Mulon, Pierre-Yves; Achard, Damien; Babkine, Marie
A 17-month-old Holstein heifer was presented for persistent enlargement above the right hind fetlock of 1-month's duration. Diffuse plantar soft tissue swelling was present on the radiographs and ultrasonography revealed the presence of multiple porcupine quill extremities embedded in the subcutaneous tissue within the flexor tendon sheath wall. Surgical removal was performed.
Rispler, D; Greenwald, D; Shumway, S; Allan, C; Mass, D
The efficiency of the flexor tendon system was examined in a human cadaver model. Pulleys were randomly sectioned, and the results were evaluated on the basis of the tendon excursion, force generated at the fingertip, and the work (force multiplied by distance) involved, as compared to the intact pulley system. When a single minor pulley (A1 or A5) was cut, there was no statistical difference in work efficiency or excursion efficiency from controls. Cutting all minor pulleys (A1, A3, A5) lead to a significant loss in excursion efficiency. The intact three pulley systems of A2, A3, and A4 were near normal and statistically better than A2 and A4 together for work efficiency. Cutting one of the major pulleys (A2, A4) resulted in significant changes in efficiency, but what was unexpected was to find an 85% loss of both work and excursion efficiency for the loss of A4 but only an excursion difference of 94% for the loss of A2. Our findings demonstrated that in this model, with the influence of the skin removed, A4 absence produced the largest biomechanically measured efficiency changes and that a combination of A2, A3, and A4 was necessary to preserve both work and excursion efficiency.
Jacoby, Sidney M; Sivalingam, Jocelyn J; Raikin, Steven Mark
Mycobacterium fortuitum (M. fortuitum), a rapidly growing non-tuberculous mycobacterium is a well-recognized, yet uncommon cause of soft tissue infection. The incidence of post surgical wound infections from this organism is increasing. The presentation of infection is atypical and failure to consider this pathogen can cause diagnostic delay and increased morbidity. Achilles tendon debridement with FHL augmentation is commonly used in patients with chronic Achilles tendinosis. Wound-edge necrosis is the most common surgical complication of this procedure, and superficial and deep infections are potentially devastating complications. We report the case of a patient who underwent Achilles tendon debridement with flexor hallucis longus augmentation, whose postoperative course was complicated by a deep M. FORTUITUM infection. Critical to the identification and ultimate treatment of this particular pathogen is the utilization of appropriate intraoperative cultures and microbiologic testing. In addition, repeat aggressive irrigation and debridement procedures coupled with removal of foreign materials and the appropriate use of prolonged antibiotic therapy can result in a successful long-term outcome.
Wu, Jingheng; Thoreson, Andrew R.; Reisdorf, Ramona L.; An, Kai-Nan; Moran, Steven L.; Amadio, Peter C.; Zhao, Chunfeng
The purpose of this study was to investigate the biomechanical properties of modified repair techniques for flexor tendon reconstruction and the effects of surface modification using carbodiimide-derivatized synovial fluid plus gelatin (cd-SF-G), compared to the traditional repair techniques. The second and fifth digits from 16 canine forepaws were randomly divided into 4 groups: (1) traditional graft repairs (TGR group) including distal Bunnell repair and proximal Pulvertaft weave repair; (2) modified graft repairs (MGR group) including distal graft bony attachment repair and proximal step-cut repair; (3) group TGR coated with cd-SF-G (TGR-C group); and (4) group MGR coated with cd-SF-G (MGR-C group). Digit normalized work of flexion (nWOF), ultimate failure strength, and stiffness were measured. The nWOF in MGR group was significantly less than TGR group (p < 0.05). The nWOF in groups treated with cd-SF-G was significantly less than their untreated counterparts (p < 0.05). Ultimate load to failure of the MGR-C group was significantly greater than the TGR-C group (p < 0.05), but no significant difference in stiffness was found between these two groups. The modified techniques cannot only improve tendon gliding abilities but can also improve breaking strength. Additionally, surface modification with cd-SF-G significantly decreased the work of flexion. PMID:25665071
Ramsey, M L
Rupture of the distal biceps tendon occurs most commonly in the dominant extremity of men between 40 and 60 years of age when an unexpected extension force is applied to the flexed arm. Although previously thought to be an uncommon injury, distal biceps tendon ruptures are being reported with increasing frequency. The rupture typically occurs at the tendon insertion into the radial tuberosity in an area of preexisting tendon degeneration. The diagnosis is made on the basis of a history of a painful, tearing sensation in the antecubital region. Physical examination demonstrates a palpable and visible deformity of the distal biceps muscle belly with weakness in flexion and supination. The ability to palpate the tendon in the antecubital fossa may indicate partial tearing of the biceps tendon. Plain radiographs may show hypertrophic bone formation at the radial tuberosity. Magnetic resonance imaging is generally not required to diagnose a complete rupture but may be useful in the case of a partial rupture. Early surgical reattachment to the radial tuberosity is recommended for optimal results. A modified two-incision technique is the most widely used method of repair, but anterior single-incision techniques may be equally effective provided the radial nerve is protected. The patient with a chronic rupture may benefit from surgical reattachment, but proximal retraction and scarring of the muscle belly can make tendon mobilization difficult, and inadequate length of the distal biceps tendon may necessitate tendon augmentation. Postoperative rehabilitation must emphasize protected return of motion for the first 8 weeks after repair. Formal strengthening may begin as early as 8 weeks, with a return to unrestricted activities, including lifting, by 5 months.
Ramesh, R; Kumar, N; Sharma, A K; Maiti, S K; Singh, G R
Sixteen tenorrhaphies were performed at the mid-metatarsal region in eight buffalo calves under lignocaine epidural analgesia. A 2 cm long gap was created in the superficial digital flexor (SDF) tendon and immediately repaired with acellular grafts in animals of group I, 1% glutaraldehyde-preserved tendon allografts in group II. In group III, the defect was repaired with autografts. This group served as control. The contralateral limb in each animal was operated after an interval of 60 days and the animals underwent the same procedure according to the designed groups. Diclofenac sodium and Enrofloxacin was given post-operatively for 5 days. Clinical examination revealed significant increase (P < 0.05) in rectal temperature, heart and respiratory rate for 3-4 postoperative days in all the animals. Mild pain and exudation as well as early restoration of tendon gliding movements and weight-bearing were observed earlier in group I in comparison with group II. Air-tendograms revealed early organization, minimal adhesion formation and lesser thickening of tendon at the reconstructive site in the acellular group whereas in the glutaraldehyde group dense homogenous swelling with adhesions was seen along the flexors. Angiography on day 30 showed that the area of proximal and distal host tendon graft junction appeared hypervascularized, whereas the area occupied by the graft appeared relatively less vascularized. Normal vascularization was observed on day 90 in all the three groups.
Crevier-Denoix, Nathalie; Ravary-Plumioën, Bérangère; Evrard, Delphine; Pourcelot, Philippe
A non-invasive ultrasonic (US) technique of tendon force measurement has been recently developed. It is based on the relationship demonstrated between the speed of sound (SOS) in a tendon and the traction force applied to it. The objectives of the present study were to evaluate the variability of this non-linear relationship among 7 equine superficial digital flexor (SDF) tendons, and the reproducibility of SOS measurements in these tendons over successive loading cycles and tests. Seven SDF tendons were equipped with an US probe (1MHz), secured in contact with the skin overlying the tendon metacarpal part. The tendons were submitted to a traction test consisting in 5 cycles of loading/unloading between 50 and 4050N. Four tendons out of the 7 were submitted to 5 additional cycles up to 5550N. The SOS-tendon force relationships appeared similar in shape, although large differences in SOS levels were observed among the tendons. Reproducibility between cycles was evaluated from the root mean square of the standard deviations (RMS-SD) of SOS values observed every 100N, and of force values every 2m/s. Reproducibility of SOS measurements revealed high between successive cycles: above 500N the RMS-SD was less than 2% of the corresponding traction force. Reproducibility between tests was lower, partly due to the experimental set-up; above 500N the difference between the two tests stayed nevertheless below 15% of the corresponding mean traction force. The reproducibility of the US technique here demonstrated in vitro has now to be confirmed in vivo.
Schöffl, V; Winkelmann, H-P
Tendon lesions are the second most common injury in the hand and therefore an important factor in orthopedic patients. Most injuries are open injuries to the flexor or extensor tendons; nevertheless, also less frequent injuries such as damage to the functional system of tendon sheath and pulley or dull avulsions need to be considered. Besides the clinical examination, ultrasound and MRI have proven to be important diagnostic tools. In the postoperative course of flexor tendon injuries, the principle of early passive movement is important to trigger "intrinsic" tendon healing to guarantee a good outcome.
Messina, A; Messina, J C
The direct midlateral approach and the lateral enlarging procedure of the pulley system have been utilized in our service since 1972. The incision runs directly behind the neurovascular pedicle, which is left in the palmar skin flap of the anterior compartment of the finger, in order to ensure its blood supply and sensibility. The transverse digital lamina of Landsmeer's skin anchoring system and Cleland's ligament are preserved and are used to perform a lateral enlargement of the pulleys after tendon repair. The technique allows wide surgical exposure of the digital fibro-osseous tunnel, enlargement and reconstruction of the pulley system and tendon sheath, flexor tendon repair (using the technique of choice) and reduces postoperative impingement in zone 2.
Romero Nakagaki, Wilson; Rosa Pimentel, Edson; Pereira Benevides, Gustavo; Gomes, Laurecir
The aim of this study was to evaluate if spontaneous (nonforced active) exercise and age (maturation process) alter the biomechanical and biochemical properties of superficial digital flexor tendon. Chickens aged 1, 5, and 8 months were divided into two groups: caged and penned. The caged group was reared in an area of 0.5 m(2) (3 animals/cage), while the penned group was reared in an area of 60 m(2) (3 animals/area). For biochemical analysis, the tendon was divided into tensile and compressive regions for quantification of hydroxyproline and glycosaminoglycan content. Biomechanical properties were analyzed from tensile tests of intact tendons. The biomechanical measurements were taken at maximum load and maximum stress. In both the caged and penned groups, maximum load and energy absorption increased with maturation; however, the elastic modulus, maximum stress, and maximum strain did not increase with maturation. Exercise resulted in a higher load, stress, and elastic modulus in the fifth month. Collagen content increased with age in the penned group and with exercise in the fifth and eighth months. Exercise results in a higher expression of glycosaminoglycans in young tendons compared to mature tendons. Thus, low-intensity mechanical stimuli promote the synthesis and possible rearrangement of molecules in immature tendons, whereas inactivity leads to deleterious effects on the material properties (maximum stress and elastic modulus) during growth and maturation.
Tendon injures cause a great deal of disability and pain, and increase medical costs. However, relatively little is known about tendon biology and healing. Many tendon-related surgical procedures are not very successful and leave the patient with essentially a chronic injury. New therapeutic approaches for tendon injury are needed. Preliminary evidence suggests that various nutrients such as proteins, amino acids (leucine, arginine, glutamine), vitamins C and D, manganese, copper, zinc, and phytochemicals may be useful in improving tendon growth and healing. More research on nutrition and tendon health is needed. Because many nutrients are required for tendon health, nutritional interventions involving multiple nutrients may be more effective than single-nutrient strategies. In the future, ideal treatment regimens for tendon injuries may include a multifaceted "bundle" of nutrition, drugs, biologic products, extracellular matrix therapies, exercise/physical therapy, and possibly surgery.
Iyer, Srinivasan; Basu, Indraneil; Kaba, Rahim; Pabari, Amit
Flexor tendon rupture following a Colles' fracture is a rare complication with only a handful of cases reported since the initial report in 1932. We present a case in which all digital flexor tendons ruptured within 6 months of a Colles' fracture. Previous reported cases have demonstrated rupture of either the radial or ulnar digital flexors but this case is the first in which all the digital flexors have been involved. This case report highlights the clinical implications of this rare occurrence and stresses the importance of accurate reduction and thorough clinical examination following bony injuries to the wrist.
Sudoł-Szopińska, Iwona; Zaniewicz-Kaniewska, Katarzyna; Kwiatkowska, Brygida
Summary Background Enthesitis is considered a characteristic presentation of the second most common group of rheumatoid disorders, i.e. spondyloarthropathies (SpAs), particularly peripheral spondyloarthropathies. At the initial stages, enthesitis may be the only symptom of SpA, particularly in patients lacking the HLA-B27 receptor. Material/Methods In light of diagnostic difficulties with detecting enthesitis in clinical examinations and laboratory investigations, many studies point out the high specificity of imaging studies, and particularly ultrasonography. Results A total of 20% Achilles tendon entheses, 45% plantar aponeurosis entheses and 89.5% of flexor digiti brevis tendon entheses were unremarkable. In the remaining cases, the presentation of pathological lesions was not specific to enthesitis and might more likely correspond to degeneration or microinjuries of the entheses, beside the most obvious cases of achillobursitis or Kager’s fat pad inflammation. Conclusions The studies demonstrated that ultrasound scans rarely confirm the clinical diagnosis of enthesitis. PMID:25674194
Kumar, N; Sharma, A K; Sharma, A K; Kumar, S
The efficacy of carbon fibres and plasma-preserved tendon allografts for gap repair in the superficial digital flexor tendon in the mid-metatarsal region was evaluated in 12 crossbred calves. Experimental tenectomies were performed, followed by implantation of carbon fibres in group I (12 legs) and plasma-preserved tendon allografts in group II (12 legs). Gross observations in group I showed filling of the defect with granulation tissue with more vascularity on day 7, which was less prominent at day 14. On day 30, the neotendon formed was slightly thicker and comparable to normal tendon in appearance and texture. On day 90, it exhibited all the characteristics of a fully developed tendon. Whereas, in group II increased vascularity at the site and encapsulation of the graft with connective tissue in early periods was observed. The gap between graft and host was filled with fibrous connective tissue. Peritendinous adhesions were maximum on day 7 which were gradually reduced in both groups. Microscopically, an acute inflammatory reaction in the periphery of carbon fibres was observed on day 7. Immature fibroblasts were arranged in a haphazard pattern at this stage. By day 14, numerous newly formed capillaries and comparatively more mature fibroblasts were present in between and around the carbon fibres which were aligning parallel to the longitudinal axis of the tendon. By day 30 the healing tissue exhibited longitudinal orientation of collagen fibres and was at a more advance stage of maturation. By day 90, the neotendon formed simulated the picture of normal tendon. In the grafted tendon group, there was normal healing tissue at the functional sites between host and grafted tendon. The fibroblastic activity appeared to be both extrinsic and intrinsic in origin. The connective tissue had invaded the graft to a variable distance and there was resorption of graft which was replaced by newly formed connective tissue on day 90. Scanning electron microscopic observation
Thorpe, C T; Udeze, C P; Birch, H L; Clegg, P D; Screen, H Rc
Age-related tendinopathy is common in both humans and horses; the initiation and progression of which is similar between species. The majority of tendon injuries occur to high-strain energy storing tendons, such as the human Achilles tendon and equine superficial digital flexor (SDFT). By contrast, the low-strain positional human anterior tibialis tendon and equine common digital extensor (CDET) are rarely injured. It has previously been established that greater extension occurs at the fascicular interface in the SDFT than in the CDET; this may facilitate the large strains experienced during locomotion in the SDFT without damage occurring to the fascicles. This study investigated the alterations in whole tendon, fascicle and interfascicular mechanical properties in the SDFT and CDET with increasing age. It was hypothesised that the amount of sliding at the fascicular interface in the SDFT would decrease with increasing horse age, whereas the properties of the interface in the CDET would remain unchanged with ageing. Data support the hypothesis; there were no alterations in the mechanical properties of the whole SDFT or its constituent fascicles with increasing age. However, there was significantly less sliding at the fascicular interface at physiological loads in samples from aged tendons. There was no relationship between fascicle sliding and age in the CDET. The increase in stiffness of the interfascicular matrix in aged SDFT may result in the fascicles being loaded at an earlier point in the stress strain curve, increasing the risk of damage. This may predispose aged tendons to tendinopathy.
Crevier-Denoix, N; Ruel, Y; Dardillat, C; Jerbi, H; Sanaa, M; Collobert-Laugier, C; Ribot, X; Denoix, J-M; Pourcelot, P
The objective of this study was to test the hypothesis that tendon echogenicity is associated with the material properties of the corresponding tendon site, especially in case of lesions, due to local changes in tendon matrix composition. Four normal and nine spontaneously injured equine superficial digital flexor tendons (SDFT) were isolated then ultrasonographically examined under tension, in a special device placed in a water bath. Ultrasonographic transversal images (7.5MHz linear transducer) of five segments along each tendon were digitized, and analyzed in order to measure the mean cross-sectional area (MCSA) and mean echogenicity (ME) of each segment. The tendons were then tested in traction until rupture in a testing machine. For each segment, stress and strain were determined throughout the test, and the elastic modulus (EM) was evaluated. The tendon lesions were also documented by histology. No correlation was found between ME and the material properties of normal tendon segments. At the rupture sites of the nine diseased tendons, ME was positively correlated with maximal stress and EM, whereas no correlation was demonstrated with maximal strain. Besides, a positive correlation was demonstrated between ME and both MCSA and EM, when the three metacarpal segments of the diseased tendons were considered. Although ME gives only rough information about tendon matrix structure, it does show, under these in vitro conditions, significant correlations with material properties of pathological tendon segments, which may improve the functional significance and therefore the prognostic value of the ultrasonographic examination of tendon lesions.
O'Brien, Etienne John Ogilvy; Shrive, Nigel G; Rosvold, Joshua M; Thornton, Gail M; Frank, Cyril B; Hart, David A
Heterotopic mineralization may result in tendon weakness, but effects on other biomechanical responses have not been reported. We used a needle injury, which accelerates spontaneous mineralization of murine Achilles tendons, to test two hypotheses: that injured tendons would demonstrate altered biomechanical responses; and that unilateral injury would accelerate mineralization bilaterally. Mice underwent left hind (LH) injury (I; n = 11) and were euthanized after 20 weeks along with non-injured controls (C; n = 9). All hind limbs were examined by micro computed tomography followed by biomechanical testing (I = 7 and C = 6). No differences were found in the biomechanical responses of injured tendons compared with controls. However, the right hind (RH) tendons contralateral to the LH injury exhibited greater static creep strain and total creep strain compared with those LH tendons (p ≤ 0.045) and RH tendons from controls (p ≤ 0.043). RH limb lesions of injured mice were three times larger compared with controls (p = 0.030). Therefore, despite extensive mineralization, changes to the responses we measured were limited or absent 20 weeks postinjury. These results also suggest that bilateral occurrence should be considered where tendon mineralization is identified clinically. This experimental system may be useful to study the mechanisms of bilateral new bone formation in tendinopathy and other conditions.
Demirseren, Mustafa Erol; Afandiyev, Kamran; Durgun, Mustafa; Kilicarslan, Kasim; Yorubulut, Mehmet
In this paper, we report a case of a 14-year-old girl with congenital aplasia of the flexor pollicis longus tendon who had no other associated anomalies of thumb hypoplasia and no trauma history. Flexor pollicis longus tendon anomalies are rare; several types of this congenital anomaly have been reported in the literature. The diagnosis should be considered if a patient is unable to flex the interphalangeal joint of the thumb. A hypoplastic thumb or an absent interphalangeal joint crease may be a diagnostic feature in such cases. Besides physical examination, we also used direct radiography and magnetic resonance imaging to diagnose this rare congenital anomaly in our patient.
Momose, T; Amadio, P C; Zhao, C; Zobitz, M E; Couvreur, P J; An, K N
We studied the breaking strength and gliding resistance between the pulley and flexor tendon for various suture techniques. Canine flexor digitorum profundus tendons were transected and sutured using one of eight repair techniques: modified Kessler (MK); Tsuge (Tsuge); two variations of a double modified Kessler (DK1, DK2); combined modified Kessler-modified Tsuge (MKT); augmented Becker (Becker); Cruciate (Cruciate); and modified double Tsuge (DT). The force to produce a 1.5 mm gap, ultimate failure load, resistance to gap formation, and gliding resistance were measured. The force to produce a 1.5 mm gap and the ultimate breaking force were higher with the DK1, DK2, MKT, Becker, Cruciate, and DT repairs than they were with the MK and Tsuge repair, while the gliding resistance of the Becker was higher than that of the MK, DK1, DK2, MKT. Cruciate, and UT repairs. In addition to confirming that repair strength increases as the number of strands crossing the repair increases, we also found that these stronger repairs need not produce higher gliding resistance than less robust repairs.
Jordana, M; Cornillie, P; Oosterlinck, M; Simoens, P; Pille, F; Martens, A
During endoscopy (tenoscopy) of the distal aspect of the equine digital flexor tendon sheath (DFTS), the digital manica flexoria can be visualized connecting the distal branches of the superficial digital flexor tendon. However, this structure has been inconsistently described and variably named in the veterinary literature. The objectives of this study were to describe the presence, configuration and variability of the digital manica flexoria in the equine distal limb. Dissection of 144 equine cadaveric limbs revealed the presence of this structure in all the feet, although different types and conformations were identified. In the forelimbs, a membranous digital manica flexoria predominated (94%; P < 0.001), in particular a synovial bridge type (83%; P < 0.001). In the hindlimbs, a tendinous digital manica flexoria predominated (93%; P < 0.001), in particular the oblique-crossing of tendinous bundles (61%; P < 0.001). Passage dorsal to the digital manica flexoria towards the distal DFTS was only possible in 22 of the 144 limbs, all forelimbs. Clinicians should be aware of the intra- and inter-individual anatomical variations of the digital manica flexoria to avoid misinterpretation during ultrasonographic and tenoscopic examinations of the DFTS.
Yang, Tai-Hua; Lu, Szu-Ching; Lin, Wei-Jr; Zhao, Kristin; Zhao, Chunfeng; An, Kai-Nan; Jou, I-Ming; Lee, Pei-Yuan
Background The flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) are critical for finger flexion. Although research has recently focused on these tendons’ coactivity, their contributions in different tasks remain unclear. This study created a novel simultaneous approach to investigate the coactivity between the tendons and to clarify their contributions in different tasks. Methods Ten human cadaveric hands were mounted on our custom frame with the FDS and FDP of the third finger looped through a mechanical pulley connected to a force transducer. Joint range of motion, tendon excursion and loading force were recorded during individual joint motion and free joint movement from rest to maximal flexion. Each flexor tendon’s moment arm was then calculated. Results In individual motions, we found that the FDP contributed more than the FDS in proximal interphalangeal (PIP) joint motion, with an overall slope of 1.34 and all FDP-to-FDS excursion (P/S) ratios greater than 1.0 with force increase. However, the FDP contributed less than the FDS in metacarpophalangeal (MCP) joint motion, with an overall slope of 0.95 and P/S ratios smaller than 1.0 throughout the whole motion except between 1.9% and 13.1% force. In free joint movement, the FDP played a greater role than the FDS, with an overall ratio of 1.37 and all P/S ratios greater than 1.0. Conclusions The new findings include differences in finger performance and excursion amounts between the FDS and FDP throughout flexion. Such findings may provide the basis for new hand models and treatments. PMID:27513744
Lui, Tun Hing
Tendosynovial chondromatosis of the foot and ankle is a rare disease entity. We reported 3 patients with tenosynovial osteochondromatosis of flexor hallucis longus. They were successfully treated by arthroscopic synovectomy and removal of the loose bodies.
Smith, Andrew C; Mummidisetty, Chaithanya K; Rymer, William Zev; Knikou, Maria
In humans, a chronic spinal cord injury (SCI) impairs the excitability of pathways mediating early flexor reflexes and increases the excitability of late, long-lasting flexor reflexes. We hypothesized that in individuals with SCI, locomotor training will alter the behavior of these spinally mediated reflexes. Nine individuals who had either chronic clinically motor complete or incomplete SCI received an average of 44 locomotor training sessions. Flexor reflexes, elicited via sural nerve stimulation of the right or left leg, were recorded from the ipsilateral tibialis anterior (TA) muscle before and after body weight support (BWS)-assisted treadmill training. The modulation pattern of the ipsilateral TA responses following innocuous stimulation of the right foot was also recorded in 10 healthy subjects while they stepped at 25% BWS to investigate whether body unloading during walking affects the behavior of these responses. Healthy subjects did not receive treadmill training. We observed a phase-dependent modulation of early TA flexor reflexes in healthy subjects with reduced body weight during walking. The early TA flexor reflexes were increased at heel contact, progressively decreased during the stance phase, and then increased throughout the swing phase. In individuals with SCI, locomotor training induced the reappearance of early TA flexor reflexes and changed the amplitude of late TA flexor reflexes during walking. Both early and late TA flexor reflexes were modulated in a phase-dependent pattern after training. These new findings support the adaptive capability of the injured nervous system to return to a prelesion excitability and integration state.
Ferlic, D C
Rheumatoid flexor tenosynovitis at the wrist can cause locking, limitation of motion, nerve compression, and rupture of tendons. To prevent and treat these conditions, a flexor tenosynovectomy, combined with nerve decompression and tendon reconstruction as indicated, is necessary. If tendons are ruptured, the flexor pollicis longus and profundus to the index finger are most commonly affected. On the fingers flexor tenosynovitis can also cause locking, decrease in range of motion and rupture tendons. Flexor tenosynovitis of the fingers should be treated with decompression of the tendons health with preservation of the pulley system.
Lapole, Thomas; Temesi, John; Gimenez, Philippe; Arnal, Pierrick J; Millet, Guillaume Y; Petitjean, Michel
Daily Achilles tendon vibration has been shown to increase muscle force, likely via corticospinal neural adaptations. The aim of the present study was to determine the extent by which corticospinal excitability is influenced during direct Achilles tendon vibration. Motor-evoked potentials (MEPs) were elicited in the soleus (SOL), gastrocnemius medialis (GM) and tibialis anterior (TA) by transcranial magnetic stimulation of the motor cortical area of the leg with and without Achilles tendon vibration at various frequencies (50, 80 and 110 Hz). Contralateral homologues were also investigated. SOL and GM MEP amplitude significantly increased by 226 ± 188 and 66 ± 39%, respectively, during Achilles tendon vibration, without any difference between the tested frequencies. No MEP changes were reported for TA or contralateral homologues. Increased SOL and GM MEP amplitude suggests increased vibration-induced corticospinal excitability independent of vibration frequency.
TAKAHASHI, Toshiyuki; MUKAI, Kazutaka; OHMURA, Hajime; AIDA, Hiroko; HIRAGA, Atsushi
ABSTRACT The purpose of this study was to create a lower forelimb model of the Thoroughbred horse for measuring the force in the superficial and deep digital flexor tendons (SDFT and DDFT), and the suspensory ligament (SL) during a trot. The mass, centers of gravity, and inertial moments in the metacarpus, pastern, and hoof segments were measured in 4 Thoroughbred horses. The moment arms of the SDFT, DDFT, and SL in the metacarpophalangeal (fetlock) and distal interphalangeal (coffin) joints were measured in 7 Thoroughbred horses. The relationship between the fetlock joint angle and the force in the SL was assessed in 3 limbs of 2 Thoroughbred horses. The forces in the SDFT, DDFT, and SL during a trot were also measured in 7 Thoroughbred horses. The mass of the 3 segments, and the moment arms of the SDFT and DDFT in the fetlock joint of the Thoroughbred horses were smaller than those of the Warmblood horses, whereas the other values were almost the same in the 2 types. The calculated force in the SDFT with this Thoroughbred model reached a peak (4,615 N) at 39.3% of the stance phase, whereas that in the DDFT reached a peak (5,076 N) at 51.2% of the stance phase. The force in the SL reached a peak (11,957 N) at 49.4% of the stance phase. This lower forelimb model of the Thoroughbred can be applied to studying the effects of different shoe types and change of hoof angle for the flexor tendon and SL forces. PMID:24834009
Netscher, D; Mosharrafa, A; Lee, M; Polsen, C; Choi, H; Steadman, A K; Thornby, J
A three-part study is described that examines postoperative weakness after open carpal tunnel release and investigates the role of the transverse carpal ligament in the digital flexor pulley system. The effect of this ligament on flexor tendon excursion is evaluated in a cadaver study. Magnetic resonance imaging analysis is used to determine whether division of the transverse carpal ligament promotes volar migration of the median nerve and flexor tendons. Finally, the effects of ligament division and various methods of transverse carpal ligament reconstruction on the return of grip and pinch strengths after open carpal tunnel release are evaluated. The authors were able to determine that transverse carpal ligament reconstruction, particularly the transposition flap repair technique, after open carpal tunnel release confers a mechanical advantage and that the transverse carpal ligament is an important pulley for flexor tendon excursion. Based on the magnetic resonance imaging studies, volar displacement of carpal contents is reduced in patients undergoing transverse carpal ligament reconstruction by means of a transposition flap compared with those undergoing no ligament reconstruction and those undergoing reconstruction using the palmar aponeurosis. Postoperative grip and pinch strength values for the transposition flap repair group surpassed those of the other two groups at 12 weeks.
Otayek, Salma; Pierrart, Jérôme; Masmejean, Emmanuel H.
Introduction: The Percutaneous Needle Aponeurotomy (PNA) is a known and validated non-surgical treatment for Dupuytren’s disease with a low rate of complications. Initially described for purely palmar forms, the indications extended to digital adhesions. Numerous surgeons remain hesitant about performing the PNA for digital treatment because of the risk of lesions in the noble structures. In literature, one complication is still rare, even non-existent, i.e. the tendon rupture. Case Presentation: We are reporting here the case of a rupture of the deep common flexor tendon, secondary to a needle aponeurotomy, for a recurring digital form in a 72-year-old woman. We performed surgical treatment by tenodesis of the distal stump and resection of the proximal stump. The result was satisfactory. Conclusion: The purpose of describing this case is to report this rare complication leading to surgical revision. Within our team, we do not recommend performing PNAs for digital cases, and even less so for recurrences. For those who wish to perform the PNA, they need to know some technical artifices that enable these complications to be reduced, albeit not eliminated. PMID:28116281
Csapo, R.; Malis, V.; Hodgson, J.
The aim of the present study was to test the hypothesis that the age-associated decrease of tendon stiffness would necessitate greater muscle fascicle strains to produce similar levels of force during isometric contraction. Greater fascicle strains could force sarcomeres to operate in less advantageous regions of their force-length and force-velocity relationships, thus impairing the capacity to generate strong and explosive contractions. To test this hypothesis, sagittal-plane dynamic velocity-encoded phase-contrast magnetic resonance images of the gastrocnemius medialis (GM) muscle and Achilles tendon (AT) were acquired in six young (YW; 26.1 ± 2.3 yr) and six senior (SW; 76.7 ± 8.3 yr) women during submaximal isometric contraction (35% maximum voluntary isometric contraction) of the plantar flexor muscles. Multiple GM fascicle lengths were continuously determined by automatically tracking regions of interest coinciding with the end points of muscle fascicles evenly distributed along the muscle's proximo-distal length. AT stiffness and Young's modulus were measured as the slopes of the tendon's force-elongation and stress-strain curves, respectively. Despite significantly lower AT stiffness at older age (YW: 120.2 ± 52.3 N/mm vs. SW: 53.9 ± 44.4 N/mm, P = 0.040), contraction-induced changes in GM fascicle lengths were similar in both age groups at equal levels of absolute muscular force (4–5% fascicle shortening in both groups), and even significantly larger in YW (YW: 11–12% vs. SW: 6–8% fascicle shortening) at equal percentage of maximum voluntary contraction. These results suggest that factors other than AT stiffness, such as age-associated changes in muscle composition or fascicle slack, might serve as compensatory adaptations, limiting the degree of fascicle strains upon contraction. PMID:24505104
Zhang, Jacques X; Gray, Jason; Lalonde, Donald H; Carr, Nicholas
The literature generally supports the safety of epinephrine injection in the digits, but recent case reports describe ischemic adverse events associated with the use of lidocaine and epinephrine in which phentolamine rescue was not performed. We present a case of finger necrosis and subsequent amputation in a patient after 1% lidocaine with 1:100,000 epinephrine was injected in the fat and flexor sheaths in the palm for a 3-finger trigger release. Phentolamine rescue was not performed. All surgeons who use epinephrine in the finger should be prepared to reverse vasoconstriction with phentolamine rescue if there is persistently inadequate perfusion of the fingertip.
Couceiro, Jose; Fraga, Javier; Sanmartin, Marcos
Introduction Post-traumatic trigger finger is considerably rarer than normal trigger finger. The diagnosis is usually made on a clinical basis. This can be obscured; however, by concurrent pathological conditions. We report a case of post-traumatic trigger finger in which diagnosis was aided by magnetic resonance imaging (MRI). Presentation of case Our patient is a 32-year-old male who had a previous laceration with a subsequent surgery for infectious tenosynovitis. The MRI showed the impinging tendon tag. Surgical excision of the tag successfully solved the case. Discussion The use of imaging studies for the diagnosis of post-traumatic trigger finger has been previously reported, the authors described a variation on the contour of the pulley system. The full lacerated tendon tag can be seen on our patient's MRI. Conclusion On this case, the use of MRI was a useful aid for the differential diagnosis of post-traumattic trigger finger. PMID:25765739
Rodger, M P; Theobald, P; Giddins, G
The ultimate tensile repair strength and gap formation of the pig extensor tendons repaired with a standard 4-strand Savage with epitendinous suture repair, was compared with a new technique of adding a vein sleeve. Force and displacement data were recorded, and video images during linear cyclic loading up to failure. At 35 N, video-graphic observation detected significantly smaller gap lengths in the standard and vein repair specimens compared with standard repair specimens (p = 0.047). The incidence of 3 mm gaps between the repaired tendon ends in the standard repair group was 20 %, but no 3 mm gaps were seen in the standard and vein specimens. The addition of a vein sleeve increased the ultimate tensile strength of the standard repair from 50.4 N (4.5) to 55.4 N (4.5); this was statistically significant (p = 0.03). This study demonstrated that the addition of a vein graft prevented gap formation and increased ultimate tensile strength of tendon repair.
Chang, Song Ho; Naito, Masashi
This report presents a case of stenosing tenosynovitis of the flexor hallucis longus tendon associated with the plantar capsular accessory ossicle at the interphalangeal joint of the great toe, which was confirmed by intraoperative observation and was successfully treated with surgical resection of the ossicle. As the plantar capsular accessory ossicle was not visible radiographically due to the lack of ossification, ultrasonography was helpful for diagnosing this disorder. PMID:28255483
Sharma, Pankaj; Maffulli, Nicola
Tendon disorders are frequent and are responsible for substantial morbidity both in sports and in the workplace. Tendinopathy, as opposed to tendinitis or tendinosis, is the best generic descriptive term for the clinical conditions in and around tendons arising from overuse. Tendinopathy is a difficult problem requiring lengthy management, and patients often respond poorly to treatment. Preexisting degeneration has been implicated as a risk factor for acute tendon rupture. Several physical modalities have been developed to treat tendinopathy. There is limited and mixed high-level evidence to support the, albeit common, clinical use of these modalities. Further research and scientific evaluation are required before biological solutions become realistic options.
Kontor, J. A.
Due to their superficial course, the extensor tendons are frequently lacerated over the dorsum of the hand and fingers. Excellent functional results are obtained in repairs of simple tendon lacerations. ‘Open’ mallet lacerations over the distal IP joint or involving the central extensor slip over the proximal IP joint require more precise suturing methods. More proximal extensor tendon divisions near the wrist involve dissection of the retracted finger extensors or long thumb extensor in the distal forearm and more formal tendon repairs, including a possible tendon transfer to the thumb. ‘Closed injuries’, with varying degrees of extensor tendon disruption, occur at three main sites. The mallet injury at the DIP joint and the boutonnière deformity over the PIP joint are sometimes recognized late, but respond to conservative splinting for a minimum of four weeks with guarded motion avoiding secondary stiffening of the remaining small joints of the hand. Surgery of closed injuries most frequently involves the intra-articular traction fracture type of mallet deformities in which the DIP joint has taken the brunt of the injury. PMID:21286174
Kawano, Cezar Teruyuki; de Moraes Barros Fucs, Patrícia Maria; Severino, Nilson Roberto
Pretensioning of the flexor tendon graft of the knee is used to improve the stability of anterior cruciate ligament (ACL) reconstructions. The objective was to demonstrate the pretensioning of grafts of the semitendinosus and gracilis in situ with range of flexion and extension of 0-110°, and determine the appropriate number of cycles in two types of femoral fixation. ACL reconstruction was performed in 60 patients, aged 16-48 years, 90% male, with 50% right knees and 50% left knees, divided into two groups of 30 patients: One with the femur fixed using interference screws (direct form) and the other with the transcondylar cross-pin screw (from a distance). Total length of the grafts, their circumference and the measurements on the radiographs of length of the grafts submitted to pretensioning and the measurements with ten, 25 and 50 cycles of flexion and extension were determined. There was no significant difference in relation to the total tendon lengths and their circumferences. The lengths of the portions submitted to pretensioning were significantly different: 7.90 cm for the interference and 10.92 cm for the transcondylar (mean). After tensioning, in the interference and transcondylar groups, respectively, lengthening was 3.57 mm/3.97 mm with ten, 6.30 mm/7.03 mm with 25, and 6.83 mm/7.7 mm with 50 cycles. The greater the length of the graft, the greater the lengthening on pretensioning throughout the substance; the shorter the length, the earlier the end of the lengthening was achieved, close to 25 cycles; more than ten cycles were necessary, 25 being sufficient.
da Silva, Ary Gomes; Machado, Elbe Rodrigues; de Almeida, Leonardo Mendes; Nunes, Ricardo Marcelo Menezes; Giesbrecht, Patrícia Caldeira Pena; Costa, Regina Mamed; Costa, Helber B; Romão, Wanderson; Kuster, Ricardo Machado
One of the Brazilian arnicas, Solidago chilensis Meyen, is a species of the Asteraceae family. This plant is known by this common name because it shares remarkably similar organoleptic properties with the genus Arnica L., also within the family Asteraceae. We examined the effectiveness of the S. chilensis fluid extract used externally for treating tendinitis of flexor and extensor tendons of wrist and hand in placebo-controlled double-blind clinical pharmacological studies. This study was approved by the Ethical Committee for Scientific Research in Human Beings at University Vila Velha-UVV. Two daily skin applications on the arm skin of a gel cream containing a 5% glycolic plant extract were administered to eight volunteers for 21 days. Among the volunteers, one of their arms was used as the placebo group, and the other one was used as a test group. Statistical data analyses demonstrated a significant reduction in the perception of pain in the arms in the test group, when it was compared to those receiving only the placebo.
Mitsionis, G; Bastidas, J A; Grewal, R; Pfaeffle, H J; Fischer, K J; Tomaino, M M
We investigated the effect of partial excision of the A2 and A4 digital pulleys, separately and in combination, on finger angular rotation and the energy for finger flexion. Statistically significant decreases in angular rotation resulted only after 50% and 75% excision of A2, A4, or A2 and A4 in combination. Work of flexion trends were weak and none of the changes were statistically significant. Although optimal finger function relies on the integrity of the A2 and A4 pulleys to maintain the efficiency of the digital flexor system, these data suggest that the A2 and A4 pulleys can be excised up to 25%, either separately or in combination, without significant effects on angular rotation. Decreases in total angular range of motion after 50% and 75% pulley excision were small, even for combined pulley excision (9 degrees +/- 3 degrees and 15 degrees +/- 5 degrees [mean +/- SD], respectively), and may be clinically acceptable.
Farris, Dominic James; Lichtwark, Glen A; Brown, Nicholas A T; Cresswell, Andrew G
Humans utilise elastic tendons of lower limb muscles to store and return energy during walking, running and jumping. Anuran and insect species use skeletal structures and/or dynamics in conjunction with similarly compliant structures to amplify muscle power output during jumping. We sought to examine whether human jumpers use similar mechanisms to aid elastic energy usage in the plantar flexor muscles during maximal vertical jumping. Ten male athletes performed maximal vertical squat jumps. Three-dimensional motion capture and a musculoskeletal model were used to determine lower limb kinematics that were combined with ground reaction force data in an inverse dynamics analysis. B-mode ultrasound imaging of the lateral gastrocnemius (GAS) and soleus (SOL) muscles was used to measure muscle fascicle lengths and pennation angles during jumping. Our results highlighted that both GAS and SOL utilised stretch and recoil of their series elastic elements (SEEs) in a catapult-like fashion, which likely serves to maximise ankle joint power. The resistance of supporting of body weight allowed initial stretch of both GAS and SOL SEEs. A proximal-to-distal sequence of joint moments and decreasing effective mechanical advantage early in the extension phase of the jumping movement were observed. This facilitated a further stretch of the SEE of the biarticular GAS and delayed recoil of the SOL SEE. However, effective mechanical advantage did not increase late in the jump to aid recoil of elastic tissues.
de Castro, Renato Luiz Bevilacqua; Acras, Sandor Dosa
Objective: The aim of this study was to analyze the results of ACL (anterior cruciate ligament) reconstruction using quadruple flexor tendons as grafts, with ligament fixation in the femur using a rigid guide transverse screw and in the tibia, using a cancellous screw with a fixing washer. Methods: 173 knees (166 from males and seven from females) that had undergone surgery with ACL reconstruction using this technique between December 2002 and February 2007 were evaluated. The mean age was 30 years (from 13 to 56 years), and the mean follow-up time was 30 months (6-55 months). We divided the knees into three groups, which were assessed using the Lysholm scale: Group A with six months of follow-up; Group B with 12 months of follow-up; and Group C with 24 months of follow-up. Results: We evaluated the results, and groups A, B and C received 94, 95 and 95 points respectively on the Lysholm scale. Conclusions: The surgical technique proved to be safe and easy to perform, with good results and a low complication rate. Also, its results were maintained throughout the study period of 24 months. PMID:27027002
Davalos, Eric A; Barank, David; Varma, Rajeev K
Injuries to the popliteus tendon are less frequent than injuries to the menisci or ligamentous structures of the knee. When they do occur, injuries to the popliteus tendon tend to be the result of trauma and associated with injuries to other components of the knee. The most commonly seen injuries include tears at the musculotendinous junction and avulsion tears at the lateral femoral condyle insertion site. This report presents two unusual injuries of the popliteus tendon in patients with chronic knee pain: an isolated split tear of the tendon and a subluxed tendon residing within the lateral joint space.
DAVALOS, ERIC A.; BARANK, DAVID; VARMA, RAJEEV K.
Injuries to the popliteus tendon are less frequent than injuries to the menisci or ligamentous structures of the knee. When they do occur, injuries to the popliteus tendon tend to be the result of trauma and associated with injuries to other components of the knee. The most commonly seen injuries include tears at the musculotendinous junction and avulsion tears at the lateral femoral condyle insertion site. This report presents two unusual injuries of the popliteus tendon in patients with chronic knee pain: an isolated split tear of the tendon and a subluxed tendon residing within the lateral joint space. PMID:27386449
Funasaki, Hiroki; Hayashi, Hiroteru; Sakamoto, Kanako; Tsuruga, Rei; Marumo, Keishi
Stenosing tenosynovitis of the flexor hallucis longus (FHL) tendon is known as a major overuse lesion in female dancers. We describe arthroscopic surgical techniques in relation to the dynamic pathology of the disease. Crepitus and pain on moving the great toe with the ankle in plantar flexion on preoperative examination confirm the diagnosis of FHL stenosing tenosynovitis even if the os trigonum is not evident. The ankle is approached through standard posterolateral and posteromedial portals. A 4.0-mm-diameter 30° arthroscope is used. Soft tissues around the talus are cleared with a motorized shaver and a radiofrequency device. The posterior aspects of the talus, os trigonum, and FHL tendon surrounded by the tendon sheath are visualized. The dynamic pathology of the FHL tendon is well observed on passive motion of the great toe. The prominent bone fragment of the talus is removed and the tendon sheath is cut with a retrograde knife and a motorized shaver from the superior border down to the entrance of the fibro-osseous tunnel. Arthroscopic release of the FHL tendon sheath is a useful and easy method to directly approach the dynamic pathology of FHL tenosynovitis in female ballet dancers.
Severo, Antônio Lourenço; Arenhart, Rodrigo; Silveira, Daniela; Ávila, Aluísio Otávio Vargas; Berral, Francisco José; Lemos, Marcelo Barreto; Piluski, Paulo César Faiad; Lech, Osvandré Luís Canfield; Fukushima, Walter Yoshinori
Objective: Analyzing suture time, biomechanics (deformity between the stumps) and the histology of three groups of tendinous surgical repair: Brazil-2 (4-strands) which the end knot (core) is located outside the tendon, Indiana (4-strands) and Tsai (6-strands) with sutures technique which the end knot (core) is inner of the tendon, associated with early active mobilization. Methods: The right calcaneal tendons (plantar flexor of the hind paw) of 36 rabbits of the New Zealand breed (Oryctolagus cuniculus) were used in the analysis. This sample presents similar size to human flexor tendon that has approximately 4.5 mm (varying from 2mm). The selected sample showed the same mass (2.5 to 3kg) and were male or female adults (from 8 ½ months). For the flexor tendons of the hind paws, sterile and driven techniques were used in accordance to the Committee on Animal Research and Ethics (CETEA) of the University of the State of Santa Catarina (UDESC), municipality of Lages, in Brazil (protocol # 1.33.09). Results: In the biomechanical analysis (deformity) carried out between tendinous stumps, there was no statistically significant difference (p>0.01). There was no statistical difference in relation to surgical time in all three suture techniques with a mean of 6.0 minutes for Tsai (6- strands), 5.7 minutes for Indiana (4-strands) and 5.6 minutes for Brazil (4-strands) (p>0.01). With the early active mobility, there was qualitative and quantitative evidence of thickening of collagen in 38.9% on the 15th day and in 66.7% on the 30th day, making the biological tissue stronger and more resistant (p=0.095). Conclusion: This study demonstrated that there was no histological difference between the results achieved with an inside or outside end knot with respect to the repaired tendon and the number of strands did not affect healing, vascularization or sliding of the tendon in the osteofibrous tunnel, which are associated with early active mobility, with the repair techniques
Park, Don Young; Chou, Loretta
Professional and recreational athletes commonly perform pre-exercise stretching to prevent musculoskeletal injuries. Little definitive evidence exists that clearly demonstrates the efficacy of stretching in reducing injury. Achilles tendon injuries are among the most common injuries affecting active individuals in the United States today. Clinicians commonly recommend stretching the Achilles tendon without concrete scientific evidence to support such a claim. Few studies have addressed the effect of stretching in Achilles tendon injuries, and it is unclear if the conclusions made for musculoskeletal injuries can be applied to the Achilles tendon. Biomechanical studies of the Achilles tendon and measurements of the tendon's reflex activity have demonstrated possible mechanisms for the potential benefit of stretching, including load-induced hypertrophy and increased tendon tensile strength. Recent prospective studies have contended that reductions in plantarflexor strength and increases in ankle dorsiflexion range of motion from stretching the Achilles tendon may increase the risk of injury. Studies examining stretching in injury prevention, the biomechanical properties of injuries to the Achilles tendon were compiled and reviewed. Although many theories have been published regarding the potential benefits and limitations of stretching, few studies have been able to definitively demonstrate its utility in injury prevention.
Hahn, P; Lanz, U
Primary or secondary flexor tendon surgery occasionally leads to damaged flexor pulleys. Insufficient pulley reconstruction causes loss of finger function by bow stringing of the flexor tendon. This paper reviews the anatomy and biomechanics of the flexor pulley system. Different techniques of reconstruction are discussed.
Amadio, Peter C
The smooth gliding of the normal human digital flexor is maintained by synovial fluid lubrication and lubricants bound to the tendon surface. This system can be disrupted by degenerative conditions such as trigger finger, or by trauma. The resistance to tendon gliding after surgical repair of the lacerated digital flexor tendon relates to location of suture knots, exposure of suture materials, and type of surgical repair and materials. Restoration of a functioning gliding surface after injury can be helped by using low-friction, high-strength suture designs, therapy that enables gliding, and the addition of lubricants to the tendon surface.
Dar, Tahir Ahmed; Sultan, Asif; Dhar, Shabir Ahmed; Ali, Murtaza Fazal; Wani, Mohammed Iqbal; Wani, Sharief Ahmed
Lacerations of the Achilles tendon are caused by a number of mechanisms. The toilet seat as a cause of Achilles tendon injury is rare. We report on this rare mechanism of laceration of the tendo Achilles. The injury can be avoided with the use of western toilets and the additional devascularisation caused by extending the wound should be avoided while repairing the tendon in such situations.
Gulati, Vivek; Jaggard, Matthew; Al-Nammari, Shafic Said; Uzoigwe, Chika; Gulati, Pooja; Ismail, Nizar; Gibbons, Charles; Gupte, Chinmay
Achilles tendon rupture has been on the rise over recent years due to a variety of reasons. It is a debilitating injury with a protracted and sometimes incomplete recovery. Management strategy is a controversial topic and evidence supporting a definite approach is limited. Opinion is divided between surgical repair and conservative immobilisation in conjunction with functional orthoses. A systematic search of the literature was performed. Pubmed, Medline and EmBase databases were searched for Achilles tendon and a variety of synonymous terms. A recent wealth of reporting suggests that conservative regimens with early weight bearing or mobilisation have equivalent or improved rates of re-rupture to operative regimes. The application of dynamic ultrasound assessment of tendon gap may prove crucial in minimising re-rupture and improving outcomes. Studies employing functional assessments have found equivalent function between operative and conservative treatments. However, no specific tests in peak power, push off strength or athletic performance have been reported and whether an advantage in operative treatment exists remains undetermined. PMID:25992315
Kim, Jin Sung; Sung, Seung Je; Choi, Young Woong
Background The purpose of this study was to identify the epidemiologic characteristics of hand tendon injuries in children and to compare these with those of adults. Methods This retrospective study was conducted on acute traumatic tendon injuries of the hand treated at our institution from 2005 to 2013, based on medical records and X-ray findings. Age, sex, hand injured, mechanism of injury, tendons and zones injured, number of affected digits, and comorbidities and complications were analyzed. Patients were divided into 2 groups: a pediatric group (≤15 years) and an adult group (>15 years). Results Over the 9-year study period, 533 patients were surgically treated for acute traumatic tendon injuries of the hand. In the pediatric group (n=76), being male, the right hand, the extensor tendon, complete rupture, the middle finger, and glass injury predominated in hand tendon injuries. In the adult group (n=457), results were similar, but injury to the index finger and knife injury were the most common. An accompanying fracture was more common in the adult group and complication rates were non-significantly different. Conclusions This comparative analysis revealed no significant epidemiologic intergroup differences. The belief that pediatric tendon injuries tend to be less severe is misplaced, and careful physical examination and exploration should be conducted in pediatric cases of hand injury. PMID:28352603
... tendon. It can occur as a result of injury, overuse, or with aging as the tendon loses elasticity. Any action that places prolonged repetitive strain on the forearm muscles can cause tendonitis. The ...
Use of the Taguchi method for biomechanical comparison of flexor-tendon-repair techniques to allow immediate active flexion. A new method of analysis and optimization of technique to improve the quality of the repair.
Singer, G; Ebramzadeh, E; Jones, N F; Meals, R
The current trend toward early active flexion after repair of the flexor tendons necessitates a stronger repair than that provided by a modified Kessler technique with use of 4-0 nylon suture. The purpose of the current study was to determine, with use of the Taguchi method of analysis, the strongest and most consistent repair of the flexor tendons. Flexor tendons were obtained from fresh-frozen hands of human cadavera. Eight flexor tendons initially were repaired with the modified Kessler technique with use of 4-0 nylon core suture and 6-0 nylon epitenon suture. A test matrix was used to analyze a total of twenty variables in sixty-four tests. These variables included eight techniques for core-suture repair, four types of core suture, two sizes of core suture, four techniques for suture of the epitenon, and two distances from the repair site for placement of the core suture. After each repair, the specimens were mounted in a servohydraulic mechanical testing machine for tension-testing to failure. The optimum combination of variables was determined, with the Taguchi method, to be an augmented Becker technique with use of 3-0 Mersilene core suture, placed 0.75 centimeter from the cut edge with volar epitenon suture. The four-strand, double modified Kessler technique provided the second strongest repair. Five tendons that had been repaired with use of the optimum combination then were tested and compared with tendons that had been repaired with the standard modified Kessler technique. With the optimum combination of variables, the strength of the repair improved from a mean (and standard deviation) of 17.2 +/- 2.9 to 128 +/- 5.6 newtons, and the stiffness improved from a mean of 4.6 to 16.2 newtons per millimeter.
Taylor, Sarah Elizabeth; García, Eugenio Cillán; Reardon, Richard J.M.
Objective To evaluate the frequency of inadvertent penetration of the digital flexor tendon sheath (DFTS) and/or distal interphalangeal joint (DIPJ) when using a direct endoscopic approach to the navicular bursa, and to evaluate an alternate direct approach to the navicular bursa. Study Design Cadaveric study. Sample Population Equine cadaver limbs (n = 40 for direct; n = 12 for alternate approach). Methods Four surgeons performed the direct endoscopic approach to the navicular bursa on 10 limbs each. Frequencies of inadvertent synovial penetration and iatrogenic damage were compared between surgeons. Use of an alternate direct approach, adopting a straight parasagittal trajectory, was evaluated by 2 surgeons. Results Inadvertent synovial penetration occurred in 45% of limbs (DFTS 37.5%; DIPJ 17.5%; and both structures 10%). Successful bursa entry was achieved on the first attempt in 45% of limbs. Significant variation in frequency of inadvertent synovial penetration was observed between surgeons (range 10–80%). Inadvertent synovial penetration did not occur when using the alternate direct technique. Iatrogenic damage to navicular bone fibrocartilage and/or deep digital flexor tendon occurred in 55% of limbs using the direct endoscopic approach and in 0% of limbs using the alternate direct approach. Conclusion Because of the considerable risk of inadvertent penetration of the DFTS and/or the DIPJ when making a direct endoscopic approach to the navicular bursa, it is advisable to investigate for inadvertent penetration when treating navicular bursa sepsis using a direct approach. The alternate direct technique may reduce the risk of inadvertent penetration; however, the view within the bursa may be restricted. PMID:26971252
Flexor tendonitis and suspensory desmitis are among most prevalent musculoskeletal injuries observed in racehorses. The aim of this study was to determine which horse and race-related parameters can help to diminish the possibility of injury or--when injury has occurred--to evaluate the potential for the horse to continue a successful career after convalescence. Special attention was given to the comparison of Arabian and Thoroughbred racehorses. 187 horses with ultrasonographically visible lesions were included in the study. Following parameters were analyzed: structure (Superficial Digital Flexor Tendon [SDFT], Deep Digital Flexor Tendon [DDFT], Suspensory Ligament [SL]); percentage of cross sectional area increase; hypoechogenic lesion character; in horses with SDF tendonitis - tendonitis grade according to Genovese. This study showed that Thoroughbreds are more at risk of musculoskeletal problems than Arabian racehorses. In both breeds, the most frequent injuries concern SDFT, then SL. Over 95% of tendonitis concern forelimbs. In Thoroughbreds, the prevalence of tendonitis is higher in bigger horses, in males when compared to females and in fence/steeple racehorses when compared to flat track racehorses. The inside limb is more at risk of SDF tendonitis, when the external limb - of SL desmitis. Tendonitis severity increases with age and is greater in steeplechasers when compared to flat track racehorses. The outcome of tendonitis without hypoechogenic lesion is much better than that with hypoechogenic lesion. Evaluation of hypoechogenic lesion length is an easy and accurate prognosis tool, as the chances of returning to racing drop dramatically with lesions longer than 12 cm.
Kang, Yeoun-Seung; Park, Yoon-Ghil; Lee, Bum-Suk; Park, Hyung-Soon
The wrist-driven flexor hinge orthosis (WDFHO) is a device used to restore hand function in persons with tetraplegic spinal cord injury by furnishing three-point prehension. We assessed the effectiveness and biomechanical properties of the WDFHO in 24 persons with cervical 6 or 7 tetraplegia who have severely impaired hand function. This study introduces a mechanical operating model to assess the efficiency of the WDFHO. Experimental results showed that pinch force increased significantly (p < 0.001) after using the WDFHO and was found to positively correlate with the strength of wrist extensor muscles (r = 0.41, p < 0.001). However, when the strength of the wrist extensors acting on the WDFHO was greater, the reciprocal wrist and finger motion that generates three-point prehension was less effective (r = 0.79, p < 0.001). Reliable and valid biomechanical evaluation of the WDFHO could improve our understanding of its biomechanics.
Flexor digitorum tendon injuries are challenging conditions to manage to ensure optimal patient outcomes. While several surgical approaches with high success rates have been developed, there remains no gold standard for suture technique for the repair of flexor tendon injuries. In this study, we compared two distinct peripheral suture methods on the strength of repaired tendons. Pig flexor digitorum profundus tendons were used in biomechanical studies and the biomechanical influence on tendon repair of continuous running peripheral suture (CRPS) and continuous locking peripheral suture (CLPS), were compared, using stitch length ranging from 1mm to 5mm. In CRPS, the 1mm stitch length group displayed the highest maximum load and breaking power, which was 1.57 fold higher than the 2mm stitch length group. Pairwise comparison revealed that the 1 and 2mm groups were statistically different from the 3, 4, and 5mm stitch length groups while comparison among the latter groups was not statistically significant. For CLPS, the 1mm group exhibited consistently the highest maximum load strength and breaking power, which was twice the strength displayed by the 2mm group. Pairwise comparisons between groups showed statistical significance. For future repairs of flexor tendon injuries, 1mm stitch length is highly recommended for simple peripheral suture.
Galloway, Marc T.; Lalley, Andrea L.; Shearn, Jason T.
➤ Tendon injuries often result from excessive or insufficient mechanical loading, impairing the ability of the local tendon cell population to maintain normal tendon function. ➤ The resident cell population composing tendon tissue is mechanosensitive, given that the cells are able to alter the extracellular matrix in response to modifications of the local loading environment. ➤ Natural tendon healing is insufficient, characterized by improper collagen fibril diameter formation, collagen fibril distribution, and overall fibril misalignment. ➤ Current tendon repair rehabilitation protocols focus on implementing early, well-controlled eccentric loading exercises to improve repair outcome. ➤ Tissue engineers look toward incorporating mechanical loading regimens to precondition cell populations for the creation of improved biological augmentations for tendon repair. PMID:24005204
Kochevar, Andrew; Rayan, Ghazi
A Taekwondo participant sustained a hand injury from punching an opponent that resulted in painful instability of the ring finger extensor digitorum communis tendon due to sagittal band damage. His symptoms resolved after reconstructive surgery on the sagittal band (SB) with stabilization of the extensor tendon over the metacarpophalangeal joint.
Background Common peroneal nerve palsy leading to foot drop is difficult to manage and has historically been treated with extended bracing with expectant waiting for return of nerve function. Peroneal nerve exploration has traditionally been avoided except in cases of known traumatic or iatrogenic injury, with tendon transfers being performed in a delayed fashion after exhausting conservative treatment. We present a new strategy for management of foot drop with nerve exploration and concomitant tendon transfer. Method We retrospectively reviewed a series of 12 patients with peroneal nerve palsies that were treated with tendon transfer from 2005 to 2011. Of these patients, seven were treated with simultaneous peroneal nerve exploration and repair at the time of tendon transfer. Results Patients with both nerve repair and tendon transfer had superior functional results with active dorsiflexion in all patients, compared to dorsiflexion in 40% of patients treated with tendon transfers alone. Additionally, 57% of patients treated with nerve repair and tendon transfer were able to achieve enough function to return to running, compared to 20% in patients with tendon transfer alone. No patient had full return of native motor function resulting in excessive dorsiflexion strength. Conclusion The results of our limited case series for this rare condition indicate that simultaneous nerve repair and tendon transfer showed no detrimental results and may provide improved function over tendon transfer alone. PMID:25099247
Taljanovic, Mihra S; Alcala, Jennifer N; Gimber, Lana H; Rieke, Joshua D; Chilvers, Margaret M; Latt, L Daniel
Injuries of the peroneal tendon complex are common and should be considered in every patient who presents with chronic lateral ankle pain. These injuries occur as a result of trauma (including ankle sprains), in tendons with preexisting tendonopathy, and with repetitive microtrauma due to instability. The peroneus brevis and peroneus longus tendons are rarely torn simultaneously. Several anatomic variants, including a flat or convex fibular retromalleolar groove, hypertrophy of the peroneal tubercle at the lateral aspect of the calcaneus, an accessory peroneus quartus muscle, a low-lying peroneus brevis muscle belly, and an os peroneum, may predispose to peroneal tendon injuries. High-resolution 1.5-T and 3-T magnetic resonance (MR) imaging with use of dedicated extremity coils and high-resolution ultrasonography (US) with high-frequency linear transducers and dynamic imaging are proved to adequately depict the peroneal tendons for evaluation and can aid the orthopedic surgeon in injury management. An understanding of current treatment approaches for partial- and full-thickness peroneal tendon tears, subluxation and dislocation of these tendons with superior peroneal retinaculum (SPR) injuries, intrasheath subluxations, and peroneal tendonopathy and tenosynovitis can help physicians achieve a favorable outcome. Patients with low functional demands do well with conservative treatment, while those with high functional demands may benefit from surgery if nonsurgical treatment is unsuccessful. Radiologists should recognize the normal anatomy and specific pathologic conditions of the peroneal tendons at US and MR imaging and understand the various treatment options for peroneal tendon and SPR superior peroneal retinaculum injuries. Online supplemental material is available for this article.
Hess, Gregory William
Sports participation has undergone an increase in recent decades. Injury due to sporting activity has also recently risen. The Achilles tendon has been one of the most common sports-related injuries. A 2 in 100,000 individual Achilles tendon injury rate increased to a 12 in 100,000 individual injury rate in less than 10 years. The injury is typically observed in men in the fourth to fifth decades of life. Male to female injury ratios range from 2:1 to 12:1. Running, jumping, and agility activities involving eccentric loading and explosive plyometric contractions are usual mechanisms. Natural aging allows predisposing chronic degeneration of the tendon. Blood flow decreases and stiffness increases with aging to decrease the ability to withstand stress. Noninflammatory tendinosis and chronic tendinopathy are 2 separate processes proposed for tendon degeneration and subsequent rupture. Rupture typically occurs 2 to 6 cm proximal to the calcaneal insertion. Predisposing factors are grouped into 2 categories: intrinsic and extrinsic risk factors. Avoidance of degenerative changes within the tendon is the primary method to prevent rupture. Regular physical activity as athletes age also promotes tendon hypertrophy, increases nutrient delivery, and reduces collagen fiber fatigue.
Batista, Jorge Pablo; del Vecchio, Jorge Javier; Golanó, Pau; Vega, Jordi
Endoscopy for the posterior region of the ankle through two portals is becoming more widespread for the treatment of a large number of conditions which used to be treated with open surgery years ago. The tendon of the flexor hallucis longus (FHL) travels along an osteofibrous tunnel between the posterolateral and posteromedial tubercles of the talus. Chronic inflammation of this tendon may lead to painful stenosing tenosynovitis. The aim of this report is to describe two cases depicting an accessory tendon which is an anatomical variation of the flexor hallucis longus in patients with posterior friction syndrome due to posterior ankle impingement and associated with a posteromedial osteochondral lesion of the talus. The anatomical variation (FDAL) described was a finding during an endoscopy of the posterior region of the ankle, and we have spared it by sectioning the superior flexor retinaculum only. The accessory flexor digitorum longus is an anatomical variation and should be taken into account when performing an arthroscopy of the posterior region of the ankle. We recommend this treatment on this type of injury although we admit this does not make a definite conclusion. PMID:26060592
Rigó, István Zoltán; Røkkum, Magne
We compared the results of two methods for reinsertion of flexor digitorum profundus tendons retrospectively. In 35 fingers of 29 patients pull-out suture and in 13 fingers of 11 patients transverse intraosseous loop technique was performed with a mean follow-up of 8 and 6 months, respectively. Eleven and nine fingers achieved "excellent" or "good" function according to Strickland and Glogovac at 8 weeks; 20 and ten at the last control in the pull-out and transverse intraosseous loop groups, respectively. The difference at 8 weeks was statistically significant in favour of the transverse intraosseous loop group. Ten patients underwent 12 complications in the pull-out group (four superficial infections; one rerupture, one PIP and one DIP joint contracture, one adhesion, two granulomas, one nail deformity and one carpal tunnel syndrome) and four of them were reoperated (one carpal tunnel release, one teno-arthrolysis and two resections of granuloma). There was no complication and no reoperation in the transverse intraosseous loop group, the difference being statistically significant for the former. In our study the transverse intraosseous loop technique seemed to be a safe alternative with possibly better functional results compared to the pull-out suture.
Sherlock, C E; Mair, T S
Recognition of artefacts is an essential component of the accurate interpretation of diagnostic images. This study aimed to investigate the presence of magic angle effect in the superficial digital flexor tendon (SDFT) in the equine proximal pastern region. The proximal pastern of four cadaver limbs was imaged using a 0.27 Tesla magnet with high-resolution sequences that are commonly utilised in clinical equine practice. The limbs were imaged in a neutral position and positions that simulated the horse 'leaning in', 'leaning out' and having internal and external rotation of the distal limb. Signal intensity changes in the SDFT were described and compared. The simulated 'leaning in' and external rotation positions resulted in increased signal intensity in the axial and middle thirds of the lateral half of the SDFT on sequences with short echo times. The simulated 'leaning out' and internal rotation positions resulted in increased signal intensity in the axial and middle thirds of the medial half of the SDFT on sequences with short echo times. These signal intensity changes did not occur or were only mild and inconsistent on T2 fast spin echo sequences with longer echo times. The increases in signal intensity in the SDFT are consistent with a position-induced magic angle artefact that has been noted in clinical cases. Attention to positioning of the equine distal limb is essential during clinical imaging; radiologists should be aware of position-induced artefacts to ensure accurate image interpretation.
Mokhtee, David B; Brown, Justin M; Mackinnon, Susan E; Tung, Thomas H
Surgical repair of distal biceps tendon rupture is a technically challenging procedure that has the potential for devastating and permanently disabling complications. We report two cases of posterior interosseous nerve (PIN) injury following successful biceps tendon repair utilizing both the single-incision and two-incision approaches. We also describe our technique of posterior interosseous nerve repair using a medial antebrachial cutaneous nerve graft (MABC) and a new approach to the terminal branches of the posterior interosseous nerve that makes this reconstruction possible. Finally, we advocate consideration for identification of the posterior interosseous nerve prior to reattachment of the biceps tendon to the radial tuberosity.
Richter, Martinus; Zech, Stefan
Lengthening osteotomy of the calcaneus (LO) and flexor digitorum longus tendon (FDL) transfer to the navicular is one option for the treatment of flexible flatfoot deformity (FD). The aim of the study was to analyse the amount of correction and clinical outcome including pedographic assessment. In a prospective consecutive non-controlled clinical followup study, all patients with FD that were treated with LO and FDL from September 1st 2006 to August 31st, 2009 were included. Assessment was performed before surgery and at 2-year-followup including clinical examination (with staging of posterior tibialis insufficiency) weight bearing radiographs (Talo-1st metatarsal angles (TMT)), pedography (increased midfoot contact area and force) and Visual Analogue Scale Foot and Ankle (VAS FA). 112 feet in 102 patients were analysed (age, 57.6 (13-82), 42% male). In 12 feet (9%) wound healing delay without further surgical measures was registered. All patients achieved full weight bearing during the 7th postoperative week. Until followup, revision surgery was done in 3 patients (fusion calcaneocuboid joint (n=2), correction triple arthrodesis (n=1)). 101 feet (90%) completed 2-year-followup. TMT dorsoplantar/lateral/Index and VAS FA scores were increased, and posterior tibialis insufficiency stage, pedographic midfoot contact area and force percentage were decreased (each p<.05). All relevant parameters (stage of posterior tibialis insufficiency, TMT angles and Index, pedographic midfoot contact area and force percentage, VAS FA) were improved 2 years after LO and FDL transfer to the navicular in FD. The complication rate was low. This method allows safe and predictable correction.
Steiner, Adrian; Anderson, David E; Desrochers, André
Contracted flexor tendon leading to flexural deformity is a common congenital defect in cattle. Arthrogryposis is a congenital syndrome of persistent joint contracture that occurs frequently in Europe as a consequence of Schmallenberg virus infection of the dam. Spastic paresis has a hereditary component, and affected cattle should not be used for breeding purposes. The most common tendon avulsion involves the deep digital flexor tendon. Tendon disruptions may be successfully managed by tenorrhaphy and external coaptation or by external coaptation alone. Medical management alone is unlikely to be effective for purulent tenosynovitis.
Davies, Michael R; Ravishankar, Bharat; Laron, Dominique; Kim, Hubert T; Liu, Xuhui; Feeley, Brian T
Rotator cuff tears (RCTs) are among the most common musculoskeletal injuries seen by orthopaedic surgeons. Clinically, massive cuff tears lead to unique pathophysiological changes in rotator cuff muscle, including atrophy, and massive fatty infiltration, which are rarely seen in other skeletal muscles. Studies in a rodent model for RCT have demonstrated that these histologic findings are accompanied by activation of the Akt/mammalian target of rapamycin (mTOR) and transforming growth factor-β (TGF-β) pathways following combined tendon-nerve injury. The purpose of this study was to compare the histologic and molecular features of rotator cuff muscle and gastrocnemius muscle--a major hindlimb muscle, following combined tendon-nerve injury. Six weeks after injury, the rat gastrocnemius did not exhibit notable fatty infiltration compared to the rotator cuff. Likewise, the adipogenic markers SREBP-1 and PPARγ as well as the TGF-β canonical pathway were upregulated in the rotator cuff, but not the gastrocnemius. Our study suggests that the rat rotator cuff and hindlimb muscles differ significantly in their response to a combined tendon-nerve injury. Clinically, these findings highlight the unique response of the rotator cuff to injury, and may begin to explain the poor outcomes of massive RCTs compared to other muscle-tendon injuries.
Protocol for an investigator-blinded, randomised, 3-month, parallel-group study to compare the efficacy of intraoperative tendon sheath irrigation only with both intraoperative and postoperative irrigation in the treatment of purulent flexor tenosynovitis
Jokihaara, Jarkko; Kaivorinne, Antti; Havulinna, Jouni; Göransson, Harry
Introduction The management of purulent flexor tenosynovitis of the hand consists of surgical debridement followed by antibiotic treatment. Usually, the debridement is carried out by irrigating the tendon sheath in a proximal to distal direction facilitated by two small incisions. It is unclear whether intraoperative irrigation by itself is adequate for healing or if it should be combined with postoperative irrigation in the ward. The hypothesis of this prospective randomised trial is that intraoperative catheter irrigation alone is as effective as a combination of intraoperative and postoperative intermittent catheter irrigation in the treatment of purulent flexor tenosynovitis. Methods and analysis In this investigator-blinded, prospective randomised trial, 48 patients suffering from purulent flexor tenosynovitis are randomised in two groups. Intraoperative catheter irrigation of the flexor tendon sheath and antibiotic treatment is identical in both groups, whereas only the patients in one group are subjected to intermittent postoperative catheter irrigation three times a day for 3 days. The primary outcome measure is total active range of movement of the affected finger after 3 months of surgery. The secondary outcome is the need for reoperation. Ethics and dissemination The research ethics committee of Pirkanmaa Hospital District has approved the study protocol. The protocol has been registered with ClinicalTrials.gov registry (#NCT02320929). All participants will give written informed consent. The study results will elucidate the role of postoperative irrigation, which can be criticised as being labour consuming and unpleasant to the patient. The results of the study will be disseminated as a published article in a peer-reviewed journal. Trial registration number: NCT02320929; pre-results. PMID:26671952
Zhang, Jianying; Yuan, Ting; Wang, James H-C
The effect of exercise on wound healing in aging tendon was tested using a rat moderate treadmill running (MTR) model. The rats were divided into an MTR group that ran on a treadmill for 4 weeks and a control group that remained in cages. After MTR, a window defect was created in the patellar tendons of all rats and wound healing was analyzed. We found that MTR accelerated wound healing by promoting quicker closure of wounds, improving the organization of collagen fibers, and decreasing senescent cells in the wounded tendons when compared to the cage control. MTR also lowered vascularization, increased the numbers of tendon stem/progenitor cells (TSCs) and TSC proliferation than the control. Besides, MTR significantly increased the expression of stem cell markers, OCT-4 and Nanog, and tenocyte genes, Collagen I, Collagen III and tenomodulin, and down-regulated PPAR-γ, Collagen II and Runx-2 (non-tenocyte genes). These findings indicated that moderate exercise enhances healing of injuries in aging tendons through TSC based mechanisms, through which exercise regulates beneficial effects in tendons. This study reveals that appropriate exercise may be used in clinics to enhance tendon healing in aging patients.
Zhang, Jianying; Yuan, Ting; Wang, James H-C.
The effect of exercise on wound healing in aging tendon was tested using a rat moderate treadmill running (MTR) model. The rats were divided into an MTR group that ran on a treadmill for 4 weeks and a control group that remained in cages. After MTR, a window defect was created in the patellar tendons of all rats and wound healing was analyzed. We found that MTR accelerated wound healing by promoting quicker closure of wounds, improving the organization of collagen fibers, and decreasing senescent cells in the wounded tendons when compared to the cage control. MTR also lowered vascularization, increased the numbers of tendon stem/progenitor cells (TSCs) and TSC proliferation than the control. Besides, MTR significantly increased the expression of stem cell markers, OCT-4 and Nanog, and tenocyte genes, Collagen I, Collagen III and tenomodulin, and down-regulated PPAR-γ, Collagen II and Runx-2 (non-tenocyte genes). These findings indicated that moderate exercise enhances healing of injuries in aging tendons through TSC based mechanisms, through which exercise regulates beneficial effects in tendons. This study reveals that appropriate exercise may be used in clinics to enhance tendon healing in aging patients. PMID:26885754
Walden, Grace; Liao, Xin; Donell, Simon; Raxworthy, Mike J.; Riley, Graham P.
Tendon injury is common and debilitating, and it is associated with long-term pain and ineffective healing. It is estimated to afflict 25% of the adult population and is often a career-ending disease in athletes and racehorses. Tendon injury is associated with high morbidity, pain, and long-term suffering for the patient. Due to the low cellularity and vascularity of tendon tissue, once damage has occurred, the repair process is slow and inefficient, resulting in mechanically, structurally, and functionally inferior tissue. Current treatment options focus on pain management, often being palliative and temporary and ending in reduced function. Most treatments available do not address the underlying cause of the disease and, as such, are often ineffective with variable results. The need for an advanced therapeutic that addresses the underlying pathology is evident. Tissue engineering and regenerative medicine is an emerging field that is aimed at stimulating the body's own repair system to produce de novo tissue through the use of factors such as cells, proteins, and genes that are delivered by a biomaterial scaffold. Successful tissue engineering strategies for tendon regeneration should be built on a foundation of understanding of the molecular and cellular composition of healthy compared with damaged tendon, and the inherent differences seen in the tissue after disease. This article presents a comprehensive clinical, biological, and biomaterials insight into tendon tissue engineering and regeneration toward more advanced therapeutics. PMID:27596929
Walden, Grace; Liao, Xin; Donell, Simon; Raxworthy, Mike J; Riley, Graham P; Saeed, Aram
Tendon injury is common and debilitating, and it is associated with long-term pain and ineffective healing. It is estimated to afflict 25% of the adult population and is often a career-ending disease in athletes and racehorses. Tendon injury is associated with high morbidity, pain, and long-term suffering for the patient. Due to the low cellularity and vascularity of tendon tissue, once damage has occurred, the repair process is slow and inefficient, resulting in mechanically, structurally, and functionally inferior tissue. Current treatment options focus on pain management, often being palliative and temporary and ending in reduced function. Most treatments available do not address the underlying cause of the disease and, as such, are often ineffective with variable results. The need for an advanced therapeutic that addresses the underlying pathology is evident. Tissue engineering and regenerative medicine is an emerging field that is aimed at stimulating the body's own repair system to produce de novo tissue through the use of factors such as cells, proteins, and genes that are delivered by a biomaterial scaffold. Successful tissue engineering strategies for tendon regeneration should be built on a foundation of understanding of the molecular and cellular composition of healthy compared with damaged tendon, and the inherent differences seen in the tissue after disease. This article presents a comprehensive clinical, biological, and biomaterials insight into tendon tissue engineering and regeneration toward more advanced therapeutics.
The objective of the two-staged flexor tendon method is to improve the predictability of final results in difficult problems dealing with tendon reconstruction. This article reviews the evolution and benefits of this procedure. It also considers the use of the technique to help deal with problems requiring pulley and skin reconstruction simultaneously with re-constituting the flexor tendon system.
Huang, Deqing; Balian, Gary; Chhabra, A Bobby
Technologic improvements in the field of tissue engineering are leading to new potential developments in the currently used approaches to treat tendon injuries including difficult clinical scenarios such as zone II flexor tendon injuries of the hand and the mutilated hand with extensive tendon defects. A combination of mesenchymal (adult stem) cells, growth factors, and bioresorbable polymers can provide a solution for the treatment of difficult tendon injuries. Extensive research is needed to show that the extracellular matrix produced in response to the cell/growth factor/polymer composites in vivo is effective and functional as a regenerate tissue. Further exciting advances are foreseen in cell-based genetic engineering with the transfer of DNA to the site of tendon lacerations. These treatment modalities require improved safety precautions to reduce the risks and enhance the benefits of gene therapy.
Kisi, Shinya; Yoshida, Munehito
[Purpose] We investigated Achilles tendon injury in Kendo players in junior and senior high schools to obtain a possible indicator for preventing an outbreak of Achilles tendon injury and tendonitis, possible risk factors concerning foot function and morphology were extracted. [Subjects and Methods] The subjects were 60 Kendo players aged 14–18 years from Wakayama Prefecture, Japan (33 boys and 27 girls). A questionnaire survey was conducted on the past history, current status, time of occurrence about Achilles tendon pain or rupture, and site of Achilles tendon pain or rupture. Based on the responses to the questionnaire, these students were divided into two groups, i.e., those who had a history of Achilles tendon pain (n=30) or rupture (n=3) (pain group) and those who had no history of Achilles tendon pain (no-pain group), and they were examined for foot alignment, flexion and extension Range of motion test of the first toe, flexion and extension muscle strength of the first toe, and opening movement of the toes. [Results] Achilles tendon pain had occurred in 53% of the Kendo players (including 3 who had suffered Achilles tendon rupture). Poor foot alignment and deterioration of opening movement of the toes were noted in the pain group. [Conclusion] Foot alignment was poor and opening function of the toes deteriorated in the pain group, suggesting that these may be some of factors for Achilles tendon injury. Training aimed at improving foot alignment and function is important to prevent and improve Achilles tendon injury. PMID:28265159
Ribbans, William John; Garde, Ajit
The tibialis posterior tendon and the spring and deltoid ligament complexes combine to provide dynamic and passive stabilization on the medial side of the ankle and hindfoot. Some of the injuries will involve acute injury to previous healthy structures, but many will develop insidiously. The clinician must be aware of new treatment strategies and the level of accompanying scientific evidence regarding injuries sustained by athletes in these areas, while acknowledging that more traditional management applied to nonathletic patients is still likely to be appropriate in the setting of treatment for elite athletes.
Guevara-Alvarez, Alberto; Schmitt, Andreas; Russell, Ryan P.; Imhoff, Andreas B.; Buchmann, Stefan
Summary Background: tendon tissue shows limited regeneration potential with formation of scar tissue and inferior mechanical properties. The capacity of several growth factors to improve the healing response and decrease scar formation is described in different preclinical studies. Besides the application of isolated growth factors, current research focuses on two further strategies to improve the healing response in tendon injuries: platelet rich plasma (PRP) and mesenchymal stem cells (MSCs). Objective: the present review focuses on these two options and describes their potential to improve tendon healing. Results: in vitro experiments and animal studies showed promising results for the use of PRP, however clinical controlled studies have shown a tendency of reduced pain related symptoms but no significant differences in overall clinical scores. On the other hand MSCs are not totally arrived in clinical use so that there is still a lack of randomized controlled trials. In basic research experiments they show an extraordinary paracrine activity, anti-inflammatory effect and the possibility to differentiate in tenocytes when different activating-factors are added. Conclusion: preclinical studies have shown promising results in improving tendon remodeling but the comparability of current literature is difficult due to different compositions. PRP and MSCs can act as efficient growth factor vehicles, however further studies should be performed in order to adequate investigate their clinical benefits in different tendon pathologies. PMID:25489557
Lui, Tun Hing
Tenosynovitis of the flexor hallucis longus tendon is a condition typically found in ballet dancers and sometimes in soccer players and is related to chronic overuse. It mostly involves the portion of the tendon behind the ankle joint. However, the portion of the tendon under the sustentaculum tali can also be involved. Open synovectomy requires extensive dissection. We report the technique of arthroscopic synovectomy of the deep portion of the flexor hallucis longus.
Wei, David H; Terrono, Andrew L
Swan neck deformity, or hyperextension of the proximal interphalangeal joint, may occur secondary to trauma, rheumatoid arthritis, cerebral palsy, or Ehlers-Danlos syndrome, and can be treated with tenodesis of one slip of the flexor digitorum sublimis tendon. This technique has several variations, differing primarily in the specific location and method that a single slip of the flexor digitorum sublimis tendon is secured, but they all serve to create a static volar restraint against hyperextension. Options include tunneling the tendon through the bone of the proximal phalanx, attaching the tendon to the A1 or A2 pulley, or securing the tendon with bone anchors in the proximal phalanx.
Wang, Yi; Lu, Liangyu; Lu, Zhe; Xiao, Lei; Kang, Yifan; Wang, Zimin
Objective: To evaluate clinical efficacy of arthroscopic transtendinous repair of partial articular-sided PASTA (partial articular supraspinatus tendon avulsion) injury. Methods: From February 2011 to July 2014, 12 cases of PASTA, aged 29 to 72 years with an average of 52.9 ± 13.3 years, were treated arthoscopically. To repair PASTA, articular-sided rotator cuff tear was explored, injury site was punctured and labeled with PDS absorbable monofilament suture (Ethicon, Somerville, NJ, USA) suture, subacromial bursa was cleaned up with acromioplasty, and integrity of bursa-side rotator cuff was assessed. Then with arthroscope in glenohumeral joint, footprint of the bursa-side supraspinatus tendon was preserved, rivets were introduced into the joint through supraspinatus tendon, joint-side partial tear was sutured, and anatomical reconstruction of the rotator cuff footprint was established. The patients were followed up post-operatively for 12-36 months, average 22 ± 7.3 months. The clinical outcomes were emulated with ASES (American Shoulder and Elbow Surgeons) Shoulder Score system and UCLA (University of California at Los Angeles) Shoulder rating scale. Results: The post-operative ASES score was 89.7 ± 5.6, higher than the pre-operative one 49.8 ± 9.8 (t = 12.25, P <0.0001). While UCLA scale increased from the pre-operative 17.3, ± 3.3 to the post-operative 30.4 ± 3.2 points (t = 9.87, P <0.0001), with a satisfaction rate of 11/12 (91.7%). Conclusion: Trans-tendon repair is ideal for PASTA with advantage of maximal preservation of the normal rotator cuff tissue, anatomical reconstruction of the rotator cuff footprint and stable fixation of tendon-bone interface. PMID:25784979
Evgeniou, Evgenios; Iyer, Srinivasan
Flexor tenosynovitis is an aggressive closed-space infection of the digital flexor tendon sheaths of the hand. We present a case of pyogenic flexor tenosynovitis in an immunocompromised patient and discuss the importance of early diagnosis and referral to a specialist hand surgery unit. A 61-year-old man visited his general practitioner because of swelling and tenderness of his left index finger. The patient was discharged on oral antibiotics but returned 4 days after because of deterioration of his symptoms and was referred to a plastic surgery unit. A diagnosis of flexor tenosynovitis was made and the patient required multiple debridements in theatre, resulting in the amputation of the infected finger. Pyogenic flexor tenosynovitis is a relatively common but often misdiagnosed hand infection. Patients with suspected flexor tenosynovitis should be referred and treated early to avoid significant morbidity, especially when risk factors for poor prognosis are present.
Reed, S A; Leahy, E R
Tendon injuries affect all levels of athletic horses and represent a significant loss to the equine industry. Accumulation of microdamage within the tendon architecture leads to formation of core lesions. Traditional approaches to tendon repair are based on an initial period of rest to limit the inflammatory process followed by a controlled reloading program designed to promote the maturation and linear arrangement of scar tissue within the lesion. However, these treatment protocols are inefficient, resulting in prolonged recovery periods and frequent recurrence. Current alternative therapies include the use of bone marrow-derived mesenchymal stem cells (BMSC) and a population of nucleated cells from adipose containing adipose-derived mesenchymal stem cells (AdMSC). Umbilical cord blood-derived stem cells (UCB) have recently received attention for their increased plasticity in vitro and potential as a therapeutic aid. Both BMSC and AdMSC require expansion in culture before implantation to obtain a pure stem cell population, limiting the time frame for implantation. Collected at parturition, UCB can be cryopreserved for future use. Furthermore, the low immunogenicity of the UCB population allows for allogeneic implantation. Current research indicates that BMSC, AdMSC, and UCB can differentiate into tenocyte-like cells in vitro, increasing expression of scleraxis, tenascin c, and extracellular matrix proteins. When implanted, BMSC and AdMSC engraft into the tendon and improve tendon architecture. However, treatment with these stem cells does not decrease recovery period. Furthermore, the resulting regeneration is not optimal, as the resulting tissue is still inferior to native tendon. Umbilical cord blood-derived stem cells may provide an alternate source of stem cells that promote improved regeneration of tendon tissue. A more naïve cell population, these cells may have a greater rate of engraftment as well as an increased ability to secrete bioactive factors and
Merenda, Lisa A.; Rutter, Laure; Curran, Kimberly; Kozin, Scott H.
Background: Tendon transfer surgery can restore elbow extension in approximately 70% of persons with tetraplegia and often results in antigravity elbow extension strength. However, we have noted an almost 15% rupture/attenuation rate. Objective: This investigation was conducted to analyze potential causes in adolescents/young adults with spinal cord injury (SCI) who experienced tendon rupture or attenuation after biceps-to-triceps transfer. Methods: Medical charts of young adults with SCI who underwent biceps-to-triceps transfer and experienced tendon rupture or attenuation were reviewed. Data collected by retrospective chart review included general demographics, surgical procedure(s), use and duration of antibiotic treatment, time from tendon transfer surgery to rupture/attenuation, and method of diagnosis. Results: Twelve subjects with tetraplegia (mean age, 19 years) who underwent biceps-to-triceps reconstruction with subsequent tendon rupture or attenuation were evaluated. Mean age at time of tendon transfer was 18 years (range, 14-21 years). A fluoroquinolone was prescribed for 42% (n=5) of subjects. Tendon rupture was noted in 67% (n=8), and attenuation was noted in 33% (n=4). Average length of time from surgery to tendon rupture/attenuation was 5.7 months (range, 3-10 months). Conclusion: Potential contributing causes of tendon rupture/attenuation after transfer include surgical technique, rehabilitation, co-contraction of the transfer, poor patient compliance, and medications. In this cohort, 5 subjects were prescribed fluoroquinolones that have a US Food and Drug Administration black box concerning tendon ruptures. Currently, all candidates for upper extremity tendon transfer reconstruction are counseled on the effects of fluoroquinolones and the potential risk for tendon rupture. PMID:23459326
Thorpe, Chavaunne T; Godinho, Marta S C; Riley, Graham P; Birch, Helen L; Clegg, Peter D; Screen, Hazel R C
While the predominant function of all tendons is to transfer force from muscle to bone and position the limbs, some tendons additionally function as energy stores, reducing the cost of locomotion. Energy storing tendons experience extremely high strains and need to be able to recoil efficiently for maximum energy storage and return. In the equine forelimb, the energy storing superficial digital flexor tendon (SDFT) has much higher failure strains than the positional common digital extensor tendon (CDET). However, we have previously shown that this is not due to differences in the properties of the SDFT and CDET fascicles (the largest tendon subunits). Instead, there is a greater capacity for interfascicular sliding in the SDFT which facilitates the greater extensions in this particular tendon (Thorpe et al., 2012). In the current study, we exposed fascicles and interfascicular matrix (IFM) from the SDFT and CDET to cyclic loading followed by a test to failure. The results show that IFM mechanical behaviour is not a result of irreversible deformation, but the IFM is able to withstand cyclic loading, and is more elastic in the SDFT than in the CDET. We also assessed the effect of ageing on IFM properties, demonstrating that the IFM is less able to resist repetitive loading as it ages, becoming stiffer with increasing age in the SDFT. These results provide further indications that the IFM is important for efficient function in energy storing tendons, and age-related alterations to the IFM may compromise function and predispose older tendons to injury.
Thorpe, Chavaunne T.; Godinho, Marta S.C.; Riley, Graham P.; Birch, Helen L.; Clegg, Peter D.; Screen, Hazel R.C.
While the predominant function of all tendons is to transfer force from muscle to bone and position the limbs, some tendons additionally function as energy stores, reducing the cost of locomotion. Energy storing tendons experience extremely high strains and need to be able to recoil efficiently for maximum energy storage and return. In the equine forelimb, the energy storing superficial digital flexor tendon (SDFT) has much higher failure strains than the positional common digital extensor tendon (CDET). However, we have previously shown that this is not due to differences in the properties of the SDFT and CDET fascicles (the largest tendon subunits). Instead, there is a greater capacity for interfascicular sliding in the SDFT which facilitates the greater extensions in this particular tendon (Thorpe et al., 2012). In the current study, we exposed fascicles and interfascicular matrix (IFM) from the SDFT and CDET to cyclic loading followed by a test to failure. The results show that IFM mechanical behaviour is not a result of irreversible deformation, but the IFM is able to withstand cyclic loading, and is more elastic in the SDFT than in the CDET. We also assessed the effect of ageing on IFM properties, demonstrating that the IFM is less able to resist repetitive loading as it ages, becoming stiffer with increasing age in the SDFT. These results provide further indications that the IFM is important for efficient function in energy storing tendons, and age-related alterations to the IFM may compromise function and predispose older tendons to injury. PMID:25958330
... up. Tight calf muscles or muscles that lack flexibility decrease a person's range of motion and put an extra strain on the tendon. Running or exercising on a hard or uneven surface or doing lunges or plyometrics without adequate training. A traumatic injury to the Achilles tendon. How ...
Singh, Rohit; Manoharan, Gopikanthan; Moores, Thomas Steven; Patel, Amit
Achilles tendon ruptures tend to occur more commonly in healthy men between the ages of 30 and 50 years who have had no previous injury or problem reported in the affected leg. The injury is usually due to sudden forced plantar flexion of the foot, unexpected dorsiflexion of the foot and violent dorsiflexion of a plantar flexed foot, all of which occur during high impact activities. We present the first reported case of interactive activity with Nintendo Wii games that have resulted in Achilles tendon rupture in a 46-year-old man. There have been no previous reports of Achilles tendon rupture with Nintendo Wii usage; it is a relatively uncommon mode of injury and is rare in terms of epidemiology of motion sensing video game injuries.
Lustgarten, Meghann; Redding, W Rich; Labens, Raphael; Davis, Weston; Daniel, Thomas M; Griffith, Emily; Seiler, Gabriela S
Compression elastography is an ultrasonographic technique that estimates tissue strain and may have utility in diagnosing and monitoring soft tissue injuries in the equine athlete. Recently, elastography has been proven to be a feasible and repeatable imaging modality for evaluating normal tendons and ligaments of the equine distal forelimb. The purposes of this prospective study were to investigate the ability of elastography to detect spontaneously occurring lesions of equine tendons and ligaments diagnosed with magnetic resonance imaging (MRI) and gray-scale ultrasound (US) and to characterize the differences in the elastographic appearance of acute vs. chronic injuries. Fifty seven horses with a total of 65 lesions were evaluated. Images were assessed quantitatively and qualitatively. Acute lesions were found to be significantly softer (P < 0.0001) than chronic lesions (P < 0.0001) and the stiffness of lesions increased with progression of healing (P = 0.0138). A negative correlation between lesion hypoechogenicity and softness was appreciated with more hypoechoic lesions appearing softer (P = 0.0087) and more hyperechoic regions harder (P = 0.0002). A similar finding occurred with increased signal intensity on short tau inversion recovery (STIR) and proton density (PD) MRI sequences correlating with increased softness on elastography (P = 0.0164). Using US and MRI as references, commonly encountered soft tissue injuries of the equine distal limb could be detected with elastography. However, elastography was limited for detecting small, proximal injuries of the hindlimb proximal suspensory ligament. Elastographic evaluation of equine tendons and ligaments may allow better characterization of lesion chronicity and severity, and sequential examinations may optimize lesion management, rehabilitation, and return to training.
Wong, J.K.F.; Alyouha, S.; Kadler, K.E.; Ferguson, M.W.J.; McGrouther, D.A.
Trauma by suturing tendon form areas devoid of cells termed “acellular zones” in the matrix. This study aimed to characterise the cellular insult of suturing and acellular zone formation in mouse tendon. Acellular zone formation was evaluated using single grasping sutures placed using flexor tendons with time lapse cell viability imaging for a period of 12 h. Both tension and injury were required to induce cell death and cell movement in the formation of the acellular zone. DNA fragmentation studies and transmission electron microscopy indicated that cells necrosed. Parallel in vivo studies showed that cell-to-cell contacts were disrupted following grasping by the suture in tensioned tendon. Without tension, cell death was lessened and cell-to-cell contacts remained intact. Quantitative immunohistochemistry and 3D cellular profile mapping of wound healing markers over a one year time course showed that acellular zones arise rapidly and showed no evidence of healing whilst the wound healing response occurred in the surrounding tissues. The acellular zones were also evident in a standard modified “Kessler” clinical repair. In conclusion, the suture repair of injured tendons produces acellular zones, which may potentially cause early tendon failure. PMID:20600895
Hayashi, Masanori; Zhao, Chunfeng; Thoreson, Andrew R; Chikenji, Takako; Jay, Gregory D; An, Kai-Nan; Amadio, Peter C
The purpose of this study was to investigate the role of lubricin on the gliding resistance of intrasynovial tendons by comparing lubricin knockout, heterozygous, and wild type mice. A total of thirty-six deep digital flexor (DDF) tendons in the third digits of each hind paw from eighteen adult mice were used, including six lubricin knockout mice (Prg4 -/-), six heterozygous mice (Prg4 +/-), and six wild type mice (Prg4 +/+). The tendon gliding resistance was measured using a custom-made device. Tendon structural changes were evaluated by scanning electron and light microscopy. The gliding resistance of intrasynovial tendons from lubricin knockout mice was significantly higher than the gliding resistance of either wild type or heterozygous mice. The surface of the lubricin knockout tendons appeared to be rougher, compared to the wild type and heterozygous tendons. Synovial hyperplasia was found in the lubricin knockout mice. Cartilage-like tissue was found in the tendon and pulley of the lubricin knockout mice. Our findings confirm the importance of lubricin in intrasynovial tendon lubrication. This knockout model may be useful in determining the effect of lubricin on tendon healing and the response to injury.
Jahani, S; Moslemi, H. R.; Dehghan, M. M.; Sedaghat, R; Mazaheri Nezhad, R; Rezaee Moghaddam, D
In this study, the role of local injection of butyric acid (BA) with autogenous omental graft was evaluated in healing of experimental Achilles tendon injury in rabbits. Nine adult male New Zealand rabbits were anesthetized and a partial thickness tenotomy was created on both hindlimbs. In treated group, omental graft was secured in place using BA soaked polygalactin 910 suture. In control group, the graft was sutured without BA. Butyric acid and normal saline were injected daily to treatment and control groups for three days, respectively. Based on the findings, on day 15 after injury, the tendon sections showed that healing rate in BA treated group was higher than that in control group. Furthermore, at days 28 and 45, comparison between BA treated and control groups demonstrated that BA increased the healing rate but with no significance. In summary, results of this study show that application of BA with autogenous omental graft can improve healing process of damaged Achilles tendon. PMID:27175160
Wang, Lin; Gao, Weiwei; Xiong, Kaiyu; Hu, Kuan; Liu, Xincun; He, Hui
Bone-tendon junction (BTJ) injuries are common and may be caused by acute trauma and delayed healing during exercise or work. To understand the nature of the healing process of BTJ injuries would help to prevent injuries and improve treatment. Thirty-three mature female rabbit hindlimbs were assigned to normal control (CON, n = 7) and injury groups (n = 26). The acute injury was established by administering one 7 plum-blossom needle puncture. Specimens were harvested post injury at 1, 2, 4, and 8 weeks (ND1W, n = 6; ND2W, n = 6; ND4W, n = 7; and ND8W, n = 7). The injury existed in all of the injury groups. Compared with the CON group, all of the animals in the injury group showed poor cell profiles, an unclear or undetectable tide mark, a proteoglycan area and profile changes; the BTJ cell density diminished significantly in the ND1W (p < 0.01), ND2W (p < 0.05), ND4W (p < 0.01), and ND8W groups (p < 0.01); the fibrocartilage zone thickness in all injury groups was significantly thicker than in the CON group (p < 0.05), but no significant difference was found among the injury groups (p>0.05). The basic fibroblast growth factor (bFGF) expression in the CON group was significantly less than in the ND1W group (p<0.01), but no significant difference was found when compared with the ND2W, ND4W, and ND8W groups. The bFGF expression in the ND1W group was higher than that of the ND4W (p < 0.05) and ND8W groups (p < 0.01). The vascular endothelial growth factor (VEGF) levels were not significantly different among the groups (p > 0.05). The bFGF and VEGF expression levels indicated that the healing process stopped at 8 weeks post injury or was not activated, although the injury had not healed by histological examination. A repeatable animal model of BTJ acute injury was established in this study, and the results described the BTJ acute injury healing difficult concerned with the repairing stop. Key Points This study described the bone-tendon junction acute injury nature
... Ethics Occupational Therapy Assistants Advocacy & Policy New Evaluation Codes Learn how to use the new OT CPT® Evaluation codes correctly . Congressional Affairs AOTPAC Federal Regulatory Affairs Health ...
Martinoli, Carlo; Bianchi, Stefano; Cotten, Anne
Competition climbing has grown increasingly in popularity, and many people are being drawn to this sport with a parallel increase in the occurrence of sport-related injuries. One of the most common and unique lesions occurring in the rock climbing population is the closed rupture of the flexor pulley system of the fingers. This lesion is strictly related to some climbing techniques in which the entire body weight is placed on fingerholds, which causes bowstringing of the flexor tendons with subsequent loss of strength across the full range of motion of the finger. This article summarizes the current literature regarding the application of imaging modalities in the diagnosis of rock climbing injuries with a specific focus on ultrasound and magnetic resonance imaging. Biomechanics of the sporting activity and resultant pathophysiologic and clinical considerations concerning flexor pulley system injuries are also discussed.
Qu, Jin; Thoreson, Andrew R; Chen, Qingshan; An, Kai-Nan; Amadio, Peter C; Zhao, Chunfeng
Tendon-to-bone integration is a great challenge for tendon or ligament reconstruction regardless of use of autograft or allograft tendons. We mineralized the tendon, thus transforming the tendon-to-bone into a "bone-to-bone" interface for healing. Sixty dog flexor digitorum profundus (FDP) tendons were divided randomly into five groups: (1) normal FDP tendon, (2) CaP (non-extraction and mineralization without fetuin), (3) CaPEXT (Extraction by Na2 HPO4 and mineralization without fetuin), (4) CaPFetuin (non-extraction and mineralization with fetuin), and (5) CaPEXTFetuin (extraction and mineralization with fetuin). The calcium and phosphate content significantly increased in tendons treated with combination of extraction and fetuin compared to the other treatments. Histology also revealed a dense mineral deposition throughout the tendon outer layers and penetrated into the tendon to a depth of 200 µm in a graded manner. Compressive moduli were significantly lower in the four mineralized groups compared with normal control group. No significant differences in maximum failure strength or stiffness were found in the suture pull-out test among all groups. Mineralization of tendon alters the interface from tendon to bone into mineralized tendon to bone, which may facilitate tendon-to-bone junction healing following tendon or ligament reconstruction.
Scharf, Alexandra; Holmes, Shannon; Thoresen, Merrilee; Mumaw, Jennifer; Stumpf, Alaina; Peroni, John
The goal of this study was to establish an SPIO-based cell-tracking method in an ovine model of tendonitis and to determine if this method may be useful for further study of cellular therapies in tendonitis in vivo. Functional assays were performed on labeled and unlabeled cells to ensure that no significant changes were induced by intracellular SPIOs. Following biosafety validation, tendon lesions were mechanically (n = 4) or chemically (n = 4) induced in four sheep and scanned ex vivo at 7 and 14 days to determine the presence and distribution of intralesional cells. Ovine MSCs labeled with 50 µg SPIOs/mL remained viable, proliferate, and undergo tri-lineage differentiation (p < 0.05). Labeled ovine MSCs remained detectable in vitro in concentrated cell numbers as low as 10 000 and in volumetric distributions as low as 100 000 cells/mL. Cells remained detectable by MRI at 7 days, as confirmed by correlative histology for dually labeled SPIO+/GFP+ cells. Histological evidence at 14 days suggested that SPIO particles remained embedded in tissue, providing MRI signal, although cells were no longer present. SPIO labeling has proven to be an effective method for cell tracking for a large animal model of tendon injury for up to 7 days post-injection. The data obtained in this study justify further investigation into the effects of MSC survival and migration on overall tendon healing and tissue regeneration.
Shepherd, Jennifer H; Legerlotz, Kirsten; Demirci, Taylan; Klemt, Christian; Riley, Graham P; Screen, Hazel R C
Most overuse tendinopathies are thought to be associated with repeated microstrain below the failure threshold, analogous to the fatigue failure that affects materials placed under repetitive loading. Investigating the progression of fatigue damage within tendons is therefore of critical importance. There are obvious challenges associated with the sourcing of human tendon samples for in vitro analysis so animal models are regularly adopted. However, data indicates that fatigue life varies significantly between tendons of different species and with different stresses in life. Positional tendons such as rat tail tendon or the bovine digital extensor are commonly applied in in vitro studies of tendon overuse, but there is no evidence to suggest their behaviour is indicative of the types of human tendon particularly prone to overuse injuries. In this study, the fatigue response of the largely positional digital extensor and the more energy storing deep digital flexor tendon of the bovine hoof were compared to the semitendinosus tendon of the human hamstring. Fascicles from each tendon type were subjected to either stress or strain controlled fatigue loading (cyclic creep or cyclic stress relaxation respectively). Gross fascicle mechanics were monitored after cyclic stress relaxation and the mean number of cycles to failure investigated with creep loading. Bovine extensor fascicles demonstrated the poorest fatigue response, while the energy storing human semitendinosus was the most fatigue resistant. Despite the superior fatigue response of the energy storing tendons, confocal imaging suggested a similar degree of damage in all three tendon types; it appears the more energy storing tendons are better able to withstand damage without detriment to mechanics.
Sakabe, Tomoya; Sakai, Takao
Introduction Tendons establish specific connections between muscles and the skeleton by transferring contraction forces from skeletal muscle to bone thereby allowing body movement. Tendon physiology and pathology are heavily dependent on mechanical stimuli. Tendon injuries clinically represent a serious and still unresolved problem since damaged tendon tissues heal very slowly and no surgical treatment can restore a damaged tendon to its normal structural integrity and mechanical strength. Understanding how mechanical stimuli regulate tendon tissue homeostasis and regeneration will improve the treatment of adult tendon injuries that still pose a great challenge in today's medicine. Source of data This review summarizes the current status of tendon treatment and discusses new directions from the point of view of cell-based therapy and regenerative medicine approach. We searched the available literature using PubMed for relevant original articles and reviews. Growing points Identification of tendon cell markers has enabled us to study precisely tendon healing and homeostasis. Clinically, tissue engineering for tendon injuries is an emerging technology comprising elements from the fields of cellular source, scaffold materials, growth factors/cytokines and gene delivering systems. Areas timely for developing research The clinical settings to establish appropriate microenvironment for injured tendons with the combination of these novel cellular- and molecular-based scaffolds will be critical for the treatment. PMID:21729872
Riley, G P; Harrall, R L; Constant, C R; Chard, M D; Cawston, T E; Hazleman, B L
OBJECTIVES--To analyse the collagen composition of normal adult human supraspinatus tendon and to compare with: (1) a flexor tendon (the common biceps tendon) which is rarely involved in any degenerative pathology; (2) degenerate tendons from patients with chronic rotator cuff tendinitis. METHODS--Total collagen content, collagen solubility and collagen type were investigated by hydroxyproline analysis, acetic acid and pepsin digestion, cyanogen bromide peptide analysis, SDS-PAGE and Western blotting. RESULTS--The collagen content of the normal cadaver supraspinatus tendons (n = 60) was 96.3 micrograms HYPRO/mg dry weight (range 79.3-113.3) and there was no significant change across the age range 11 to 95 years. There was no significant difference from the common biceps tendon [93.3 (13.5) micrograms HYPRO/mg dry weight, n = 24]. Although extremely insoluble in both acetic acid and pepsin, much of the collagen was soluble after cyanogen bromide digestion [mean 47.9% (29.8)]. Seventeen per cent (10/60) of the 'normal' cadaver supraspinatus tendon sample contained more than 5% type III collagen, although none of the common biceps tendons had significant amounts. Degenerate supraspinatus and subscapularis tendons had a reduced collagen content [83.8 (13.9) micrograms/mg dry weight and 76.9 (16.8) micrograms/mg dry wt respectively) and were more soluble in acetic acid, pepsin and cyanogen bromide (p < 0.001). Eighty two per cent (14/17) of supraspinatus tendons and 100% (8/8) of subscapularis tendons from patients with tendinitis contained more than 5% type III collagen. CONCLUSIONS--The changes in collagen composition in rotator cuff tendinitis are consistent with new matrix synthesis, tissue remodelling and wound healing, in an attempt to repair the tendon defect, even in old and degenerate tendons. An increase in type III collagen in some 'normal' cadaver supraspinatus tendons is evidence that changes in collagen synthesis and turnover may precede tendon rupture
Stefanato, Catherine M; Turner, Matthew S; Bhawan, Jag
High-pressure paint guns deliver paint at approximately 3000 pounds per square inch. At this pressure, paint will penetrate the skin and spread quickly through fascial planes and tendon sheaths. The present case is that of a lesion from the finger of a 35-year-old white male in whom a history was initially unavailable. Histologic examination revealed diffuse fibrohistiocytic proliferation and giant cells, with numerous darkly pigmented, uniformly small-sized particles throughout the lesion. The initial impression was that of a giant cell tumor of tendon sheath. However, the pigment particles were negative for Perls stain, and polariscopic examination revealed clear refractile fragments. These findings raised the possibility that the lesion was the result of a traumatic event. On further inquiry, it was revealed that the patient had sustained a high-pressure paint-gun injury 1 year earlier. The simulation, histopathologically, of a giant cell tumor of tendon sheath by a high-pressure paint-gun injury has not, to our knowledge, been reported previously, nor has the histologic finding of small, uniformly sized pigment particles and polarizable refractile fragments in this particular type of injury.
Yammine, Kaissar; Rafi, Sidiqa M; Furhad, Sadia
Tendon and nerve structures are at risk when displaced fractures of the distal radius are pinned using K-wires. The aim of this meta-analysis (MA) is to examine the published evidence of such complications in cadavers. Eight studies met our inclusion criteria. The meta-analytical results were as follows: (a) 2.87% and 30.5% tendon involvement at the radial styloid process (RSP) and the dorso-radial area of the distal radius, respectively; (b) 3.5% and 1.1% tendon involvement when the percutaneous pinning (PP) and the limited open pinning (LOP) techniques were used, respectively; (c) 16.1% and 3.4% nerve involvement at the RSP and the dorso-radial area of the distal radius, respectively; (d) in 35.7% the nerve was speared and in 64.3% it touched the K-wire at the styloid area; (e) 61.3% cephalic vein involvement in the styloid area; (f) the second branch of the sensitive branch of the radial nerve (SBRN) was the closest to a wire inserted into the RSP; (g) the mean (±SD) distance between a branch of the SBRN and a styloid wire was 2.17 ± 0.82 mm. Our results for nerve and tendon injury frequencies in the RSP were close to those in clinical meta-analytical studies, offering an excellent statistical model of evidence synthesis based on cadaveric studies to assess the frequency of such injuries in clinical practice. However, this cadaveric MA yielded more accurate data than the previously reported clinical MA in assessing the real risk of injury of such structures in the distal radius in terms of their proximity to the inserted K-wires.
Docheva, Denitsa; Müller, Sebastian A.; Majewski, Martin; Evans, Christopher H.
Tendon injuries are common and present a clinical challenge to orthopedic surgery mainly because these injuries often respond poorly to treatment and require prolonged rehabilitation. Therapeutic options used to repair ruptured tendons have consisted of suture, autografts, allografts, and synthetic prostheses. To date, none of these alternatives has provided a successful long-term solution, and often the restored tendons do not recover their complete strength and functionality. Unfortunately, our understanding of tendon biology lags far behind that of other musculoskeletal tissues, thus impeding the development of new treatment options for tendon conditions. Hence, in this review, after introducing the clinical significance of tendon diseases and the present understanding of tendon biology, we describe and critically assess the current strategies for enhancing tendon repair by biological means. These consist mainly of applying growth factors, stem cells, natural biomaterials and genes, alone or in combination, to the site of tendon damage. A deeper understanding of how tendon tissue and cells operate, combined with practical applications of modern molecular and cellular tools could provide the long awaited breakthrough in designing effective tendon-specific therapeutics and overall improvement of tendon disease management. PMID:25446135
Faruqui, Sami; Wijdicks, Coen; Foad, Abdullah
The purpose of this study was to examine the accuracy of physical examination in the detection of subscapularis tendon tears and compare it with the gold standard of arthroscopy to determine whether clinical examination can reliably predict the presence of subscapularis tendon tears. This was a retrospective analysis of 52 patients (52 shoulders) who underwent arthroscopic subscapularis tendon repairs between September 2008 and April 2012. Positive findings on any combination of the belly press, lift-off, and bear hug tests constituted a positive physical examination result. There was a positive finding on physical examination in 42 of 52 patients. The sensitivity of the physical examination as a whole was 81%. The literature has shown that the belly press, bear hug, and lift-off tests are specific to the subscapularis tendon. To the authors’ knowledge, this is the first study to evaluate the sensitivity of these 3 separate clinical tests as a composite. Knowledge regarding the sensitivity of the subscapularis-specific physical examination as a composite can lead practitioners to implement all 3 components, even when 1 test has a negative finding, thus promoting a more thorough physical examination. Because unrepaired subscapularis tendon tears can result in poor outcomes in the repair of other rotator cuff tendons, a complete physical examination would be beneficial to patients with shoulder pathology. The authors conclude that physical examination, when performed consistently by an experienced practitioner, can reliably predict the presence of subscapularis tendon tears.
...) Identification. A passive tendon prosthesis is a device intended to be implanted made of silicon elastomer or a... flexor tendon of the hand. The device is implanted for a period of 2 to 6 months to aid growth of a new tendon sheath. The device is not intended as a permanent implant nor to function as a replacement for...
al-Qattan, M M; Duerksen, F
Anatomical variations of the muscles and nerves around the wrist are common. Knowledge of such variations is derived from 2 sources: anatomical dissections and clinically reported cases. We present a case of duplication of the tendon of flexor carpi ulnaris with splitting of the ulnar nerve. The ulnar slip of the tendon was inserted into the pisiform bone and the radial slip into the proximal phalanx of the ring finger. The anatomical literature and the clinically reported cases of variations of the flexor carpi ulnaris are reviewed. Images Fig. 1 PMID:1452475
Behfar, Mehdi; Hobbenaghi, Rahim; Sarrafzadeh-Rezaei, Farshid
Tendons are frequently targets of injury in sports and work. Whether nonsteroidal anti-inflammatory drugs (NSAIDs) have beneficial effects on tendon healing is still a matter of debate. This study was conducted to evaluate effects of flunixin meglumine (FM) on tendon healing after experimentally induced acute trauma. Twenty eight adult male New Zealand White rabbits were subjected to complete transection of deep digital flexor tendons followed by suture placement. Treatment group received intramuscular injection of FM for three days, and controls received placebo. Subsequently, cast immobilization was continued for two weeks. Animals were sacrificed four weeks after surgery and tissue samples were taken. The histological evaluations revealed improved structural characteristics of neotendon formation including fibrillar linearity, fibrillar continuity and neovascularization in treatment group compared to those of controls (p < 0.05). However, no significant differences were found between two groups in terms of epitenon thickness (p > 0.05). Mechanical evaluation revealed significant increase in load-related material properties including ultimate load, yield load, energy absorption and ultimate stress in treatment group compared to those of control group (p < 0.05). However, no statistically significant differences in terms of stiffness and ultimate strain were found (p > 0.05). The present study showed that intramuscular injection of FM resulted in improved structural and mechanical properties of tendon repairs and it could be an effective treatment for acute tendon injuries like severance and laceration.
Aiyegbusi, Ayoola I; Olabiyi, Olaleye O; Duru, Francis I O; Noronha, Cressie C; Okanlawon, Abayomi O
Bromelain, an enzyme extracted from the stem of the pineapple plant, has been reported to reduce pain and swelling in acute soft tissue injuries, but no study has been done to compare its effect with that of fresh pineapple juice on the healing of acute tendon injuries. This study compared the effects of commercial bromelain and fresh pineapple juice on tenocyte proliferation and the malondialdehyde (MDA) level in the early stage of healing in a crush injury to the Achilles tendon of Sprague-Dawley rats. Twenty-four male rats were divided randomly into three groups of eight rats each; all the rats had induced crush injury to the Achilles tendon: Group 1 (control), no treatment; Group 2, oral bromelain treatment at a dosage of 7 mg/kg of body weight daily; and Group 3, fresh diluted pineapple juice at a dosage of 30 mg/kg of body weight. Treatment was given over the first 14 days post-injury. On day 15 post-injury, the animals were sacrificed, and the tendons were excised and processed for histological study and MDA assay. Results show a significant difference in the tenocyte population between the bromelain group and the control (P < .05), whereas pineapple juice also increased the tenocyte population, although not significantly (P = .36). Pineapple juice, however, significantly lowered the MDA level compared with both the control and bromelain-treated groups. Based on this study, 600 GDU bromelain given at a dosage of 7 mg/kg had a better effect on tenocyte proliferation than fresh pineapple juice given once daily in acute tendon injury.
Lin, G T; Amadio, P C; An, K N; Cooney, W P
The anatomy of 55 cadaver digits was studied, both statistically and with simulated active motion using weights attached to the flexor tendons. The modified description of Doyle and Blythe accurately described the anatomy observed. Serial pulley sectioning showed two types of bowstringing, both of which affected the relationship of tendon excursion to joint motion. The most constant, resulting in 15% loss of motion for a fixed tendon excursion, occurred over the concave surfaces of the proximal and middle phalanges. Bowstringing at the proximal interphalangeal joint was present only after 30 degrees of flexion had occurred, because of the convexity of the phalangeal condyles.
Hodgson, R J; O'Connor, P J; Grainger, A J
MRI and ultrasound are now widely used for the assessment of tendon and ligament abnormalities. Healthy tendons and ligaments contain high levels of collagen with a structured orientation, which gives rise to their characteristic normal imaging appearances as well as causing particular imaging artefacts. Changes to ligaments and tendons as a result of disease and injury can be demonstrated using both ultrasound and MRI. These have been validated against surgical and histological findings. Novel imaging techniques are being developed that may improve the ability of MRI and ultrasound to assess tendon and ligament disease. PMID:22553301
Rieger, H; Grünert, J; Winckler, S; Brug, E
The closed rupture of the distal digital extensor tendon at its attachment on the terminal phalanx the so-called mallet finger - is seen very often in ball games ("basketball finger", "baseball finger"). Closed rupture with and without a bony fragment can be distinguished. We demonstrate a rational and anatomy related way of treatment.
Reiman, Michael; Burgi, Ciara; Strube, Eileen; Prue, Kevin; Ray, Keaton; Elliott, Amanda; Goode, Adam
Objective: To summarize and evaluate the current diagnostic accuracy of clinical measures used to diagnose Achilles tendon injuries. Data Sources: A literature search of MEDLINE, CINAHL, and EMBASE databases was conducted with key words related to diagnostic accuracy and Achilles tendon injuries. Study Selection: Original research articles investigating Achilles tendon injuries against an acceptable reference standard were included. Data Extraction: Three studies met the inclusion criteria. Quality assessment was conducted using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. DerSimonian-Laird random-effects models were used to pool sensitivity (SN), specificity (SP), and diagnostic odds ratios with their 95% confidence intervals (CIs). Data Synthesis: The SN and negative likelihood ratio (−LR) values for Achilles tendon rupture measures ranged from 0.73 (95% CI = 0.65, 0.81) and 0.30 (95% CI = 0.23, 0.40) to 0.96 (95% CI = 0.93, 0.99) and 0.04 (95% CI = 0.02, 0.10), respectively, whereas SP and positive likelihood ratio (+LR) values ranged from 0.85 (95% CI = 0.72, 0.98) and 6.29 (95% CI = 2.33, 19.96) to 0.93 (95% CI = 0.84, 1.00) and 13.71 (95% CI = 3.54, 51.24), respectively, with the highest SN and SP both reported in the calf-squeeze test. The SN and −LR values for Achilles tendinopathy measures ranged from 0.03 (95% CI = 0.00, 0.08) and 0.97 (95% CI = not reported) to 0.89 (95% CI = 0.75, 0.98) and 0.19 (95% CI = not reported), whereas SP and +LR values ranged from 0.58 (95% CI = 0.38, 0.77) and 2.12 (95% CI = not reported) to 1.00 (95% CI = 1.00, 1.00) and infinity, respectively, with the highest SN and SP reported for morning stiffness and palpation for crepitus. Pooled analyses demonstrated similar diagnostic properties in all 3 clinical measures (arc sign, palpation, and Royal London Hospital test), with SN and −LR ranging from 0.42 (95% CI = 0.23, 0.62) and 0.68 (95% CI = 0.50, 0.93), respectively, for the arc sign, to 0.64 (95% CI
Fuentes, Christina T; Gomi, Hiroaki; Haggard, Patrick
Muscle spindles provide information about the position and movement of our bodies. One method for investigating spindle signals is tendon vibration. Vibration of flexor tendons can produce illusions of extension, and vibration of extensor tendons can produce illusions of flexion. Here we estimate the temporal resolution and persistence of these illusions. In Experiments 1 and 2, sequences of alternating vibration of wrist flexor and extensor tendons produced position illusions that varied with alternation period. When vibrations alternated at 1 Hz or slower, perceived position at the end of the sequence depended on the last vibration. When vibrations alternated every 0.3 s, perceived position was independent of the last vibration. Experiment 2 verified and extended these results using more trials and concurrent electromyographic recording. Although tendon vibrations sometimes induce reflexive muscle activity, we found no evidence that such activity contributed to these effects. Experiment 3 investigated how long position sense is retained when not updated by current information from spindles. Our first experiments suggested that vibrating antagonistic tendons simultaneously could produce conflicting inputs, leaving position sense reliant on memory of position prior to vibration onset. We compared variability in position sense after different durations of such double vibration. After 12 s of double vibration, variability across trials exceeded levels predicted from vibrations of flexor or extensor tendons alone. This suggests that position sense memory had decayed too much to substitute for the current conflicting sensory information. Together, our results provide novel, quantitative insight into the temporal properties of tendon vibration illusions.
... teens, biceps tendonitis is usually an overuse injury. Baseball pitchers, swimmers, tennis players, and people who have ... But if you swim or play tennis or baseball, that might not be an option! If your ...
Cockenpot, Eric; Lefebvre, Guillaume; Demondion, Xavier; Chantelot, Christophe; Cotten, Anne
Hand and wrist injuries are common occurrences in amateur and professional sports and many of them are sport-specific. These can be divided into two categories: traumatic injuries and overuse injuries. The aim of this article is to review the most common hand and wrist sports-related lesions. Acute wrist injuries are predominantly bone fractures, such as those of the scaphoid, hamate hook, and ulnar styloid. Ligament lesions are more challenging for radiologists and may lead to carpal instability if undiagnosed. Overuse wrist injuries are mainly represented by tendinous disorders, with De Quervain syndrome and extensor carpi ulnaris tendon disorders being the most common among them; however, there are other possible disorders such as impaction syndromes, stress fractures, and neurovascular lesions. Finally, finger lesions, including closed-tendon injuries (mallet and boutonniere injuries, jersey finger, and boxer's knuckle), flexor pulley injuries, and skier's thumb, should also be detected. (©) RSNA, 2016 Online supplemental material is available for this article.
Tang, Jin Bo; Chen, Chuan Hao; Zhou, You Lang; McKeever, Clarie; Liu, Paul Y
In this study of a tendon injury model, we investigated how injection of a vector incorporating one growth factor gene changes expression levels of multiple growth factor genes in the healing process. The flexor tendon of chicken toes was completely cut and repaired surgically. The tendons in the experimental arm were injected with an adeno-associated virus-2 vector incorporating basic fibroblast growth-factor gene, whereas the tendons in the control arm were not injected or injected with sham vectors. Using real-time polymerase chain reaction, we found that, within the tendon healing period, a set of growth factor genes-transforming growth factor-β1, vascular endothelial growth factor, and connective tissue growth factor-were significantly up-regulated. Expression of the platelet-derived growth factor-B gene was not changed, and the insulin-like growth factor was down-regulated. A tendon marker gene, scleraxis, was significantly up-regulated in the period. Our study revealed an intriguing finding that introduction of one growth factor gene in the healing tendon modulated expression of multiple growth factor genes. We believe this study may have significant implications in determining the approach of gene therapy, and the findings substantiate that gene therapy using a single growth factor could affect multiple growth factors.
Miao, Xudong; Wu, Yongping; Tao, Huimin; Yang, Disheng; Huang, Lu
Background: Transfer of a flexor hallucis longus (FHL) tendon can not only reconstruct the Achilles tendon but also provide ischemic tendinous tissues with a rich blood supply to enhance wound healing. This retrospective study aims to investigate clinical outcomes in patients who underwent repair of Kuwada grade IV chronic Achilles tendon rupture with long hallucis longus tendons harvested using a minimally invasive technique. Materials and Methods: 35 patients who were treated for Kuwada grade IV Achilles tendon injuries from July 2006 to June 2011 were included in this retrospective study. The age ranged between 23 and 71 years. The duration from primary injury to surgery ranged from 29 days to 34 months (mean value, 137.6 days). All 35 patients had difficulties in lifting their calves. Thirty two were followed up for a mean 32.2 months (range 18–72 months), whereas three were lost to followup. Magnetic resonance imaging (MRI) showed that the tendon rupture gap ranged from 6.0 to 9.2 cm. During surgery, a 2.0 cm minor incision was made vertically in the medial plantar side of the midfoot, and a 1.5 cm minor transverse incision was made in the plantar side of the interphalangeal articulation of the great toe to harvest the FHL tendon, and the tendon was fixed to the calcaneus with suture anchors. Postoperative appearance and function were evaluated by physiotherapists based American Orthopedic Foot and Ankle Society-ankle and hindfoot score (AOFAS-AH), and Leppilahti Achilles tendon ratings. Results: Results were assessed in 32 patients. Except for one patient who suffered complications because of wound disruption 10 days after the operation, all other patients had primary wound healing, with 28 of 32 able to go up on their toes at last followup. The AOFAS-AH score was increased from preoperative (51.92 ± 7.08) points to (92.56 ± 6.71) points; Leppilahti Achilles tendon score was increased from preoperative (72.56 ± 7.43) to (92.58 ± 5.1). There were
Bianchi, S.; Martinoli, C.; de Gautard, R.; Gaignot, C.
Recent improvements in ultrasound (US) software and hardware have markedly increased the role of this imaging modality in the evaluation of the musculoskeletal system. US is currently one of the main imaging tools used to diagnose and assess most tendon, muscle, and ligament disorders. Compared with magnetic resonance imaging, US is much less expensive; it has no contraindications and is also widely available. Diseases affecting the digital flexor system (DFS) require early diagnosis if treatment is expected to limit functional impairment of the hand. US scans performed with high-resolution, broad-band transducers allows superb visualization of the flexor tendons of the hand and the annular digital pulleys. In addition, dynamic US can be used to assess movement of the tendon within the pulleys during passive or active joint movements. This article examines the anatomy and US appearance of the normal DFS and reviews the US findings associated with the most common disorders affecting it. PMID:23396583
Screen, H R C; Toorani, S; Shelton, J C
Tendons experience widely varying loading conditions in vivo. They may be categorised by their function as either positional tendons, which are used for intricate movements and experience lower stress, or as energy storage tendons which act as highly stressed springs during locomotion. Structural and compositional differences between tendons are thought to enable an optimisation of their properties to suit their functional environment. However, little is known about structure-function relationships in tendon. This study adopts porcine flexor and extensor tendon fascicles as examples of high stress and low stress tendons, comparing their mechanical behaviour at the micro-level in order to understand their stress relaxation response. Stress-relaxation was shown to occur predominantly through sliding between collagen fibres. However, in the more highly stressed flexor tendon fascicles, more fibre reorganisation was evident when the tissue was exposed to low strains. By contrast, the low load extensor tendon fascicles appears to have less capacity for fibre reorganisation or shearing than the energy storage tendon, relying more heavily on fibril level relaxation. The extensor fascicles were also unable to sustain loads without rapid and complete stress relaxation. These findings highlight the need to optimise tendon repair solutions for specific tendons, and match tendon properties when using grafts in tendon repairs.
Dakin, Stephanie Georgina; Werling, Dirk; Hibbert, Andrew; Abayasekara, Dilkush Robert Ephrem; Young, Natalie Jayne; Smith, Roger Kenneth Whealands; Dudhia, Jayesh
Macrophages (Mφ) orchestrate inflammatory and reparatory processes in injured connective tissues but their role during different phases of tendon healing is not known. We investigated the contribution of different Mφ subsets in an equine model of naturally occurring tendon injury. Post mortem tissues were harvested from normal (uninjured), sub-acute (3-6 weeks post injury) and chronically injured (>3 months post injury) superficial digital flexor tendons. To determine if inflammation was present in injured tendons, Mφ sub-populations were quantified based on surface antigen expression of CD172a (pan Mφ), CD14(high)CD206(low) (pro-inflammatory M1Mφ), and CD206(high) (anti-inflammatory M2Mφ) to assess potential polarised phenotypes. In addition, the Lipoxin A(4) receptor (FPR2/ALX) was used as marker for resolving inflammation. Normal tendons were negative for both Mφ and FPR2/ALX. In contrast, M1Mφ predominated in sub-acute injury, whereas a potential phenotype-switch to M2Mφ polarity was seen in chronic injury. Furthermore, FPR2/ALX expression by tenocytes was significantly upregulated in sub-acute but not chronic injury. Expression of the FPR2/ALX ligand Annexin A1 was also significantly increased in sub-acute and chronic injuries in contrast to low level expression in normal tendons. The combination of reduced FPR2/ALX expression and persistence of the M2Mφ phenotype in chronic injury suggests a potential mechanism for incomplete resolution of inflammation after tendon injury. To investigate the effect of pro-inflammatory mediators on lipoxin A(4) (LXA(4)) production and FPR2/ALX expression in vitro, normal tendon explants were stimulated with interleukin-1 beta and prostaglandin E(2). Stimulation with either mediator induced LXA(4) release and maximal upregulation of FPR2/ALX expression after 72 hours. Taken together, our data suggests that although tenocytes are capable of mounting a protective mechanism to counteract inflammatory stimuli, this
Ultrasound (US) plays an essential role in the follow-up of operated tendons. The US operator must keep in mind three main elements: healing of traumatic injuries of the tendons seems to follow the biological model of histologic healing, surgical repair of a tendon rupture improves the structural parameters of the operated tendon, but it does not grant restitutio ad integrum, and US findings therefore seem poorly correlated with the functional evolution.Before examination, the US operator should be familiar with the nature of the tendon injury that has led to surgery including location, severity, time elapsed between tendon injury and surgical repair, surgical technique, postoperative course and possible complications. US findings in operated as well as non-operated tendons depend on several factors: morphology, structure, vascularization of the tendon, mobility of the tendon and mobility of the peritendinous tissues. Particular features are therefore considered according to the location: shoulder, elbow, wrist, hand, knee, ankle and foot. Interpretation of the US image requires knowledge of the surgical technique and "normal" postoperative appearance of the operated tendon in order to detect pathological findings such as thinning, persistent fluid collections within or around the tendon, persistent hypervascularization, intratendinous calcifications and adhesions.
Johansson, Kristian; Lempainen, Lasse; Sarimo, Janne; Laitala-Leinonen, Tiina; Orava, Sakari
Summary Background the origin of chronic Achilles tendinopathy (AT) is currently unclear and epidemiological factors, such as ethnicity, may be associated. Methods intraoperative findings from the treatment of 865 Finnish and 156 Italian athletic patients with chronic Achilles tendon related pain were evaluated, retrospectively. The mean age was 34 years (range, 18 to 65 years) in the Finnish and 29 years (range, 17–63 years) in the Italian patients. In total, 786 patients were males and 226 females of which 84 and 87% Finnish, respectively. Data were collected, retrospectively from patient records. The differences in the frequencies of operative findings were assessed for statistical significance. Results retrocalcaneal bursitis, partial tear and chronic paratenonitis were the most prevalent findings in patients with chronic AT undergoing surgery. Tendinosis and chronic paratenonitis were significantly (p=0.011) more common in Finnish athletes. Italian patients exhibited significantly (p<0.001) more insertional calcific tendinopathy (heel spurs) and prominent posterosuperior calcaneal corners (Haglund’s heel). Conclusion ethnicity appears to be associated with specific characteristics of overuse-related Achilles tendon pathology. This is an issue that should be considered in the planning of genetic research on AT. PMID:27331038
Lalley, Andrea L.; Dyment, Nathaniel A.; Kazemi, Namdar; Kenter, Keith; Gooch, Cynthia; Rowe, David W.; Butler, David L.; Shearn, Jason T.
Musculoskeletal injuries greatly affect the U.S. population and current clinical approaches fail to restore long-term native tissue structure and function. Tissue engineering is a strategy advocated to improve tendon healing; however, the field still needs to establish biological benchmarks for assessing the effectiveness of tissue-engineered structures. Investigating superior healing models, such as the MRL/MpJ, offers the opportunity to first characterize successful healing and then apply experimental findings to tissue-engineered therapies. This study seeks to evaluate the MRL/MpJ’s healing response following a central patellar tendon injury compared to wildtype. Gene expression and histology were assessed at 3, 7, and 14 days following injury and mechanical properties were measured at 2, 5, and 8 weeks. Native patellar tendon biological and mechanical properties were not different between strains. Following injury, the MRL/MpJ displayed increased mechanical properties between 5 and 8 weeks; however, early tenogenic expression patterns were not different between the strains. Furthermore, expression of the cyclin-dependent kinase inhibitor, p21, was not different between strains, suggesting an alternative mechanism may be driving the healing response. Future studies will investigate collagen structure and alignment of the repair tissue and characterize the complete healing transcriptome to identify mechanisms driving the MRL/MpJ response. PMID:25982892
... 21 Food and Drugs 8 2011-04-01 2011-04-01 false Passive tendon prosthesis. 888.3025 Section 888.3025 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED... flexor tendon of the hand. The device is implanted for a period of 2 to 6 months to aid growth of a...
... 21 Food and Drugs 8 2014-04-01 2014-04-01 false Passive tendon prosthesis. 888.3025 Section 888.3025 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED... flexor tendon of the hand. The device is implanted for a period of 2 to 6 months to aid growth of a...
Sollender, J L; Rayan, G M; Barden, G A
Triceps tendon avulsion injuries are rare. We report four weight lifters with triceps tendon raptures, two of whom had received local steroid injections for pain in the triceps. All four patients had taken oral anabolic steroids before injury. All patients had closed avulsion of the triceps tendon from its insertion into the olecranon. Three patients were injured while bench pressing heavy weights, and one patient was injured while swinging a baseball bat. Satisfactory results were achieved after surgical reinsertion of the tendon.
Thorpe, C T; Chaudhry, S; Lei, I I; Varone, A; Riley, G P; Birch, H L; Clegg, P D; Screen, H R C
Tendon injury is thought to involve both damage accumulation within the matrix and an accompanying cell response. While several studies have characterized cell and matrix response in chronically injured tendons, few have assessed the initial response of tendon to overload-induced damage. In this study, we assessed cell response to cyclic loading. Fascicle bundles from the equine superficial digital flexor tendon were exposed to cyclic loading in vitro, designed to mimic a bout of high-intensity exercise. Changes in cell morphology and protein-level alterations in markers of matrix inflammation and degradation were investigated. Loading resulted in matrix damage, which was accompanied by cells becoming rounder. The inflammatory markers cyclooxygenase-2 and interleukin-6 were increased in loaded samples, as were matrix metalloproteinase-13 and the collagen degradation marker C1,2C. These results indicate upregulation of inflammatory and degradative pathways in response to overload-induced in vitro, which may be initiated by alterations in cell strain environment because of localized matrix damage. This provides important information regarding the initiation of tendinopathy, suggesting that inflammation may play an important role in the initial cell response to tendon damage. Full understanding of the early tenocyte response to matrix damage is critical in order to develop effective treatments for tendinopathy.
Kaji, Yoshio; Nakamura, Osamu; Yamaguchi, Konosuke; Tobiume, Sachiko; Yamamoto, Tetsuji
Abstract Rationale: For localized type Volkmann's contracture, in which degeneration of the flexor digitorum profundus (FDP) muscle to one or two fingers and restriction of finger extension occur, dissection or excision of the affected muscle is usually recommended. However, these surgical procedures need relatively wide exposure of the muscle, because the FDP muscle is in the deep portion of the forearm. Patient concerns: In this report, the case of a 35-year-old woman with localized type Volkmann's contracture is presented. Her left forearm had been compressed with an industrial roller 4 months earlier, and severe flexion contracture of the long finger and mild flexion contracture of the ring finger developed gradually. Diagnoses: localized type Volkmann's contracture. Intervention: Five months after the injury, transection of the FDP tendon to the long finger and transfer of the transected tendon to the FDP tendon to the index finger was performed after adjusting the tonus of these two tendons using a small skin incision. This procedure was followed by a tension-reduced early mobilization technique in which a tension-reduced position of the tendon suture site was maintained by taping the long finger to the volar side of the index finger, and then immediate active range of motion (ROM) exercise was started. Outcomes: Within 9 weeks after surgery, full ROM had been regained. Lessons: Using the treatment procedure presented in this case report, a good clinical result was obtained in a minimally invasive manner. PMID:28072735
Ackermann, Paul W
The regulation of tendon homoeostasis, including adaptation to loading, is still not fully understood. Accumulating data, however, demonstrates that in addition to afferent (sensory) functions, the nervous system, via efferent pathways which are associated with through specific neuronal mediators plays an active role in regulating pain, inflammation and tendon homeostasis. This neuronal regulation of intact-, healing- and tendinopathic tendons has been shown to be mediated by three major groups of molecules including opioid, autonomic and excitatory glutamatergic neuroregulators. In intact healthy tendons the neuromediators are found in the surrounding structures: paratenon, endotenon and epitenon, whereas the proper tendon itself is practically devoid of neurovascular supply. This neuroanatomy reflects that normal tendon homoeostasis is regulated from the tendon surroundings. After injury and during tendon repair, however, there is extensive nerve ingrowth into the tendon proper, followed by a time-dependent emergence of sensory, autonomic and glutamatergic mediators, which amplify and fine-tune inflammation and regulate tendon regeneration. In tendinopathic condition, excessive and protracted presence of sensory and glutamatergic neuromediators has been identified, suggesting involvement in inflammatory, nociceptive and hypertrophic (degenerative) tissue responses. Under experimental and clinical conditions of impaired (e.g. diabetes) as well as excessive (e.g. tendinopathy) neuromediator release, dysfunctional tendon homoeostasis develops resulting in chronic pain and gradual degeneration. Thus there is a prospect that in the future pharmacotherapy and tissue engineering approaches targeting neuronal mediators and their receptors may prove to be effective therapies for painful, degenerative and traumatic tendon disorders.
Ackermann, Paul W
The regulation of tendon homoeostasis, including adaptation to loading, is still not fully understood. Accumulating data, however, demonstrates that in addition to afferent (sensory) functions, the nervous system, via efferent pathways which are associated with through specific neuronal mediators plays an active role in regulating pain, inflammation and tendon homeostasis. This neuronal regulation of intact-, healing- and tendinopathic tendons has been shown to be mediated by three major groups of molecules including opioid, autonomic and excitatory glutamatergic neuroregulators. In intact healthy tendons the neuromediators are found in the surrounding structures: paratenon, endotenon and epitenon, whereas the proper tendon itself is practically devoid of neurovascular supply. This neuroanatomy reflects that normal tendon homoeostasis is regulated from the tendon surroundings. After injury and during tendon repair, however, there is extensive nerve ingrowth into the tendon proper, followed by a time-dependent emergence of sensory, autonomic and glutamatergic mediators, which amplify and fine-tune inflammation and regulate tendon regeneration. In tendinopathic condition, excessive and protracted presence of sensory and glutamatergic neuromediators has been identified, suggesting involvement in inflammatory, nociceptive and hypertrophic (degenerative) tissue responses. Under experimental and clinical conditions of impaired (e.g. diabetes) as well as excessive (e.g. tendinopathy) neuromediator release, dysfunctional tendon homoeostasis develops resulting in chronic pain and gradual degeneration. Thus there is a prospect that in the future pharmacotherapy and tissue engineering approaches targeting neuronal mediators and their receptors may prove to be effective therapies for painful, degenerative and traumatic tendon disorders. PMID:23718724
Chin, Brian; Cheung, Kevin; Farhangkhoee, Hana; Thoma, Achilleas
Proliferative flexor tenosynovitis of the hand is an inflammatory process involving the synovial sheaths surrounding the tendons. It is most commonly caused by infection, but may also be caused by overuse, diabetes and rheumatic conditions such as rheumatoid arthritis and crystal arthropathies. The present report describes two patients with severe proliferative tenosynovitis, who developed a fistula between the tendon sheath and skin after instrumentation, resulting in persistent synovial drainage. After failing conservative management, both patients were managed with extensive flexor tenosynovectomy to prevent inoculation of bacteria into the flexor sheath. The presentation, management and outcome of each case is described in addition to a discussion of the literature on tenosynovial fistulas.
Kaufmann, Robert A; Kozin, Scott H; Mirarchi, Adam; Holland, Burt; Porter, Scott
Grip strength is generated through extrinsic flexor tendon and intrinsic muscle actuation. In the study reported here, we analyzed the grip-generating properties of the flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) tendons during grip-strength generation. In vivo gripping was reproduced in 11 cadaveric forearms through pneumatic tensioning of flexor tendons. A Jamar dynamometer (TEC, Clifton, NJ) was positioned in the hand at varying degrees of angulation measured between the Jamar compression axis and the second metacarpal. Maximum gripping strength during isolated FDP and FDS tensioning generated maximum compressive forces at different angles (P < .0001). The isolated FDP showed continued increased grip strength with larger angles and was most effective when the dynamometer handle was in contact with the distal phalanx. The isolated FDS was most effective at smaller angles when the handle made contact with the middle phalanx. The isolated FDS shows an initial increase in grip strength as the contact point moves toward the middle phalanx (P < .01) and then a tendency for grip strength to decline as the contact point moves over the distal phalanx (P < .01). The FDP and FDS tendons demonstrate unique abilities to generate compression on a dynamometer. This knowledge is important to consider when evaluating grip strength in patients who have injured the extrinsic finger flexors.
Perry, Stephanie M; Getz, Charles L; Soslowsky, Louis J
Although presumed, damage in the remaining (intact) rotator cuff tendons in the presence of an isolated supraspinatus tendon tear or multiple tendon tear has not been well studied. This study used an animal model of multiple rotator cuff tendon tears to investigate alterations in the remaining (intact) tendon mechanical properties at 4 and 8 weeks after injury. Twenty-four rats served as uninjured controls, whereas 72 were divided among 3 tendon detachment groups: supraspinatus tendon detachment, supraspinatus + infraspinatus tendon detachment, and supraspinatus + subscapularis tendon detachment. The remaining (intact) rotator cuff tendons had decreased mechanical properties in the presence of rotator cuff tears. The remaining (intact) subscapularis and infraspinatus tendon cross-sectional areas increased, whereas tendon modulus decreased after tears of both 1 and 2 tendons. The remaining (intact) tendon cross-sectional areas continued to increase with time after injury. These alterations could potentially lead to further tendon damage and tear progression.
Tuan, Rocky S.
Tendon and ligament (T/L) are dense connective tissues connecting bone to muscle and bone to bone, respectively. Similar to other musculoskeletal tissues, T/L arise from the somitic mesoderm, but they are derived from a recently discovered somitic compartment, the syndetome. The adjacent sclerotome and myotome provide inductive signals to the interposing syndetome, thereby upregulating the expression of the transcription factor Scleraxis, which in turn leads to further tenogenic and ligamentogenic differentiation. These advances in the understanding of T/L development have been sought to provide a knowledge base for improving the healing of T/L injuries, a common clinical challenge due to the intrinsically poor natural healing response. Specifically, the three most common tendon injuries involve tearing of the rotator cuff of the shoulder, the flexor tendon of the hand, and the Achilles tendon. At present, injuries to these tissues are treated by surgical repair and/or conservative approaches, including biophysical modalities such as physical rehabilitation and cryotherapy. Unfortunately, the healing tissue forms fibrovascular scar and possesses inferior mechanical and biochemical properties as compared to native T/L. Therefore, tissue engineers have sought to improve upon the natural healing response by augmenting the injured tissue with cells, scaffolds, bioactive agents, and mechanical stimulation. These strategies show promise, both in vitro and in vivo, for improving T/L healing. However, several challenges remain in restoring full T/L function following injury, including uncertainties over the optimal combination of these biological agents as well how to best deliver tissue engineered elements to the injury site. A greater understanding of the molecular mechanisms involved in T/L development and natural healing, coupled with the capability of producing complex biomaterials to deliver multiple growth factors with high spatiotemporal resolution and specificity
Woo, Sang-Hyun; Lee, Young-Keun; Kim, Jong-Min; Cheon, Ho-Jun; Chung, William H J
A thorough understanding of the swing phases and mechanisms of injury in golf allows accurate diagnosis, treatment, and future prevention of injuries. Recommended initial treatment starts with cessation of practice to rest the wrist, a splint or orthotic brace, and nonsteroidal antiinflammatory drug medication with corticosteroid injection and swing modification. Pisiform excision is the best treatment of the most severe chronic cases of pisiform ligament complex syndrome. Delayed diagnosis of hook of hamate fracture may lead to complications, including flexor tendon rupture. Prompt surgical resection is recommended to hasten return to sport and to prevent further complications.
... You Prevent Achilles Tendonitis? Take these steps to reduce your risk of Achilles tendonitis: Stay in good shape year-round and try to keep your muscles as strong as they can be. Strong, flexible muscles work more efficiently and put less stress on your tendon. Increase the intensity and length ...
Elhassan, Bassem; Bishop, Alan; Shin, Alexander; Spinner, Robert
Enhancement of upper-extremity function, specifically shoulder function, after brachial plexus injury requires a good understanding of nerve repair and transfer, with their expected outcome, as well as shoulder anatomy and biomechanics enabling the treating surgeon to use available functioning muscles around the shoulder for transfer, to improve shoulder function. Surgical treatment should address painful shoulder subluxation in addition to improvement of function. The literature focuses on improving shoulder abduction, but improving shoulder external rotation should take priority because this function, even if isolated, will allow patients to position their hand in front of their body. With a functional elbow and hand, patients will be able to do most activities of daily living. The lower trapezius has been shown to be a good transfer to restore external rotation of the shoulder. Other parts of the trapezius, levator scapulae, rhomboids, and, when available, the latissimus dorsi, pectoralis major, teres major, biceps, triceps, and serratus anterior muscles can all be used to replace the rotator cuff and deltoid muscle function. To optimize the results, a close working relationship is required between surgeons reconstructing brachial plexus injury and shoulder specialists.
Spiesz, Ewa M; Thorpe, Chavaunne T; Chaudhry, Saira; Riley, Graham P; Birch, Helen L; Clegg, Peter D; Screen, Hazel R C
The role of inflammation in tendon injury is uncertain and a topic of current interest. In vitro studies of tendon accelerated overload damage can serve as a valuable source of information on the early stages of tendinopathy. Viable fascicle bundles from bovine flexor tendons were subjected to cyclic uniaxial loading from 1-10% strain. Immuno-staining for inflammatory markers and matrix degradation markers was performed on the samples after mechanical testing. Loaded samples exhibited visible extracellular matrix damage, with disrupted collagen fibers and fiber kinks, and notable damage to the interfascicular matrix. Inflammatory markers COX-2 and IL-6 were only expressed in the cyclically loaded samples. Collagen degradation markers MMP-1 and C1,2C were colocalized in many areas, with staining occurring in the interfascicular matrix or the fascicular tenocytes. These markers were present in control samples, but staining became increasingly intense with loading. Little MMP-3 or MMP-13 was evident in control sections. In loaded samples, some sections showed intense staining of these markers, again localized to interfascicular regions. This study suggests that inflammatory markers may be expressed rapidly after tendon overload exercise. Interestingly, both inflammation and damage-induced matrix remodeling seem to be concentrated in, or in the vicinity of, the highly cellular interfascicular matrix.
Britti, Domenico; Loprete, Giovanni; Musella, Vincenzo; Romagnoli, Noemi; Vilar, Jose M.; Valentini, Simona
The objective of this study was to evaluate relative echogenicity of superficial and deep digital flexor tendons, the accessory ligament of the deep digital flexor tendon and interosseous muscle of the metacarpal region in foals ages 1 week to 4 months; and assess the association between echogenicity and sex or side/laterality. Seven Standardbred trotter foals were examined. Right and left metacarpal regions (palmar surface) were ultrasonographically investigated, and four regions of interest were assessed. A significant increase in echogenicity was seen in superficial and deep digital flexor tendons, accessory ligament of deep digital flexor tendon, and interosseous muscle during growth from 1 week to 4 months of age. Echogenicity of examined tendons and ligaments was not influenced by gender nor laterality. Reference values for tendon and ligament echogenicity could function as a tool to discriminate between physiological and abnormal conditions such as congenital contractural conditions. PMID:27441630
Hyrkas, Jukka; Antti-Poika, Ilkka; Virkki, Liisa M; Ogino, Daisuke; Konttinen, Yrjo T
We report how scapholunate (SL) lesions found during arthroscopy were treated using a new palmar operation based on the use of a tendon loop formed using the palmaris longus tendon, with promising preliminary results. Scapholunate instability induced by hyperextension injury was diagnosed and graded arthroscopically. Volar capsuloplasty was then done by free tendon graft in the same session in 31 patients with grades II-IV scapholunate instability. Half of the patients operated on had a normal range of movement, and all except one had flexion-extension of at least 75% of the normal. Half of the patients had no pain or limitations of the use of the wrist, and although half the patients had some pain on exertion, not one had severe pain. These results are comparable to, or even better than, those reported using other methods of repair. The combined procedure saves money, diminishes the total recuperation time and, as autologous tissues are used for the repair, secondary operations for removal of the implant are unnecessary. This method seems to be a useful adjunct to the types of operative treatment available, although it is apparently not suitable in static grade IV SL instability.
Thorpe, Chavaunne T.; Udeze, Chineye P.; Birch, Helen L.; Clegg, Peter D.; Screen, Hazel R. C.
Tendons transfer force from muscle to bone. Specific tendons, including the equine superficial digital flexor tendon (SDFT), also store and return energy. For efficient function, energy-storing tendons need to be more extensible than positional tendons such as the common digital extensor tendon (CDET), and when tested in vitro have a lower modulus and failure stress, but a higher failure strain. It is not known how differences in matrix organization contribute to distinct mechanical properties in functionally different tendons. We investigated the properties of whole tendons, tendon fascicles and the fascicular interface in the high-strain energy-storing SDFT and low-strain positional CDET. Fascicles failed at lower stresses and strains than tendons. The SDFT was more extensible than the CDET, but SDFT fascicles failed at lower strains than CDET fascicles, resulting in large differences between tendon and fascicle failure strain in the SDFT. At physiological loads, the stiffness at the fascicular interface was lower in the SDFT samples, enabling a greater fascicle sliding that could account for differences in tendon and fascicle failure strain. Sliding between fascicles prior to fascicle extension in the SDFT may allow the large extensions required in energy-storing tendons while protecting fascicles from damage. PMID:22764132
Tresoldi, Ilaria; Oliva, Francesco; Benvenuto, Monica; Fantini, Massimo; Masuelli, Laura; Bei, Roberto; Modesti, Andrea
The structure of a tendon is an important example of complexity of ECM three-dimensional organization. The extracellular matrix (ECM) is a macromolecular network with both structural and regulatory functions. ECM components belong to four major types of macromolecules: the collagens, elastin, proteoglycans, and noncollagenous glycoproteins. Tendons are made by a fibrous, compact connective tissue that connect muscle to bone designed to transmit forces and withstand tension during muscle contraction. Here we show the ultrastructural features of tendon's components.
Lu, Hui; Yang, Hu; Shen, Hui; Ye, Ganmin; Lin, Xiang-Jin
Abstract Corticosteroid injections for hand tendinitis can lead to a rare significant complication of tendon spontaneous rupture. However, only sporadic cases were reported in the literature before. This study was designed to gauge the clinical effect of tendon repair in patients of tendon spontaneous rupture after corticosteroid injection and analyze our experience. This was a retrospective observational study of 13 patients (8 women and 5 men) operated between July 2011 and December 2015 for tendon spontaneous rupture after corticosteroid injection. Demographic data, clinical features, imaging data, and surgical treatments were carefully reviewed. The average age was 52.308 ± 15.381 years (range 29–71). The average injection times were 2.538 ± 1.664 times (range 1–6). The average rupture time (after last injection) was 10.923 ± 9.500 weeks (range 3–32). Nine patients were treated by tendon suture (69% of cases), and 4 patients were treated by tendon grafting (31% of cases). All patients received follow-up in our outpatient clinic. The sites of the tendon rupture (15 tendons of 13 patients had involved) include extensor pollicis longus (6 tendons, 40% of cases), extensor digiti quinti and extensor digiti minimi (4 tendons, 27% of cases), ring finger of extensor digitorum communis (3 tendons, 20% of cases), and middle finger of extensor digitorum communis (2 tendons, 13% of cases). Two patients who had tendon adhesion (15% of cases) were treated by tendon release. One patient who had tendon rerupture (8% of cases) was treated by tendon grafting. No patient had complications of infections, vascular, or nerve injury. Tendon spontaneous rupture is a serious complication after corticosteroid injection for tendinitis. Rigid standard of corticosteroid injection is very important. Magnetic resonance imaging was contributory to preoperative assess tendon defect and can be used to monitor healing quality of tendons during the follow-up. PMID:27741145
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Loren, G J; Lieber, R L
Biomechanical properties of human wrist tendons were measured under loads predicted to be experienced by those tendons under physiological conditions. This was accomplished by measuring the architectural properties of the five prime wrist movers--extensors carpi radialis brevis (ECRB), extensor carpi radialis longus (ECRL), extensor carpi ulnaris (ECU), flexor carpi radials (FCR), flexor carpi ulnaris (FCU)--and predicting their maximum tension (P0) using a specific tension value (22.5 N cm-2. Loading the corresponding tendons to P0 resulted in significantly different strain among tendons (p < 0.01) with the largest strain observed in the FCU (3.68 +/- 0.31%) and the smallest strain observed in the ECRL (1.78 +/- 0.14%). Further, strain magnitude was significantly positively correlated with the tendon length-to-fiber length ratio of the muscle-tendon unit, a measure of the intrinsic compliance of the muscle-tendon unit. Theoretical modeling of the magnitude of muscle sarcomere shortening expected based on the measured biomechanical properties revealed a maximum sarcomere length decrease of about 0.6 micron for the FCU to a minimum of about 0.2 micron for the ECRB at P0. Thus, tendon compliance may, but does not necessarily, result in significant modification of muscle force generation. The significant variation in tendon biomechanical properties was not observed using traditional elongation-to-failure methods on the same specimens. Thus, the use of elongation-to-failure experiments for determination of tendon properties may not be reasonable when the purpose of such studies is to infer physiological function. These data indicate that muscle-tendon units show remarkable specialization and that tendon intrinsic properties accentuate the muscle architectural specialization already present.
Paredes, J J; Andarawis-Puri, Nelly
Tendon injuries, known as tendinopathies, are common musculoskeletal injuries that affect a wide range of the population. Canonical tendon healing is characterized by fibrosis, scar formation, and the loss of tissue mechanical and structural properties. Understanding the regenerative tendon environment is an area of increasing interest in the field of musculoskeletal research. Previous studies have focused on utilizing individual elements from the fields of biomechanics, developmental biology, cell and growth factor therapy, and tissue engineering in an attempt to develop regenerative tendon therapeutics. Still, the specific mechanism for regenerative healing remains unknown. In this review, we highlight some of the current approaches of tendon therapeutics and elucidate the differences along the tendon midsubstance and enthesis, exhibiting the necessity of location-specific tendon therapeutics. Furthermore, we emphasize the necessity of further interdisciplinary research in order to reach the desired goal of fully understanding the mechanisms underlying regenerative healing.
Wang, Tao; Gardiner, Bruce S.; Lin, Zhen; Rubenson, Jonas; Kirk, Thomas B.; Wang, Allan; Xu, Jiake
Tendon and ligament injury is a worldwide health problem, but the treatment options remain limited. Tendon and ligament engineering might provide an alternative tissue source for the surgical replacement of injured tendon. A bioreactor provides a controllable environment enabling the systematic study of specific biological, biochemical, and biomechanical requirements to design and manufacture engineered tendon/ligament tissue. Furthermore, the tendon/ligament bioreactor system can provide a suitable culture environment, which mimics the dynamics of the in vivo environment for tendon/ligament maturation. For clinical settings, bioreactors also have the advantages of less-contamination risk, high reproducibility of cell propagation by minimizing manual operation, and a consistent end product. In this review, we identify the key components, design preferences, and criteria that are required for the development of an ideal bioreactor for engineering tendons and ligaments. PMID:23072472
Rodriguez, Mary; Patnaik, Soumya; Wang, Peter
Hip pain is one of the most common reasons for the elderly to present to the emergency department, and the differential diagnosis spectrum is vast. Iliopsoas injury is a relatively uncommon condition that may present with hip or groin pain. It is usually seen in athletes due to trauma, particularly flexion injuries. However, spontaneous iliopsoas tendon tear is extremely rare, and only a small number of cases have been reported; it has an estimated prevalence of 0.66% in individuals from 7 to 95 years. Risk factors include aging, use of steroids, and chronic diseases. Magnetic resonance imaging (MRI) using its high soft-tissue contrast resolution remains the most valuable imaging modality. A prompt diagnosis and treatment, which is usually conservative, is important to improve the quality of life in this group of patients. We describe a case of spontaneous iliopsoas tendon tear in an elderly woman. PMID:26929854
... is pain-free) Regional anesthesia (the local and surrounding areas are pain-free) General anesthesia (the patient ... used. If needed, tendons are reattached to the surrounding tissue. The surgeon examines the area to see ...
Baker, J. T.; Nicogossian, A. E.; Hoffler, G. W.; Johnson, R. L.; Hordinsky, J. R.
Postflight measurements of Achilles tendon reflex duration on Skylab crewmen indicate a state of disequilibrium between the flexor and extensor muscle groups with an initial decrease in reflex duration. As the muscles regain strength and mass there occurs an overcompensation reflected by increased reflex duration. Finally, when a normal neuromuscular state is reached the reflex duration returns to baseline value.
Kubiak, Erik N; Klugman, Jeffrey A; Bosco, Joseph A
Rock climbing, whether practiced in nature on cliffs and boulders or indoors on walls made of resin and wood, has grown in popularity in recent years. An estimated five million people participate in "rocking" at least three times a year. Climbing places unique demands on the upper extremity, especially the hands. The flexor tendons and flexor pulleys are prone to sprains and ruptures. Pulley injuries occur in up to 20% of climbers. The A2 pulley of the ring finger is the most frequently injured. Most pulley injuries can be successfully treated with a week of immobilization, followed by a range of motion (ROM) exercises for one week. Isometric training on a finger board can be started once ROM exercises are painless. A return to climbing can be initiated when the climber is able to avoid grip positions that produce pain; however, the closed crimp grip should be avoided at this time. Surgical reconstruction using the technique described by Widstrom is recommended for acute injuries with clinical evidence of bowstringing. Ultrasound and MRI are the current modalities best suited for confirming clinical findings.
Malvankar, S; Khan, W S
The Achilles tendon is believed to have first developed two million years ago enabling humans to run twice as fast. However if the Achilles tendon is so important in terms of evolution, then why is this tendon so prone to injury - especially for those more active like athletes. The Achilles tendon had an integral role in evolving apes from a herbivorous diet to early humans who started hunting for food over longer distances, resulting in bipedal locomotion. Evolutionary advantages of the Achilles tendon includes it being the strongest tendon in the body, having an energy-saving mechanism for fast locomotion, allows humans to jump and run, and additionally is a spring and shock absorber during gait. Considering these benefits it is therefore not surprising that studies have shown athletes have thicker Achilles tendons than subjects who are less active. However, contradictory to these findings that show the importance of the Achilles tendon for athletes, it is well known that obtaining an Achilles tendon injury for an athlete can be career-altering. A disadvantage of the Achilles tendon is that the aetiology of its pathology is complicated. Achilles tendon ruptures are believed to be caused by overloading the tensed tendon, like during sports. However studies have also shown athlete Achilles tendon ruptures to have degenerative changes in the tendon. Other flaws of the Achilles tendon are its non-uniform vascularity and incomplete repair system which may suggest the Achilles tendon is on the edge of evolution. Research has shown that there is a genetic influence on the predisposition a person has towards Achilles tendon injuries. So if this tendon is here to stay in our anatomy, and it probably is due to the slow rate of evolution in humans, research in genetic modification could be used to decrease athletes' predisposition to Achilles tendinopathy.
Howell, Michael A; Catanzariti, Alan R
Calcific insertional Achilles tendinopathy can result in significant pain and disability. Although some patients respond to nonoperative therapy, many patients are at risk for long-term morbidity and unpredictable clinical outcomes. There is no evidence-based data to support the timing of operative invention, choice of procedures, or whether equinus requires treatment. This article suggests the need for a classification system based on physical examination and imaging to help guide treatment. There is an obvious need for evidence-based studies evaluating outcomes and for properly conducted scientific research to establish appropriate treatment protocols.
Wertz, Jess; Galli, Melissa; Borchers, James R.
Context: Achilles tendon (AT) rupture in athletes is increasing in incidence and accounts for one of the most devastating sports injuries because of the threat to alter or end a career. Despite the magnitude of this injury, reliable risk assessment has not been clearly defined, and prevention strategies have been limited. The purpose of this review is to identify potential intrinsic and extrinsic risk factors for AT rupture in aerial and ground athletes stated in the current literature. Evidence Acquisition: A MEDLINE search was conducted on AT rupture, or “injury” and “risk factors” and “athletes” from 1980 to 2011. Emphasis was placed on epidemiology, etiology, and review articles focusing on the risk for lower extremity injury in runners and gymnasts. Thirty articles were reviewed, and 22 were included in this assessment. Results: Aerial and ground athletes share many intrinsic risk factors for AT rupture, including overuse and degeneration of the tendon as well as anatomical variations that mechanically put an athlete at risk. Older athletes, athletes atypical in size for their sport, high tensile loads, leg dominance, and fatigue also may increase risk. Aerial athletes tend to have more extrinsic factors that play a role in this injury due to the varying landing surfaces from heights and technical maneuvers performed at various skill levels. Conclusion: Risk assessment for AT rupture in aerial and ground athletes is multivariable and difficult in terms of developing prevention strategies. Quantitative measures of individual risk factors may help identify major contributors to injury. PMID:24427410
Chaudhry, Sonia; Gould, Stephen; Gupta, Salil
High-pressure injection injuries often have a misleadingly benign presentation. However, it is important to recognize the potential surgical urgency and long-term sequelae associated with these injuries. We present a case of paint gun injection to the palm and review the literature on high-pressure paint injection injuries. The 3 factors most important for the fate of the limb are material type, injection pressure, and injury site. The immediate use of antibiotics and tetanus prophylaxis, with or without steroids, is indicated. Urgent debridement in the operating room is imperative and can decompress the neurovascular structures and flexor tendon sheath by removing the irritating agents. Reported overall amputation rates have been as high as 30%.
Sobel, Dafna; Constantin, Naama; Or, Omer
Rock climbing is becoming an increasingly popular sport in Israel with more and more climbing walls being built in the cities and new routes being traced on cliffs around the country. Our account describes the case of a 15 years old climber with chronic pain (without trauma) in the 3rd finger of the right hand. A stress fracture, involving the proximal interphalangeal joint (SH3) of the middle phalanx, was diagnosed. The fracture healed following two months of rest with gradual return to activity. As this sport becomes more common, there is an increasing need for knowledge about the characteristic injuries, their diagnosis and treatment. Although considered an extreme sport, most of the injuries are overuse injuries, mainly to the upper limbs. Finger flexor tendon pulley rupture being one of the most common. Diagnosis is based on history, physical examination and ultrasonography. Conservative treatment is successful for most injuries, while more complicated cases require surgical intervention.
Kachrimanis, G; Papadopoulou, O
Rupture of the common extensor tendon is the most common acute tendon injury of the elbow. The authors describe a case of a patient with a clinical history of tendinopathy caused by functional overload of the common extensor tendon, treated also with infiltrations of steroids, and subsequent partial rupture of the tendon during sport activity. The diagnosis was made clinically and at ultrasound (US) examination; US follow-up after some time showed the healing of the lesion. This case confirms that injections of steroids may be a contributory cause of tendon rupture, and emphasizes the sensitivity and specificity of US in the study of pathologies of the elbow tendons.
Arora, R; Fritz, D; Zimmermann, R; Lutz, M; Kamelger, F; Klauser, A S; Gabl, M
The rare injury of closed rupture of the A2 and A3 flexor pulleys was treated using two non-encircling techniques of pulley reconstruction. Thirteen patients were treated with an extensor retinaculum graft (Group A). At a mean follow-up time of 48 months, the average PIP flexion was 97%, the power grip strength 96%, the pinch grip strength 100% and the thickening 94% of the uninjured side. Ten patients were treated with a free palmaris longus tendon grafts (Group B). At a mean follow-up time of 57 months, the average PIP flexion was 94%, the power grip strength 98%, the pinch grip strength 100% and the thickening 95% of the uninjured side. In both groups, finger extension was unrestricted. The Buck Gramcko score included 10 excellent, two good and one fair result in Group A and seven excellent, two good and one fair result in Group B. Both techniques proved beneficial. All climbers returned to their previous standard and all non-climbers regained full finger dexterity in their previous job.
Low, T H; Hales, P F
We reviewed the incidence and treatment of flexor carpi radialis tendinitis in 77 patients (81 thumbs) who had trapeziectomy and abductor pollicis longus suspensionplasty for thumb carpometacarpal joint arthritis. Eighteen patients, 20 wrists (25%) had flexor carpi radialis tendinitis. The onset was 2-10 months (mean 4.7) after surgery. Two cases had preceding trauma. Eight cases (40%) responded to splinting and steroid injection. Ten patients, 12 wrists (60%) underwent surgery after failing non-operative treatment. Eleven wrists had frayed or partially torn flexor carpi radialis tendon and one had a complete tendon rupture with pseudotendon formation. Flexor carpi radialis tenotomy and pseudotendon excision were performed. All operated patients obtained good pain relief initially post-operatively. However, the pain recurred in two patients after 8 months. One required a local steroid injection for localized tenderness at the site of the proximal tendon stump. The other patient required a revision operation for scaphotrapezoid impingement. Both obtained complete pain relief. Our study has shown a high incidence of flexor carpi radialis tendinitis following trapeziectomy and abductor pollicis longus suspensionplasty. Patients should be warned about this potential complication.
Oragui, Emeka; Sachinis, Nick; Hope, Natalie; Khan, Wasim S; Adesida, Adetola
Tendon injuries are common and due to their limited capacity for self-healing, the biomechanical and functional properties of healed tendon are usually inferior to normal tissue. Tissue engineering offers the hope of regenerating tendon tissue with the same biomechanical properties of the native undamaged tissue by augmenting the regenerative process of in vivo tissue or producing a functional tissue in vitro that can be implanted into the defective tendon site. Current research on tendon tissue engineering has focused on the role of stem cell and tendon derived cell therapy, scaffolds, chemical and physical stimulation and gene-therapeutic approaches. In this review we review the important functional anatomy and pathomechanics of tendon injury and discuss the current advances in tendon tissue engineering.
Hamman, J; Ali, A; Phillips, C; Cunningham, B; Mass, D P
Many reports have been devoted to characterizing the significance of the pulleys for the flexor digitorum profundus (FDP). However, no comparable work has been published on the flexor digitorum superficialis (FDS). This study characterized the FDS in a human cadaver model. Eleven fresh-frozen cadaver hands were used. By using a tensiometer, data were gathered for tendon excursion, tendon load, and work of flexion. Changes in efficiency were caused by excision of annular pulleys A1, A2, A3, and the palmar aponeurotic pulley. We also measured the effect of FDP excision on FDS efficiency. Sectioning of the A2 and A3 pulleys together caused statistically significant losses of efficiency in all three parameters (work, load, and excursion). When the FDP was removed from a finger with an intact pulley system, losses in both work and excursion efficiencies were significant. Removing the FDP while cutting different pulleys caused significant decrease in FDS excursion efficiency. We conclude that A2 and A3 are the most important pulleys for maintaining normal FDS function, and that the presence of the FDP in the digital sheath is essential for optimal FDS excursion efficiency.
Cassell, M D; Bergman, R A
An unusual and unrecorded variation in palmaris longus muscle is described. The muscle had a normal appearance and origin from the common tendon arising from the medial epicondyle of the humerus and from the surrounding intermuscular septa. The distal tendon however entered the hand via the carpal tunnel medial and deep to the median nerve, split and inserted into the lateral and medial sides of the middle phalanx of the ring finger. It therefore substituted completely for the slip to the ring finger from flexor digitorum superficials, which was absent.
Kheterpal, Arvin; Zoga, Adam; McClure, Kristen
Calcific tendinitis is a common source of musculoskeletal pain in adults; however, it is rarely encountered in children. Calcific tendinitis is the most commonly encountered manifestation of hydroxyapatite deposition disease, in which calcium hydroxyapatite crystal deposition occurs in tendons. It may cause acute or chronic pain, or may be entirely asymptomatic. We describe a case of acute calcific tendinitis of the flexor pollicis longus tendon in an 8-year-old boy, who initially presented to our department for workup of a mass felt along the volar aspect of the right wrist.
Glass, Zachary A; Schiele, Nathan R; Kuo, Catherine K
Tendon is a strong connective tissue that transduces muscle-generated forces into skeletal motion. In fulfilling this role, tendons are subjected to repeated mechanical loading and high stress, which may result in injury. Tissue engineering with stem cells offers the potential to replace injured/damaged tissue with healthy, new living tissue. Critical to tendon tissue engineering is the induction and guidance of stem cells towards the tendon phenotype. Typical strategies have relied on adult tissue homeostatic and healing factors to influence stem cell differentiation, but have yet to achieve tissue regeneration. A novel paradigm is to use embryonic developmental factors as cues to promote tendon regeneration. Embryonic tendon progenitor cell differentiation in vivo is regulated by a combination of mechanical and chemical factors. We propose that these cues will guide stem cells to recapitulate critical aspects of tenogenesis and effectively direct the cells to differentiate and regenerate new tendon. Here, we review recent efforts to identify mechanical and chemical factors of embryonic tendon development to guide stem/progenitor cell differentiation toward new tendon formation, and discuss the role this work may have in the future of tendon tissue engineering.
Glass, Zachary A.; Schiele, Nathan R.; Kuo, Catherine K.
Tendon is a strong connective tissue that transduces muscle-generated forces into skeletal motion. In fulfilling this role, tendons are subjected to repeated mechanical loading and high stress, which may result in injury. Tissue engineering with stem cells offers the potential to replace injured/damaged tissue with healthy, new living tissue. Critical to tendon tissue engineering is the induction and guidance of stem cells towards the tendon phenotype. Typical strategies have relied on adult tissue homeostatic and healing factors to influence stem cell differentiation, but have yet to achieve tissue regeneration. A novel paradigm is to use embryonic developmental factors as cues to promote tendon regeneration. Embryonic tendon progenitor cell differentiation in vivo is regulated by a combination of mechanical and chemical factors. We propose that these cues will guide stem cells to recapitulate critical aspects of tenogenesis and effectively direct the cells to differentiate and regenerate new tendon. Here, we review recent efforts to identify mechanical and chemical factors of embryonic tendon development to guide stem/progenitor cell differentiation toward new tendon formation, and discuss the role this work may have in the future of tendon tissue engineering. PMID:24484642
Scharf, Alexandra; Holmes, Shannon P.; Thoresen, Merrilee; Mumaw, Jennifer; Stumpf, Alaina
Ultrasound-guided intralesional injection of mesenchymal stem cells (MSCs) is held as the benchmark for cell delivery in tendonitis. The primary objective of this study was to investigate the immediate cell distribution following intralesional injection of MSCs. Unilateral superficial digital flexor tendon (SDFT) lesions were created in the forelimb of six horses and injected with 10 × 106 MSCs labeled with superparamagnetic iron oxide nanoparticles (SPIOs) under ultrasound guidance. Assays were performed to confirm that there were no significant changes in cell viability, proliferation, migration, or trilineage differentiation due to the presence of SPIOs. Limbs were imaged on a 1.5-tesla clinical MRI scanner postmortem before and after injection to determine the extent of tendonitis and detect SPIO MSCs. Clusters of labeled cells were visible as signal voids in 6/6 subjects. Coalescing regions of signal void were diffusely present in the peritendinous tissues. Although previous reports have determined that local injury retains cells within a small radius of the site of injection, our study shows greater than expected delocalization and relatively few cells retained within collagenous tendon compared to surrounding fascia. Further work is needed if this is a reality in vivo and to determine if directed intralesional delivery of MSCs is as critical as presently thought. PMID:27746821
Gulick, Dawn T.; Yoder, Heather N.
An injury to the ACL can result in significant functional impairment. It has been estimated that more than 100,000 new ACL injuries occur each year. Surgeons employ numerous techniques for reconstruction of the ACL. Of critical importance is the source of the graft to replace the damaged ACL. The graft choices include autografts (the patient's own tissue), allografts (donor tendon), and synthetic/prosthetic ligaments. Tissue harvest sites for autografting include the middle third of the patella tendon, the quadriceps tendon, semitendinosus tendon, gracilis tendon, iliotibial band, tensor fascia lata, and the Achilles tendon. Selection of the type of graft material is predicated upon the tissue's ability to tolerate high levels of stress. Likewise, the clinical presentation and functional outcome is related to the graft material selected. This manuscript specifically examined the patella tendon and hamstring tendon grafts. Numerous manuscripts that studied the outcomes of these graft materials were compiled to help the clinician appreciate the advantages and disadvantages of each of the graft materials. Outcome measures such as thigh circumference, knee range of motion, isokinetic strength, knee stability, pain, and vertical jump/1-leg hop were incorporated. The purpose of this manuscript was to compare and contrast the clinical presentation of patients who underwent an ACL reconstruction using the patella tendon versus the hamstring tendons. This information can be valuable to the clinician when considering the rehabilitation protocol after ACL reconstruction. PMID:24701126
Banes, A.J.; Link, G.W.; Bevin, A.G.; Peterson, H.D.; Gillespie, Y.; Bynum, D.; Watts, S.; Dahners, L.
The chemistry and cell biology of the tendon have been largely overlooked due to the emphasis on collagen, the principle structural component of the tendon. The tendon must not only transmit the force of muscle contraction to bone to effect movement, but it must also glide simultaneously over extratendonous tissues. Fibronectin is classified as a cell attachment molecule that induces cell spreading and adhesion to substratum. The external surface of intact avian flexor tendon stained positively with antibody to cellular fibronectin. However, if the surface synovial cells were first removed with collagenase, no positive reaction with antifibronectin antibody was detected. Analysis of immunologically stained frozen sections of tendon also revealed fibronectin at the tendon synovium, but little was associated with cells internal in tendon. The staining pattern with isolated, cultured synovial cells and fibroblasts from the tendon interior substantiated the histological observations. Analysis of polyacrylamide gel profiles of /sup 35/S-methionine-labeled proteins synthesized by synovial cells and internal fibroblasts indicated that fibronectin was synthesized principally by synovial cells. Fibronectin at the tendon surface may play a role in cell attachment to prevent cell removal by the friction of gliding. Alternatively, fibronectin, with its binding sites for hyaluronic acid and collagen, may act as a complex for boundary lubrication.
Lin, D; Williams, C; Zaw, H
Tarsal tunnel syndrome (TTS) is a rare entrapment neuropathy of the tibial nerve within the fibro-osseous tarsal tunnel for which multiple etiologies, including trauma, congenital foot abnormalities and space occupying lesions, have been described. We present an unusual case of TTS caused by an accessory Flexor Hallucis Longus (FHL) tendon. Surgical excision led to a complete resolution of symptoms and improved the quality of life of our patient.
Jain, D K; Kakarala, G; Compson, J; Singh, R
This study was done to identify whether the dimensions of the distal phalanges allow suture anchor fixation of the flexor digitorum profundus tendon. Forty pairs of hands were dissected to measure the anteroposterior and lateral dimensions of distal phalanges of all digits. The mean anteroposterior depth of the distal phalanx at the insertion of the tendon was found to be 4.7 mm for the little finger, 5.4 mm for the ring finger, 5.9 mm for the middle finger, 5.4 mm for the index finger and 6.9 mm for the thumb respectively. The commonly available anchors and drill bits for fingers were found to be suboptimal for anchoring the flexor digitorum profundus tendon to the distal phalanx of the little finger. The drill bits used for these anchors were found to be too long for the little fingers and some ring and index fingers.
Magnusson, S Peter; Narici, Marco V; Maganaris, Constantinos N; Kjaer, Michael
Tendon properties contribute to the complex interaction of the central nervous system, muscle–tendon unit and bony structures to produce joint movement. Until recently limited information on human tendon behaviour in vivo was available; however, novel methodological advancements have enabled new insights to be gained in this area. The present review summarizes the progress made with respect to human tendon and aponeurosis function in vivo, and how tendons adapt to ageing, loading and unloading conditions. During low tensile loading or with passive lengthening not only the muscle is elongated, but also the tendon undergoes significant length changes, which may have implications for reflex responses. During active loading, the length change of the tendon far exceeds that of the aponeurosis, indicating that the aponeurosis may more effectively transfer force onto the tendon, which lengthens and stores elastic energy subsequently released during unloading, in a spring-like manner. In fact, data recently obtained in vivo confirm that, during walking, the human Achilles tendon provides elastic strain energy that can decrease the energy cost of locomotion. Also, new experimental evidence shows that, contrary to earlier beliefs, the metabolic activity in human tendon is remarkably high and this affords the tendon the ability to adapt to changing demands. With ageing and disuse there is a reduction in tendon stiffness, which can be mitigated with resistance exercises. Such adaptations seem advantageous for maintaining movement rapidity, reducing tendon stress and risk of injury, and possibly, for enabling muscles to operate closer to the optimum region of the length–tension relationship. PMID:17855761
Farris, Dominic James; Trewartha, Grant; McGuigan, M Polly; Lichtwark, Glen A
The human Achilles tendon (AT) has often been considered to act as a single elastic structure in series with the muscles of the triceps surae. As such it has been commonly modelled as a Hookean spring of uniform stiffness. However, the free AT and the proximal AT have distinctly different structures that lend themselves to different elastic properties. This study aimed to use three-dimensional freehand ultrasound imaging to determine whether the proximal AT and the free AT exhibit different elastic behaviour during sub-maximal, fixed-end contractions of the triceps surae. Six male and five female participants (mean ± s.d. age=27 ± 5 years) performed fixed position contractions of the plantar-flexors on an isokinetic dynamometer at 50% of their maximum voluntary contraction in this position. Freehand three-dimensional ultrasound imaging was used to reconstruct the free-tendon and proximal AT at rest and during contraction. The free-tendon exhibited significantly (P=0.03) greater longitudinal strain (5.2 ± 1.7%) than the proximal AT (2.6 ± 2.0%). The lesser longitudinal strain of the proximal AT was linked to the fact that it exhibited considerable transverse (orthogonal to the longitudinal direction) strains (5.0 ± 4%). The transverse strain of the proximal AT is likely due to the triceps surae muscles bulging upon contraction, and thus the level of bulging may influence the elastic behaviour of the proximal AT. This might have implications for the understanding of triceps surae muscle-tendon interaction during locomotion, tendon injury mechanics and previous measurements of AT elastic properties.
Hill, A E; Blea, J A; Arthur, R M; McIlwraith, C W
Private-practice racetrack veterinarians in southern California recorded non-fatal injuries meeting defined criteria in Thoroughbreds for 1 year. Injury incidence was 2.29 injury events per 100 horse-months, which was lower than other studies where trainer reported injury data were collected. Of 477 injuries recorded, 344 (72.1%) were acute and 133 (27.9%) were chronic. Fractures were common (47.6% of injuries), with stress fractures accounting for 14% of injuries. Superficial digital flexor tendonitis and suspensory ligament desmitis accounted for 15.3 and 11.5% of injuries, respectively. Agreement between non-fatal injuries recorded in the current study and those recorded via an existing regulatory system (Equine Injury Database) was poor, with neither system capturing all injuries. Non-fatal injuries occurred 17-29 times more often than fatal injuries. Non-fatal musculoskeletal injury remains an ongoing issue for Thoroughbred racehorses, and an accurate, comprehensive system for recording these injuries is needed.
Wakefield, C Brent; Cottrell, G Trevor
To date, there is limited research investigating stretching of antagonist muscles and its effects on agonist muscle function. The purpose of this research was to investigate the effects of pre-static stretching (pre-SS) of the hip flexor musculature on passive hip extension range of motion (ROM) and vertical jump height. Fifteen subjects reported to the laboratory on 4 separate days (D1, D2, D3, and D4). D1 was for familiarization, while on D2 to D4, subjects randomly completed 1 of 3 intervention conditions; no stretch (CON), hip flexor stretch (HFS), or hip extensor stretch (HES). Subject's pre- and post-intervention hip extension ROM were measured before performing 3 sets of pre- and post-maximal counter-movement vertical jumps. Vertical jump height was normalized to baseline for data analysis. A repeated-measures ANOVA with post hoc paired sample t-tests revealed a significant increase in vertical jump height in the HFS condition (1.74% ± 0.73; p ≤ 0.05) when compared with CON (-1.34% ± 0.96) or HES (-1.74% ± 0.65) conditions. There was also a significant increase in hip extension ROM after the HFS stretching protocol (6.5 ± 2.75%; p ≤ 0.05) when compared with the CON protocol (-1.73 ± 3.26); however, no significant difference when compared with the HES protocol (1.84 ± 2.79). A correlation analysis showed that the relative hip laxity of each subject had no effect on response to either condition nor did the magnitude of hip ROM change predict improvement in vertical jump. These results suggest that performing SS of the hip flexors may enhance vertical jump performance independent of changes in passive compliance of the hip flexor muscular tendon unit.
Thorpe, Chavaunne T.; Streeter, Ian; Pinchbeck, Gina L.; Goodship, Allen E.; Clegg, Peter D.; Birch, Helen L.
Little is known about the rate at which protein turnover occurs in living tendon and whether the rate differs between tendons with different physiological roles. In this study, we have quantified the racemization of aspartic acid to calculate the age of the collagenous and non-collagenous components of the high strain injury-prone superficial digital flexor tendon (SDFT) and low strain rarely injured common digital extensor tendon (CDET) in a group of horses with a wide age range. In addition, the turnover of collagen was assessed indirectly by measuring the levels of collagen degradation markers (collagenase-generated neoepitope and cross-linked telopeptide of type I collagen). The fractional increase in d-Asp was similar (p = 0.7) in the SDFT (5.87 × 10−4/year) and CDET (5.82 × 10−4/year) tissue, and d/l-Asp ratios showed a good correlation with pentosidine levels. We calculated a mean (±S.E.) collagen half-life of 197.53 (±18.23) years for the SDFT, which increased significantly with horse age (p = 0.03) and was significantly (p < 0.001) higher than that for the CDET (34.03 (±3.39) years). Using similar calculations, the half-life of non-collagenous protein was 2.18 (±0.41) years in the SDFT and was significantly (p = 0.04) lower than the value of 3.51 (±0.51) years for the CDET. Collagen degradation markers were higher in the CDET and suggested an accumulation of partially degraded collagen within the matrix with aging in the SDFT. We propose that increased susceptibility to injury in older individuals results from an inability to remove partially degraded collagen from the matrix leading to reduced mechanical competence. PMID:20308077
Liu, Donghui; Andrade, Silvia Passos; Castro, Pollyana Ribeiro; Treacy, John; Ashworth, Jason; Slevin, Mark
Sodium butyrate (NaBu), a form of short-chain fatty acid (SCFA), acts classically as a potent anti-angiogenic agent in tumour angiogenesis models, some authors demonstrated that low concentrations of NaBu may contribute to healing of tendon-bone injury in part at least through promotion of tissue remodelling. Here, we investigated the effects of low-range concentrations of NaBu using in vitro and in vivo assays using angiogenesis as the primary outcome measure and the mechanisms through which it acts. We demonstrated that NaBu, alone or perfused from the UltraBraid+NaBu suture was pro-angiogenic at very low-range doses promoting migration, tube formation and cell invasion in bovine aortic endothelial cells (BAECs). Furthermore, cell exposure to low NaBu concentrations increased expression of proteins involved in angiogenic cell signalling, including p-PKCβ1, p-FAK, p-ERK1/2, p-NFκβ, p-PLCγ1 and p-VEGFR2. In addition, inhibitors of both VEGFR2 and PKCβ1 blocked the angiogenic response. In in vivo assays, low concentrations of NaBu induced neovascularization in sponge implants in mice, evidenced by increased numbers of vessels and haemoglobin content in these implants. The findings in this study indicate that low concentrations of NaBu could be an important compound to stimulate angiogenesis at a site where vasculature is deficient and healing is compromised. PMID:27694930
Achilles tendon rupture-surgery; Percutaneous Achilles tendon rupture repair ... To fix your torn Achilles tendon, the surgeon will: Make a cut down the back of your heel Make several small cuts rather than one large cut ...
patellar tendon [PT], and Achilles tendon [AT]) has increased in recent decades presumably because of increased recreational sports activity in our...1995 and 1996 were identified and evaluated for risk factors. Results: The authors identified 52 major tendon ruptures: 29 Achilles, 12 patellar , 7... patellar tendon rupture; Achilles tendon rupture; race; mechanism of injury *Address correspondence to LTC Daniel W. White, MD, 1 Jarrett White Road
Yang, Liu; Yin, Li
Background. Chronic Achilles tendon rupture is usually misdiagnosed and treated improperly. This study aims to better understand the treatment of chronic Achilles tendon rupture. Methods. Patients who were not able to perform a single-limb heel rise were chosen. Pre- and postoperative magnetic resonance imaging (MRI) were conducted. By evaluating the presence or absence of Achilles tendon stumps and the gap length of rupture, V-Y advancement, gastrocnemius fascial turndown flap, or flexor halluces longus tendon transfer were selected for tendon repair. The function of ankle and foot was assessed by American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scores and Achilles Tendon Total Rupture Score (ATRS). Results. Twenty-nine patients were followed up. One patient had superficial incision infection, which was healed after debridement and oral antibiotics. Three months postoperatively, MRI showed some signs of inflammation, which disappeared at one or two years postoperatively. All patients were able to perform a single-limb heel rise. Mean AOFAS scores and ATRS scores were increased at the latest follow-up. Conclusion. Surgical options can be determined by evaluating the presence of the Achilles tendon stumps and the gap length, which can avoid using the nearby tendon and yield satisfactory functional results. PMID:27847806
The biceps brachii muscle, which inserts proximally onto the scapula and distally onto the forearm, has several tendons with numerous anatomic peculiarities, which render their sonographic examination highly variable. Proximally, the tendon of the short head of the biceps inserts onto the coracoid process and that of the long head on the superior aspect of the glenoid. The distal biceps tendon is bifurcated, and it generally inserts on the radial tuberosity, around which it rolls during pronation/supination. There is a third distal structure, the Lacertus fibrosus, an aponeurosis that branches off from the medial aspect of the tendon, crossing the median artery and median nerve, and inserting on the superficial aponeurosis of the flexor muscles. The sonographic examination of these tendons focuses on nine separate zones of interest: the glenoid insertion of the long head, its extension to the upper pole of the humeral head, the rotator interval, the reflection to the upper bicipital groove, the bicipital groove, the upper myotendinous junction, the lower myotendinous junction, the distal tendon(s), and the inferior enthesis. Because of their morphological and topographical characteristics, the biceps tendons are subject to a variety of lesions, some of which are frequently misdiagnosed on the basis of clinical findings. Ultrasound plays an important role in detecting and characterizing these lesions. Proper examination of the biceps (the distal portion in particular) is a difficult task that cannot be improvised. PMID:23397031
Sugisaki, Norihide; Kawakami, Yasuo; Kanehisa, Hiroaki; Fukunaga, Tetsuo
Findings from animal experiments are sometimes contradictory to the idea that the tendon structure is a simple elastic spring in series with muscle fibers, and suggest influence of muscle contraction on the tendon mechanical properties. The purpose of the present study was to investigate the influence of muscle contraction levels on the force-length relationship of the human Achilles tendon during lengthening of the triceps surae muscle-tendon unit. For seven subjects, ankle dorsiflexion was performed without (passive condition) and with contraction of plantar flexor muscles (eccentric conditions, at 3 contraction levels) on an isokinetic dynamometer. Deformation of the Achilles tendon during each trial was measured using ultrasonography. The Achilles tendon force corresponding to the tendon elongation of 10mm in the passive condition was significantly smaller than those in the eccentric conditions (p<0.05 or p<0.01). Within the eccentric conditions, the Achilles tendon force corresponding to the tendon elongation of 10mm was significantly greater in the maximal contraction level than those in submaximal eccentric conditions (p<0.05 or p<0.01). In addition, the tendon stiffness was greater in higher contraction levels (p<0.05 or p<0.01). Present results suggest that the human tendon structure is not a simple elastic spring in series with muscle fibers.
Luria, Shai; Haze, Amir
Pyogenic flexor tenosynovitis is an uncommon, emergent hand infection. The literature lacks any description of the disease and the variability of its manifestations in young children. We describe 3 cases. Two cases were diagnosed and treated promptly, and the third presented late, with atypical clinical signs, causing a delay in his diagnosis and treatment and stressing the caution to be taken with the evaluation of these children with signs of hand infection.
Tempfer, Herbert; Traweger, Andreas
Tendons represent a bradytrophic tissue which is poorly vascularized and, compared to bone or skin, heal poorly. Usually, a vascularized connective scar tissue with inferior functional properties forms at the injury site. Whether the increased vascularization is the root cause of tissue impairments such as loss of collagen fiber orientation, ectopic formation of bone, fat or cartilage, or is a consequence of these pathological changes remains unclear. This review provides an overview of the role of tendon vasculature in healthy and chronically diseased tendon tissue as well as its relevance for tendon repair. Further, the nature and the role of perivascular tendon stem/progenitor cells residing in the vascular niche will be discussed and compared to multipotent stromal cells in other tissues. PMID:26635616
de Lima Lopes, Clécio; Arantes, Gabriel; de Oliveira, Rodrigo Victor Lapenda; Pinto, Dilamar Moreira; Gonçalves, Marcelo Carvalho Krause; Gonçalves, Romeu Carvalho Krause
Objectives To evaluate the prevalence of a vascular network adjacent to the insertion of the pes anserinus, so that it could be used as an anatomical reference point to facilitate harvesting flexor grafts for arthroscopic reconstruction of the anterior cruciate ligament (ACL). Methods Thirty patients with ACL tears who were going to undergo ACL reconstruction using the tendons of the semitendinosus and gracilis muscles as grafts were selected randomly. During the harvesting of these tendons, the presence or absence of this anatomical reference point was noted. Results All the patients presented a vascular network of greater or lesser diameter. Conclusion The vascular network seems to be a good reference point during harvesting of the tendons of the semitendinosus and gracilis muscles, for facilitating graft harvesting. PMID:26229911
Maas, Huub; Huijing, Peter A.
Summary We investigated the extent of mechanical interaction between rat flexor carpi ulnaris (FCU) and palmaris longus (PL) muscles following transfer of FCU to the distal tendons of extensor carpi radialis brevis and longus (ECRB/L) muscles. Five weeks after recovery from surgery, isometric forces exerted at the distal tendons of FCU and PL were quantified at various FCU lengths. PL was kept at a constant length. Changing the muscle-tendon complex length of transferred FCU (by maximally 3.5 mm) decreased PL force significantly (by 7%). A linear relationship was found between changes in FCU muscle belly length, being a measure of muscle relative positions, and PL force. These results indicate that despite transfer of FCU muscle to the extensor side of the forearm, changing FCU length still affects force transmission of its, now, antagonistic PL muscle. We conclude that a transferred muscle may still be mechanically linked to its former synergistic muscles. PMID:23738260
Jang, Eugene; Dy, Christopher J.
Purpose To investigate the graft length necessary to complete a distal radioulnar ligament reconstruction and assess the suitability of several tendon graft sources. Methods We measured the graft length needed to complete the distal radioulnar ligament reconstruction in 7 fresh-frozen cadaver specimens. The pure tendon lengths of 7 tendon graft sources were measured: palmaris longus, extensor indicis proprius, slips of extensor digiti minimi and abductor pollicis longus, and portions of flexor carpi ulnaris, flexor carpi radialis, and extensor carpi ulnaris. A modified technique which allows for a shorter length of graft is also described, and the suitability of each graft source for this technique was assessed. Results The mean graft length needed to complete the original and modified reconstructions were 138 mm and 89 mm, respectively. The average length of the tendon graft when measured as pure tendon were: palmaris longus (127 mm), slip of extensor digiti minimi (112 mm), extensor indicis proprius (100 mm), partial flexor carpi radialis (87 mm), slip of abductor pollicis longus (69 mm), partial flexor carpi ulnaris (67 mm), and partial extensor carpi ulnaris (67 mm). The palmaris longus was too short for the original technique in the majority of specimens but was sufficient to complete the modified technique in every specimen that had a palmaris longus. Six specimens also had an extensor indicis proprius of suitable length for the modified technique. Discussion The length of donor graft required for the modified reconstruction was significantly less than that needed for the original reconstruction. Three specimens had no donor tendons sufficiently long to complete the original technique if a pure tendon graft were used, whereas the modified technique could be completed in all specimens. Clinical Relevance Many tendon graft sources in the upper extremity are of insufficient length to complete the distal radioulnar ligament reconstruction as described. A modified
Wu, John Z; Sinsel, Erik W; Shroyer, Justin F; Welcome, Daniel E; Zhao, Kristin D; An, Kai-Nan; Buczek, Frank L
Strong evidence indicates that highly repetitive manual work is associated with the development of upper extremity musculoskeletal disorders (MSDs). One of the occupational activities that involves highly repetitive and forceful hand work is manual pipetting in chemical or biological laboratories. In the current study, we quantified tendon displacement as a parameter to assess the cumulative loading exposure of the musculoskeletal system in the thumb during pipetting. The maximal tendon displacement was found in the flexor pollicis longus (FPL) tendon. Assuming that subjects' pipetting rates were maintained constant during a period of 1 h, the average accumulated tendon displacement in the FPL reached 29 m, which is in the lower range of those observed in other occupational activities, such as typing and nail gun operations. Our results showed that tendon displacement data contain relatively small standard deviations, despite high variances in thumb kinematics, suggesting that the tendon displacements may be useful in evaluating the musculoskeletal loading profile.
Wu, John Z.; Sinsel, Erik W.; Shroyer, Justin F.; Welcome, Daniel E.; Zhao, Kristin D.; An, Kai-Nan; Buczek, Frank L.
Strong evidence indicates that highly repetitive manual work is associated with the development of upper extremity musculoskeletal disorders (MSDs). One of the occupational activities that involves highly repetitive and forceful hand work is manual pipetting in chemical or biological laboratories. In the current study, we quantified tendon displacement as a parameter to assess the cumulative loading exposure of the musculoskeletal system in the thumb during pipetting. The maximal tendon displacement was found in the flexor pollicis longus (FPL) tendon. Assuming that subjects’ pipetting rates were maintained constant during a period of 1 h, the average accumulated tendon displacement in the FPL reached 29 m, which is in the lower range of those observed in other occupational activities, such as typing and nail gun operations. Our results showed that tendon displacement data contain relatively small standard deviations, despite high variances in thumb kinematics, suggesting that the tendon displacements may be useful in evaluating the musculoskeletal loading profile. PMID:24018066
Gulotta, Lawrence V.; Chaudhury, Salma; Wiznia, Daniel
Tendon healing is fraught with complications such as reruptures and adhesion formation due to the formation of scar tissue at the injury site as opposed to the regeneration of native tissue. Stem cells are an attractive option in developing cell-based therapies to improve tendon healing. However, several questions remain to be answered before stem cells can be used clinically. Specifically, the type of stem cell, the amount of cells, and the proper combination of growth factors or mechanical stimuli to induce differentiation all remain to be seen. This paper outlines the current literature on the use of stem cells for tendon augmentation. PMID:22190960
within the tendon or systemic disorders such as lupus erythematosus , diabetes mellitus, chronic kidney disease, rheumatologic disease, and local or...factors for patellar tendon rupture include obesity, male gender, age 30-40, activities that increase patellar stress, systemic lupus erythematosus ...patellar tendon rupture is a rare occurrence usually associated with chronic degeneration of tendon fibers, use of steroids, or systemic illness. Our
Gibbons, C E R; Thompson, D; Sandow, M J
The integrity of the repair is critical to maintain coaptation of the severed flexor tendon end until healing has advanced sufficiently. In our hospital, we use a modified Savage repair (four-strand Adelaide technique) using 3-0 Ethibond (Ethicon, Somerville, NJ, USA) for acute flexor tenorrhaphy and an active postrepair mobilization protocol. To explain the apparent differences between the theoretical and actual repair strength of a multistrand repair in a single tension test and the reduced strength of a repair subjected to cyclic loading, we compared single and cyclical tensile loading with different suture in vitro configurations of 3-0 Ethibond (Ethicon, Somerville, NJ, USA; one, two, and four strands) and an ex vivo four-strand repair of freshly divided porcine tendon to calculate the ultimate tensile strength (UTS). Mechanical testing was repeated 15 times with both single tensile and cyclical loading for each suture configuration and porcine repair. In the in vitro model, the presence of a knot in a single strand reduced the UTS by 50%. The stiffness of a knotted strand was substantially less than the unknotted strand but became identical after cyclical loading. There was no statistical significance of the UTS between single and cyclical loading with different numbers of strands in this model. In the ex vivo four-strand porcine repair model, there was a significant reduction in UTS with cyclical loading, which equated to the number of strands times the strength of the knotted strand. This discrepancy can be explained by the change in stiffness of the knotted strand after cyclical loading and has important implications for previous studies of suture tendon repair using single tensile loading where the UTS may have been overestimated. We believe that cyclical loading is more representative of physiological loading after acute flexor tendon repair and should be the testing model of choice in suture tenorrhaphy studies.
Effect of glenohumeral abduction angle on the mechanical interaction between the supraspinatus and infraspinatus tendons for the intact, partial-thickness torn, and repaired supraspinatus tendon conditions.
Andarawis-Puri, Nelly; Kuntz, Andrew F; Ramsey, Matthew L; Soslowsky, Louis J
Rotator cuff tears are difficult to manage because of the structural and mechanical inhomogeneity of the supraspinatus tendon. Previously, we showed that with the arm at the side, the supraspinatus and infraspinatus tendons mechanically interact such that conditions that increase supraspinatus tendon strain, such as load or full-thickness tears, also increase infraspinatus tendon strain. This suggests that the infraspinatus tendon may shield the supraspinatus tendon from further injury while becoming at increased risk of injury itself. In this study, the effect of glenohumeral abduction angle on the interaction between the two tendons was evaluated for supraspinatus tendon partial-thickness tears and two repair techniques. Principal strains were quantified in both tendons for 0 degrees , 30 degrees , and 60 degrees of glenohumeral abduction. Results showed that interaction between the two tendons is interrupted by an increase in abduction angle for all supraspinatus tendon conditions evaluated. Infraspinatus tendon strain was lower at 30 degrees and 60 degrees than at 0 degrees abduction angle. In conclusion, interaction between the supraspinatus and infraspinatus tendons is interrupted with increase in abduction angle. Additionally, 30 degrees abduction should be further evaluated for management of rotator cuff tears and repairs as it is the angle at which both supraspinatus and infraspinatus tendon strain is decreased.
Sun, Yu-Long; Wei, Zhuang; Zhao, Chunfeng; Jay, Gregory D; Schmid, Thomas M; Amadio, Peter C; An, Kai-Nan
Achilles tendon is one of the most commonly injured tendons. Mechanical force is regarded as a major causative factor. However, the biomechanics of Achilles tendon and mechanical mechanism of the injuries are unclear. Lubricin expresses at regions exposed to sliding motion and shear force in a number of tissues. This study investigated the distribution and concentration of lubricin in human Achilles tendons for better understanding the biomechanics of Achilles tendon. Achilles tendons were harvested from nine cadavers. Lubricin was extracted from various locations proximal to the calcaneal insertion and quantified with ELISA. The distribution of lubricin was investigated with immunohistochemistry. Lubricin was mainly identified at the interfaces of tendon fascicles, especially in the mid-portion of the tendon. The concentration of lubricin in Achilles tendons varied by individual and the distance from its calcaneal insertion. The distal portion of the tendon had a higher concentration of lubricin than the proximal regions of the tendon. This study suggests the presence of intratendinous sliding motion of fascicles and shear force at interfaces of fascicles in human Achilles tendon. Shear force could be an important mechanical factor for the development of Achilles tendinopathy and rupture.
Restuccia, Giuseppe; Lippi, Alessandro; Casella, Francesco; Citarelli, Carmine; Sacchetti, Federico; Benifei, Maurizio
In clinical practice, chronic Achilles tendon ruptures are uncommon. Usually, these lesions are discovered four to six weeks after injuries. More frequently, Achilles tendon ruptures are acute and treated with tendon sutures.1 Many surgical techniques are available to treat chronic lesions such as sutures or V-Y elongation with or without augments.2-3 Our case is about a chronic Achilles tendon rupture discovered two years after injury. Our patient came to our attention with a 6 cm tendon gap. We performed tendon repair with cadaver allograft. After four years of follow-up, our patient has a complete functional recovery and he can normally perform daily and working tasks without pain.
Frizziero, Antonio; Salamanna, Francesca; Della Bella, Elena; Vittadini, Filippo; Gasparre, Giuseppe; Nicoli Aldini, Nicolò; Masiero, Stefano; Fini, Milena
Introduction: Several conditions such as training, aging, estrogen deficiency and drugs could affect the biological and anatomo-physiological characteristics of the tendon. Additionally, recent preclinical and clinical studies examined the effect of detraining on tendon, showing alterations in its structure and morphology and in tenocyte mechanobiology. However, few data evaluated the importance that cessation of training might have on tendon. Basically, we do not fully understand how tendons react to a phase of training followed by sudden detraining. Therefore, within this review, we summarize the studies where tendon detraining was examined. Materials and Methods: A descriptive systematic literature review was carried out by searching three databases (PubMed, Scopus and Web of Knowledge) on tendon detraining. Original articles in English from 2000 to 2015 were included. In addition, the search was extended to the reference lists of the selected articles. A public reference manager (www.mendeley.com) was adopted to remove duplicate articles. Results: An initial literature search yielded 134 references (www.pubmed.org: 53; www.scopus.com: 11; www.webofknowledge.com: 70). Fifteen publications were extracted based on the title for further analysis by two independent reviewers. Abstracts and complete articles were after that reviewed to evaluate if they met inclusion criteria. Conclusions: The revised literature comprised four clinical studies and an in vitro and three in vivo reports. Overall, the results showed that tendon structure and properties after detraining are compromised, with an alteration in the tissue structural organization and mechanical properties. Clinical studies usually showed a lesser extent of tendon alterations, probably because preclinical studies permit an in-depth evaluation of tendon modifications, which is hard to perform in human subjects. In conclusion, after a period of sudden detraining (e.g., after an injury), physical activity should
Sun, Mei; Connizzo, Brianne K; Adams, Sheila M; Freedman, Benjamin R; Wenstrup, Richard J; Soslowsky, Louis J; Birk, David E
Collagen V mutations underlie classic Ehlers-Danlos syndrome, and joint hypermobility is an important clinical manifestation. We define the function of collagen V in tendons and ligaments, as well as the role of alterations in collagen V expression in the pathobiology in classic Ehlers-Danlos syndrome. A conditional Col5a1(flox/flox) mouse model was bred with Scleraxis-Cre mice to create a targeted tendon and ligament Col5a1-null mouse model, Col5a1(Δten/Δten). Targeting was specific, resulting in collagen V-null tendons and ligaments. Col5a1(Δten/Δten) mice demonstrated decreased body size, grip weakness, abnormal gait, joint laxity, and early-onset osteoarthritis. These gross changes were associated with abnormal fiber organization, as well as altered collagen fibril structure with increased fibril diameters and decreased fibril number that was more severe in a major joint stabilizing ligament, the anterior cruciate ligament (ACL), than in the flexor digitorum longus tendon. The ACL also had a higher collagen V content than did the flexor digitorum longus tendon. The collagen V-null ACL and flexor digitorum longus tendon both had significant alterations in mechanical properties, with ACL exhibiting more severe changes. The data demonstrate critical differential regulatory roles for collagen V in tendon and ligament structure and function and suggest that collagen V regulatory dysfunction is associated with an abnormal joint phenotype, similar to the hypermobility phenotype in classic Ehlers-Danlos syndrome.
Peltz, Cathryn D; Sarver, Joseph J; Dourte, Leann M; Würgler-Hauri, Carola C; Williams, Gerald R; Soslowsky, Louis J
Rotator cuff tears are a common clinical problem that can result in pain and disability. Previous studies in a rat model showed enhanced tendon to bone healing with postoperative immobilization. The objective of this study was to determine the effect of postimmobilization activity level on insertion site properties and joint mechanics in a rat model. Our hypothesis was that exercise following a short period of immobilization will cause detrimental changes in insertion site properties compared to cage activity following the same period of immobilization, but that passive shoulder mechanics will not be affected. We detached and repaired the supraspinatus tendon of 22 Sprague-Dawley rats, and the injured shoulder was immobilized postoperatively for 2 weeks. Following immobilization, rats were prescribed cage activity or exercise for 12 weeks. Passive shoulder mechanics were determined, and following euthanasia, tendon cross-sectional area and mechanical properties were measured. Exercise following immobilization resulted in significant decreases compared to cage activity in range of motion, tendon stiffness, modulus, percent relaxation, and several parameters from both a structurally based elastic model and a quasi-linear viscoelastic model. Therefore, we conclude that after a short period of immobilization, increased activity is detrimental to both tendon mechanical properties and shoulder joint mechanics, presumably due to increased scar production.
Fessel, Gion; Wernli, Jeremy; Li, Yufei; Gerber, Christian; Snedeker, Jess G
We investigated the hypothesis that exogenous collagen cross-linking can augment intact regions of tendon to mitigate mechanical propagation of partial tears. We first screened the low toxicity collagen cross-linkers genipin, methylglyoxal and ultra-violet (UV) light for their ability to augment tendon stiffness and failure load in rat tail tendon fascicles (RTTF). We then investigated cross-linking effects in load bearing equine superficial digital flexor tendons (SDFT). Data indicated that all three cross-linking agents augmented RTTF mechanical properties but reduced native viscoelasticity. In contrast to effects observed in fascicles, methylglyoxal treatment of SDFT detrimentally affected tendon mechanical integrity, and in the case of UV did not alter tendon mechanics. As in the RTTF experiments, genipin cross-linking of SDFT resulted in increased stiffness, higher failure loads and reduced viscoelasticity. Based on this result we assessed the efficacy of genipin in arresting tendon tear propagation in cyclic loading to failure. Genipin cross-linking secondary to a mid-substance biopsy-punch significantly reduced tissue strains, increased elastic modulus and increased resistance to fatigue failure. We conclude that genipin cross-linking of injured tendons holds potential for arresting tendon tear progression, and that implications of the treatment on matrix remodeling in living tendons should now be investigated.
Lotz, J C; Hariharan, J S; Diao, E
We developed an analytic model to predict suture load-sharing immediately after flexor tendon repair in the hand. Tendon repair was mathematically modeled as two nonlinear springs in parallel, representing separate core and peripheral sutures that were in series with a third nonlinear spring representing the tendon. To serve as a basis for, and validation of, our analytic model, fresh human flexor digitorum profundus tendons were harvested and mechanically tested either intact or after surgical repair in a variety of ways: core suture alone, superficial peripheral suture alone, deep peripheral suture alone, core suture plus superficial peripheral suture, and core suture plus deep peripheral suture. The stiffness and strength of the composite repairs predicted with use of the analytic model were comparable with those determined experimentally. Furthermore, the model predicted inequities in suture load-sharing, with 64% of the applied load carried by the peripheral suture when it was placed superficially, as compared with 77% when the peripheral suture was placed deep. Our results demonstrate a disparity in load-sharing within composite suture systems, the rectification of which may lead to significant improvement in the repair strength. To this end, we expect that our analytic model will serve as a basis for the design of more efficient, and consequently stronger, suture techniques.
Salisbury, S T Samuel; Buckley, C Paul; Zavatsky, Amy B
A study was made of the deformation of tendons when compressed transverse to the fiber-aligned axis. Bovine digital extensor tendons were compression tested between flat rigid plates. The methods included: in situ image-based measurement of tendon cross-sectional shapes, after preconditioning but immediately prior to testing; multiple constant-load creep/recovery tests applied to each tendon at increasing loads; and measurements of the resulting tendon displacements in both transverse directions. In these tests, friction resisted axial stretch of the tendon during compression, giving approximately plane-strain conditions. This, together with the assumption of a form of anisotropic hyperelastic constitutive model proposed previously for tendon, justified modeling the isochronal response of tendon as that of an isotropic, slightly compressible, neo-Hookean solid. Inverse analysis, using finite-element (FE) simulations of the experiments and 10 s isochronal creep displacement data, gave values for Young's modulus and Poisson's ratio of this solid of 0.31 MPa and 0.49, respectively, for an idealized tendon shape and averaged data for all the tendons and E = 0.14 and 0.10 MPa for two specific tendons using their actual measured geometry. The compression load versus displacement curves, as measured and as simulated, showed varying degrees of stiffening with increasing load. This can be attributed mostly to geometrical changes in tendon cross section under load, varying according to the initial 3D shape of the tendon.
Zhang, Jianying; Pan, Tiffany; Wang, James H.-C.
Summary Cryotherapy (or cold treatment) has been a popular treatment to relieve pain caused by injuries to tissues such as tendons. However, the exact mechanisms behind the beneficial effects of cryotherapy in tendons remain largely unclear. As prostaglandin E2 (PGE2) is known to be a major mediator of acute inflammation in tissues, which is related to tissue pain, we hypothesized that the beneficial effects of cryotherapy in tendons are mediated by downregulation of PGE2 levels. To test this hypothesis, we applied cold treatment to mouse patellar and Achilles tendons using two animal models: exhaustive mouse treadmill running and acute mouse tendon injury by needle penetration. We then measured the levels of PGE2 and protein expression levels of COX-2, an enzyme responsible for PGE2 production in tissues, under both experimental conditions. We found that treadmill running increased PGE2 levels in both patellar and Achilles tendons compared to control mice without running. Cold treatment for 30 min after treadmill running was sufficient to reduce PGE2 levels to near baseline control levels in both tendons. An extension of cold treatment to 60 min resulted only in a marginal decrease in patellar tendons, but a marked decrease in Achilles tendons. Moreover, COX-2 protein levels in both tendons were also lowered by cold treatment, suggesting that the reduction of PGE2 levels in tendons by cold treatment is at least in part due to the decreased COX-2 expression. Similarly, in the acutely injured tendons, 30 min of cold treatment after needle penetration reduced PGE2 levels when compared to the controls at room temperature (22°C). This decrease was sustained up to at least 3 h after the administration of cryotherapy. Given that PGE2 is a known pain sensitiser, the results of this study suggest that the ability of cold treatment to reduce pain may be attributable to its ability to decrease PGE2 production in tendons. PMID:26594634
Smerdelj, M; Madjarević, M; Oremus, K
The lower leg, foot and ankle form a functional unit of the locomotor system with an important static and dynamic function. Injury or loss of function of any muscle group of the lower leg and the foot influences normal gait or impedes standing. Increased or frequent loads on the muscle group may lead to pain syndromes known as overuse syndromes or overuse injuries. Athletes and certain professions involving standing or walking for a long time are especially susceptible to increased muscle strains. This article describes and clarifies the causes and the development of the pain syndromes in the lower leg, foot and ankle associated with certain professions or sports. The description of anatomical relationships and functions of individual muscle groups is here to clarify the occurrence of overuse injuries which may involve the muscle itself, the tendon, or the point of their attachment to the bone. The article describes observations and experiences from everyday clinical practice, but it also summarises results described in recent publications. The focus is also put on the therapy, which is usually conservative. Particular mention is given to new non-invasive surgical techniques. The article describes the most common overuse injuries of the lower leg such as shin splints, tibialis posterior syndrome, chronic anterior compartment syndrome, overuse injury of the Achilles tendon, enthesitis of the tendo Achilles, retrocalcanear bursitis and rupture of the Achilles tendon. In the foot area the most frequent overuse syndromes are the plantar fasciitis, tibialis posterior tendinitis, tendinitis of the long flexor of the toe, toe extensor tendinitis, and also anterior and posterior impingement syndromes of the ankle.
Achilles tendon rupture is a serious injury for which the best treatment is still controversial. Its primary goal should be to restore normal length and tension, thus obtaining an optimal function. Tendon elongation correlates significantly with clinical outcome; lengthening is an important cause of morbidity and may produce permanent functional impairment. In this article, we review all factors that may influence the repair, including the type of surgical technique, suture material, and rehabilitation program, among many others. PMID:21966048
de la Garza, Oscar; Lierse, Werner; de los Angeles-García, Ma; Elizondo, Rodrigo; Guzmán, Santos
The blood supply for the synovial tendon sheaths of the hand was carefully investigated. We show that the origin of those arteries, supplying the synovial tendon-sheaths of the Mm. flexor pollicis longus, flexor digitorum superficialis and profundus, lies in the Canalis carpi. We also describe that the branches of the Aa. digitales palmares propriae arise independently. We emphasize that the terminal branches of the A. interossea posterior and the Rete carpi dorsalis form an arterial network on the synovial tendon sheaths of the Dorsum manus. The synovial membranes of the proximal joints of the fingers receive an ample blood supply from the Rami ascendentes of the Aa. metacarpeae palmares and the Aa. digitales palmares propriae (Aa. recurrentes).
Parchi, Paolo D.; Vittorio, Orazio; Andreani, Lorenzo; Battistini, Pietro; Piolanti, Nicola; Marchetti, Stefano; Poggetti, Andrea; Lisanti, Michele
Tendon injuries are commonly met in the emergency department. Unfortunately, tendon tissue has limited regeneration potential and usually the consequent formation of scar tissue causes inferior mechanical properties. Nanoparticles could be used in different way to improve tendon healing and regeneration, ranging from scaffolds manufacturing (increasing the strength and endurance or anti-adhesions, anti-microbial, and anti-inflammatory properties) to gene therapy. This paper aims to summarize the most relevant studies showing the potential application of nanoparticles for tendon tissue regeneration. PMID:27597828
Khan, K; Brown, J; Way, S; Vass, N; Crichton, K; Alexander, R; Baxter, A; Butler, M; Wark, J
Successful management of classical ballet dancers with overuse injuries requires an understanding of the art form, precise knowledge of anatomy and awareness of certain conditions. Turnout is the single most fundamental physical attribute in classical ballet and 'forcing turnout' frequently contributes to overuse injuries. Common presenting conditions arising from the foot and ankle include problems at the first metatarsophalangeal joint, second metatarsal stress fractures, flexor hallucis longus tendinitis and anterior and posterior ankle impingement syndromes. Persistent shin pain in dancers is often due to chronic compartment syndrome, stress fracture of the posteromedial or anterior tibia. Knee pain can arise from patellofemoral syndrome, patellar tendon insertional pathologies, or a combination of both. Hip and back problems are also prevalent in dancers. To speed injury recovery of dancers, it is important for the sports medicine team to cooperate fully. This permits the dancer to benefit from accurate diagnosis, technique correction where necessary, the full range of manual therapies to joint and soft tissue, appropriate strengthening programmes and maintenance of dance fitness during any time out of class with Pilates-based exercises and nutrition advice. Most overuse ballet conditions respond well to a combination of conservative therapies. Those dancers that do require surgical management still depend heavily on ballet-specific rehabilitation for a complete recovery.
Kellis, Eleftherios; Patsika, Glykeria; Karagiannidis, Evaggelos
The semitendinosus (ST) consists of a long distal tendon and it is divided in two parts by a tendinous inscription (TI). The purpose of this study was to quantify strain and elongation of the TI and the distal tendon of ST. Fourteen subjects performed ramp isometric contractions of the knee flexors at 0°, 45° and 90° of knee flexion. Two ultrasound probes were used to visualize the displacement of the distal tendon and selected points across the TI and aponeuroses. Three-way analysis of variance designs indicated that: (a) strain and elongation of the ST distal muscle-tendon junction were higher than that of the aponeurosis - TI junction points (p < 0.05) (b) the long arm of the TI reach strain of 49.86 ± 7.77% which was significantly (p < 0.05) higher than that displayed by the short arm (28.35 ± 0.59%) (c) Strain of tendinous and TI-aponeuroses segments significantly increased from 90° to 0° of knee flexion while the inverse was observed for the TI arm length (p < 0.05). (d) Tendon strain was significantly higher than strain of the TI-aponeuroses segments at 45° and 90° of knee flexion while the opposite was observed at 0° of knee flexion. The arrangement of TI along ST length results in differential local strains, indicating that the mechanical properties of the ST muscle are affected by tendon, aponeuroses and tendinous inscription interactions.
Langer, Phillip R; Selesnick, F Harlan
Simultaneous quadriceps and patellar tendon rupture is rare. To our knowledge, we present the first known case of simultaneous quadriceps tendon, patella tendon, and retinacula rupture in the ipsilateral knee of a high-performance elite athlete. This disabling injury in the active person results in an inability to actively obtain and maintain full knee extension. When the tendons do not heal properly, at the correct length and tension, knee range of motion and strength can become significantly altered, leading to early fatigue, patellofemoral pain, and possibly instability, preventing return to preinjury status. Immediate surgical repair is recommended for optimal return of knee function and power.
Zhang, Xu; Shao, Xinzhong; Huang, Yong
This article describes a previously unclassified type of combined tendon/bone mallet finger. This supplements the conventional Doyle classification. The article also describes the technique for surgical treatment of such mallet fingers, which involves the use of a pullout wire with K-wire stabilization of the distal interphalangeal joint.
Cohen, Shahar; Leshansky, Lucy; Zussman, Eyal; Burman, Michael; Srouji, Samer; Livne, Erella; Abramov, Natalie; Itskovitz-Eldor, Joseph
The use of stem cells for tissue engineering (TE) encourages scientists to design new platforms in the field of regenerative and reconstructive medicine. Human embryonic stem cells (hESC) have been proposed to be an important cell source for cell-based TE applications as well as an exciting tool for investigating the fundamentals of human development. Here, we describe the efficient derivation of connective tissue progenitors (CTPs) from hESC lines and fetal tissues. The CTPs were significantly expanded and induced to generate tendon tissues in vitro, with ultrastructural characteristics and biomechanical properties typical of mature tendons. We describe a simple method for engineering tendon grafts that can successfully repair injured Achilles tendons and restore the ankle joint extension movement in mice. We also show the CTP's ability to differentiate into bone, cartilage, and fat both in vitro and in vivo. This study offers evidence for the possibility of using stem cell-derived engineered grafts to replace missing tissues, and sets a basic platform for future cell-based TE applications in the fields of orthopedics and reconstructive surgery.
Kietrys, David M.; Barr-Gillespie, Ann E.; Amin, Mamta; Wade, Christine K.; Popoff, Steve N.; Barbe, Mary F.
We sought to determine if tendon inflammatory and histopathological responses increase in aged rats compared to young rats performing a voluntary upper extremity repetitive task, and if these changes are associated with motor declines. Ninety-six female Sprague-Dawley rats were used in the rat model of upper extremity overuse: 67 aged and 29 young adult rats. After a training period of 4 weeks, task rats performed a voluntary high repetition low force (HRLF) handle-pulling task for 2 hrs/day, 3 days/wk for up to 12 weeks. Upper extremity motor function was assessed, as were inflammatory and histomorphological changes in flexor digitorum and supraspinatus tendons. The percentage of successful reaches improved in young adult HRLF rats, but not in aged HRLF rats. Forelimb agility decreased transiently in young adult HRLF rats, but persistently in aged HRLF rats. HRLF task performance for 12 weeks lead to increased IL-1beta and IL-6 in flexor digitorum tendons of aged HRLF rats, compared to aged normal control (NC) as well as young adult HRLF rats. In contrast, TNF-alpha increased more in flexor digitorum tendons of young adult 12-week HRLF rats than in aged HRLF rats. Vascularity and collagen fibril organization were not affected by task performance in flexor digitorum tendons of either age group, although cellularity increased in both. By week 12 of HRLF task performance, vascularity and cellularity increased in the supraspinatus tendons of only aged rats. The increased cellularity was due to increased macrophages and connective tissue growth factor (CTGF)-immunoreactive fibroblasts in the peritendon. In conclusion, aged rat tendons were overall more affected by the HRLF task than young adult tendons, particularly supraspinatus tendons. Greater inflammatory changes in aged HRLF rat tendons were observed, increases associated temporally with decreased forelimb agility and lack of improvement in task success. PMID:23056540
Green, D. G.; Kellerth, J.-O.
1. Intracellular records have been taken from cat motoneurones innervating flexor muscles of the hind limb. Contractions of the ankle flexors tibialis anterior and extensor digitorum longus were elicited by stimulation of the peripheral end of the cut L 7 ventral root and the reflex effects of these contractions were recorded in silent and repetitively firing motoneurones. 2. Contraction usually produces a hyperpolarizing response inside flexor motoneurones. This hyperpolarization is tension-sensitive in the sense that when, at constant muscle extension, the strength of the contraction is increased, the magnitude of the inhibitory response is augmented. 3. Increasing the resting length of the muscles, while using a stimulus of constant strength to the ventral root, causes this inhibitory response to increase in some cells. More often, however, the hyperpolarization caused by contraction is gradually reduced in duration and/or amplitude as the muscles are extended. 4. Even with the muscles slackened, so that they develop no tension at their ends, contraction usually produces prominent hyperpolarization of the motoneurones. 5. By passing polarizing currents or injecting chloride ions through the intracellular micro-electrode, the hyperpolarizing potentials produced by contraction of the slack and extended muscles are shown to be, at least in part, genuinely post-synaptic inhibitory events. 6. When the neurone is fired repetitively by injected current, the `silent period' in contraction corresponds to the hyperpolarization of the post-synaptic membrane. 7. Monosynaptic testing of the flexor motoneurone pool has been used to confirm the essential features of the intracellularly recorded activity. 8. Acutely spinalizing the animal increases the magnitude of the inhibitory responses caused by contraction. 9. Recordings from dorsal root fibres show that Golgi tendon organs of the ankle flexors are very sensitive to contraction and are indeed often activated by the
Fluke, Erin C; Carayannopoulos, Nikoletta L; Lindsey, Ronald W
Pyogenic flexor tenosynovitis is an orthopedic emergency most commonly caused by Staphylococcus aureus and streptococci and occasionally, when associated with water exposure, Mycobacterium marinum. Shewanella algae, a gram-negative bacillus found in warm saltwater environments, has infrequently been reported to cause serious soft tissue infections and necrosis. In this case, S. algae caused complicated flexor tenosynovitis requiring open surgical irrigation and debridement. Flexor tenosynovitis caused by S. algae rapidly presented with all 4 Kanavel cardinal signs as well as subcutaneous purulence, ischemia, and necrosis, thus meeting the requirements for Pang et al group III classification of worst prognosis. Because of its rarity and virulence, S. algae should always be considered in cases of flexor tenosynovitis associated with traumatic water exposure to treat and minimize morbidity appropriately.
Razon, Rhea Victoria B; Nasir, Asad; Wu, George S; Soliman, Manal; Trilling, Jeffrey
Retropharyngeal calcific tendonitis is an inflammatory process of the superior oblique tendons of the longus colli muscle, a neck flexor in the upper cervical spine, caused by deposition of calcium hydroxyapatite crystals; the definitive diagnostic test is computed tomography (CT). Presented in this article are two cases seen at our institution. Patients typically present with acute onset of neck pain/spasm, odynophagia, dysphagia, and/or low grade fevers. Leukocytosis and elevated erythrocyte sedimentation rate may be noted. It is important to understand this entity because its signs and symptoms are mimickers of those of the more serious condition of retropharyngeal space abscess. Calcific tendonitis is managed conservatively whereas retropharyngeal abscess requires incision and drainage. Some may argue that this entity is a zebra because its reported incidence in the literature is low. However, most of these studies were done in an era when CT was not yet in vogue. With today's widespread use of CT and its superb ability to visualize the calcification, the true incidence of this condition is probably higher and, thus, it is important for the family practitioner to be aware of this entity. The astute clinician may save the patient from unnecessary diagnostic workup, undue anxiety, and delays in hospital discharge.
... Many things can make your elbow hurt. A common cause is tendinitis, an inflammation or injury to the tendons that attach muscle to bone. Tendinitis of the elbow is a sports injury, often from playing tennis or golf. You ...
... cuff are common. They include tendinitis, bursitis, and injuries such as tears. Rotator cuff tendons can become ... cuff depends on age, health, how severe the injury is, and how long you've had the ...
Lawson, Siân E M; Chateau, Henry; Pourcelot, Philippe; Denoix, Jean-Marie; Crevier-Denoix, Nathalie
The sagittal alteration of hoof balance is a common intervention in horses, with corrective shoeing being one of the most frequently applied methods of managing tendonitis. However, the effect of toe or heel elevation on tendon strains is poorly understood. This study aimed to examine the effect of toe and heel wedges on the superficial digital flexor tendon, deep digital flexor tendon, and the third interosseous muscle or suspensory ligament strains using in vivo data and an accurate subject-specific model. Kinematic data were recorded using invasive markers at the walk and trot. Computerized tomography was then used to create a subject-specific model of an equine distal forelimb and strains were calculated for the superficial digital flexor tendon, the deep digital flexor tendon accessory ligament and the suspensory ligament for seven trials each of normal shoes, and toe and heel elevation. As the proximal interphalangeal joint is often ignored in strain calculations, its influence on the strain calculations was also tested. The deep ligament showed the same results for walk and trot with the heel wedge decreasing peak strain and the toe wedge increasing it. The opposite results were seen in the suspensory ligament and the superficial digital flexor tendon with the heel wedge increasing peak strain and the toe wedge decreasing it. The proximal interphalangeal joint was shown to be influential on the strains calculated with normal shoes and the calculated effect of the wedges. Our results imply that corrective shoeing appears to decrease strain in the tendon being targeted; the possibility of increases in strain in other structures should also be considered.
Giusti, Betti; Pepe, Guglielmina
Tendons among connective tissue, mainly collagen, contain also elastic fibers (EF) made of fibrillin 1, fibrillin 2 and elastin that are broadly distributed in tendons and represent 1–2% of the dried mass of the tendon. Only in the last years, studies on structure and function of EF in tendons have been performed. Aim of this review is to revise data on the organization of EF in tendons, in particular fibrillin structure and function, and on the clinical manifestations associated to alterations of EF in tendons. Indeed, microfibrils may contribute to tendon mechanics; therefore, their alterations may cause joint hypermobility and contractures which have been found to be clinical features in patients with Marfan syndrome (MFS) and Beals syndrome. The two diseases are caused by mutations in genes FBN1 and FBN2 encoding fibrillin 1 and fibrillin 2, respectively. PMID:27812333
Qu, Jin; van Alphen, Nick A.; Thoreson, Andrew R.; Chen, Qingshan; An, Kai-Nan; Amadio, Peter C.; Schmid, Thomas M.; Zhao, Chunfeng
The purpose of the current study was to develop a novel technology to enhance tendon-to-bone interface healing by trypsinizing and mineralizing (TM) an intrasynovial tendon allograft in a rabbit bone tunnel model. Eight rabbit flexor digitorum profundus (FDP) tendons were used to optimize the trypsinization process. An additional 24 FDP tendons were stratified into control and TM groups; in each group, 4 tendons were used for in vitro evaluation of TM and 8 were transplanted into proximal tibial bone tunnels in rabbits. The samples were evaluated histologically and with mechanical testing at postoperative week 8. Maximum failure strength and linear stiffness were not significantly different between the control and TM tendons. A thin fibrous band of scar tissue formed at the graft-to-bone interface in the control group. However, only the TM group showed obvious new bone formation inside the tendon graft and a visible fibrocartilage layer at the bone tunnel entrance. This study is the first to explore effects of TM on the intrasynovial allograft healing to a bone tunnel. TM showed beneficial effects on chondrogenesis, osteogenesis, and integration of the intrasynovial tendon graft, but mechanical strength was the same as the control tendons in this short-term in vivo study. PMID:25611186
Qu, Jin; van Alphen, Nick A; Thoreson, Andrew R; Chen, Qingshan; An, Kai-Nan; Amadio, Peter C; Schmid, Thomas M; Zhao, Chunfeng
The purpose of the current study was to develop a novel technology to enhance tendon-to-bone interface healing by trypsinizing and mineralizing (TM) an intrasynovial tendon allograft in a rabbit bone tunnel model. Eight rabbit flexor digitorum profundus (FDP) tendons were used to optimize the trypsinization process. An additional 24 FDP tendons were stratified into control and TM groups; in each group, 4 tendons were used for in vitro evaluation of TM and 8 were transplanted into proximal tibial bone tunnels in rabbits. The samples were evaluated histologically and with mechanical testing at postoperative week 8. Maximum failure strength and linear stiffness were not significantly different between the control and TM tendons. A thin fibrous band of scar tissue formed at the graft-to-bone interface in the control group. However, only the TM group showed obvious new bone formation inside the tendon graft and a visible fibrocartilage layer at the bone tunnel entrance. This study is the first to explore effects of TM on the intrasynovial allograft healing to a bone tunnel. TM showed beneficial effects on chondrogenesis, osteogenesis, and integration of the intrasynovial tendon graft, but mechanical strength was the same as the control tendons in this short-term in vivo study.
Zini, Raul; Panascì, Manlio; Papalia, Rocco; Franceschi, Francesco; Vasta, Sebastiano; Denaro, Vincenzo
Background: Since it was developed, hip arthroscopy has become the favored treatment for femoroacetabular impingement. Due to recent considerable improvements, the indications for this technique have been widely extended. Injuries of the rectus femoris tendon origin, after an acute phase, could result in a chronic tendinopathy with calcium hydroxyapatite crystal deposition, leading to pain and loss of function. Traditionally, this condition is addressed by local injection of anesthetic and corticosteroids or, when conservative measures fail, by open excision of the calcific lesion by an anterior approach. Purpose: To assess whether arthroscopic excision of calcification of the proximal rectus is a safe and effective treatment. Study Design: Case series; Level of evidence, 4. Methods: Outcomes were studied from 6 top amateur athletes (age range, 30-43 years; mean, 32.6 years) affected by calcification of the proximal rectus who underwent arthroscopic excision of the calcification. Patients were preoperatively assessed radiographically, and diagnosis was confirmed by a 3-dimensional computed tomography scan. To evaluate the outcome, standardized hip rating scores were used pre- and postoperatively (at 6 and 12 months): the Hip disability and Osteoarthritis Outcome Score, Oxford Hip Score, and Modified Harris Hip Score. Moreover, visual analog scales (VAS) for pain, sport activity level (SAL), and activities of daily living (ADL) were also used. Results: One year after surgery, all patients reported satisfactory outcomes, with 3 of 6 rating their return-to-sport level as high as preinjury level, and the remaining 3 with a percentage higher than 80%. Five patients ranked their ability to carry on daily activities at 100%. Statistical analysis showed significant improvement of the Oxford Hip Score, the Modified Harris Hip Score, and all 3 VAS subscales (pain, SAL, and ADL) from pre- to latest postoperative assessment (P < .05). Conclusion: Arthroscopic excision of
Kirane, Y M; Michelson, J D; Sharkey, N A
Studying mechanics of the muscles spanning multiple joints provides insights into intersegmental dynamics and movement coordination. Multiarticular muscles are thought to function at "near-isometric" lengths to transfer mechanical energy between the adjacent body segments. Flexor hallucis longus (FHL) is a multiarticular flexor of the great toe; however, its potential isometric function has received little attention. We used a robotic loading apparatus to investigate FHL mechanics during simulated walking in cadaver feet, and hypothesized that physiological force transmission across the foot can occur with isometric FHL function. The extrinsic foot tendons, stripped of the muscle fibers, were connected to computer-controlled linear actuators. The FHL activity was controlled using force-feedback (FC) based upon electromyographic data from healthy subjects, and subsequently, isometric positional feedback (PC), maintaining the FHL myotendinous junction stationary during simulated walking. Tendon forces and excursions were recorded, as were the strains within the first metatarsal. Forces in the metatarsal and metatarsophalangeal joint were derived from these strains. The FHL tendon excursion under FC was 6.57+/-3.13mm. The forces generated in the FHL tendon, metatarsal and metatarsophalangeal joint with the FHL under isometric PC were not significantly different in pattern from FC. These observations provide evidence that physiological forces could be generated along the great toe with isometric FHL function. A length servo mechanism such as the stretch reflex could likely control the isometric FHL function during in vivo locomotion; this could have interesting implications regarding the conditions of impaired stretch reflex such as spastic paresis and peripheral neuropathies.
Sofos, Stratos S; Riaz, Muhammad
Purpose. We present an extremely rare anatomical variation of unilateral flexor carpi radialis (FCR) absence. This rare anatomical variation posed a clinical dilemma to us and we highlight the importance of the surgeon being aware of this anatomical variation of an important structure both as a reconstruction tool and as an anatomical landmark. Methods. This anatomical variation of the unilaterally absent FCR was found upon dissection during a carpometacarpal arthroplasty of the thumb. Results. Upon the discovery of an absent FCR tendon, we proceeded with a simple trapeziectomy. Conclusions. We present an extremely rare anatomical variation of unilateral FCR absence. This rare anatomical variation may pose clinical dilemmas to the operating surgeon who aims to utilise the FCR either for tendon transfer, for tendon graft, or, as seen in our case, in the reconstruction of a carpometacarpal excision at the thumb. We highlight this diagnosis of suspicion, which may influence the clinical procedure.
MANCINI, FEDERICO; BERNARDI, GABRIELE; DE LUNA, VINCENZO; TUDISCO, COSIMO
Rupture or avulsion of the distal triceps tendon is one of the least common tendon injuries. The most common clinical presentation of the injury is avulsion from the olecranon. The diagnosis of acute triceps tendon rupture may be missed and this can result in prolonged disability. We report the case of a 42-year-old man with isolated triceps rupture treated by an open surgical repair technique involving the use of bone suture anchors. PMID:28217662
Ignatiadis, Ioannis A; Georgakopoulos, Georgios D; Tsiampa, Vassiliki A; Polyzois, Vasilios D; Arapoglou, Dimitrios K; Papalois, Apostolos E
Management of Achilles tendon and heel area defects is a common challenge for the reconstructive surgeon due to the lack of soft tissue availability in that region. In this article, we present our experience in covering these defects by using the distal perforator propeller flaps based on the posterior tibial artery. Perforator flaps are based on cutaneous, small diameter vessels that originate from a main pedicle and perforate the fascia or muscle to reach the skin. Their development has followed the understanding of the blood supply from a source artery to the skin. Six patients (five males and one female) underwent reconstruction by using the posterior tibial artery distal perforator flap for covering defects in the distal Achilles tendon region in patients with and without diabetes mellitus. Postoperative complications included a hypertrophic scar formation in one patient, partial marginal flap necrosis in another patient, and a wound infection in a third patient. All wounds were eventually healed by the last postoperative visit. In conclusion, perforator flaps based on the distal posterior tibial artery may be a reliable option for the coverage of small to moderate size defects of the Achilles tendon and heel area regions.
Ignatiadis, Ioannis A.; Georgakopoulos, Georgios D.; Tsiampa, Vassiliki A.; Polyzois, Vasilios D.; Arapoglou, Dimitrios K.; Papalois, Apostolos E.
Management of Achilles tendon and heel area defects is a common challenge for the reconstructive surgeon due to the lack of soft tissue availability in that region. In this article, we present our experience in covering these defects by using the distal perforator propeller flaps based on the posterior tibial artery. Perforator flaps are based on cutaneous, small diameter vessels that originate from a main pedicle and perforate the fascia or muscle to reach the skin. Their development has followed the understanding of the blood supply from a source artery to the skin. Six patients (five males and one female) underwent reconstruction by using the posterior tibial artery distal perforator flap for covering defects in the distal Achilles tendon region in patients with and without diabetes mellitus. Postoperative complications included a hypertrophic scar formation in one patient, partial marginal flap necrosis in another patient, and a wound infection in a third patient. All wounds were eventually healed by the last postoperative visit. In conclusion, perforator flaps based on the distal posterior tibial artery may be a reliable option for the coverage of small to moderate size defects of the Achilles tendon and heel area regions. PMID:22396820
Rothrauff, Benjamin B; Tuan, Rocky S
The intrasynovial bone-tendon interface is a gradual transition from soft tissue to bone, with two intervening zones of uncalcified and calcified fibrocartilage. Following injury, the native anatomy is not restored, resulting in inferior mechanical properties and an increased risk of re-injury. Recent in vivo studies provide evidence of improved healing when surgical repair of the bone-tendon interface is augmented with cells capable of undergoing chondrogenesis. In particular, cellular therapy in bone-tendon healing can promote fibrocartilage formation and associated improvements in mechanical properties. Despite these promising results in animal models, cellular therapy in human patients remains largely unexplored. This review highlights the development and structure-function relationship of normal bone-tendon insertions. The natural healing response to injury is discussed, with subsequent review of recent research on cellular approaches for improved healing. Finally, opportunities for translating in vivo findings into clinical practice are identified. PMID:24326955
Wiesinger, Hans-Peter; Rieder, Florian; Kösters, Alexander; Müller, Erich; Seynnes, Olivier R.
Introduction: During running and jumping activities, elastic energy is utilized to enhance muscle mechanical output and efficiency. However, training-induced variations in tendon spring-like properties remain under-investigated. The present work extends earlier findings on sport-specific profiles of tendon stiffness and cross-sectional area to examine whether years of distinct loading patterns are reflected by tendons' ability to store and return energy. Methods:Ultrasound scans were performed to examine the morphological features of knee extensor and plantar flexor muscle-tendon units in elite ski jumpers, distance runners, water polo players, and sedentary controls. Tendon strain energy and hysteresis were measured with combined motion capture, ultrasonography, and dynamometry. Results: Apart from the fractional muscle-to-tendon cross-sectional area ratio being lower in the knee extensors of ski jumpers (−31%) and runners (−33%) than in water polo players, no difference in the considered muscle-tendon unit morphological features was observed between groups. Similarly, no significant difference in tendon energy storage or energy return was detected between groups. In contrast, hysteresis was lower in the patellar tendon of ski jumpers (−33%) and runners (−30%) compared to controls, with a similar trend for the Achilles tendon (significant interaction effect and large effect sizes η2 = 0.2). Normalized to body mass, the recovered strain energy of the patellar tendon was ~50% higher in ski jumpers than in water polo players and controls. For the Achilles tendon, recovered strain energy was ~40% higher in ski jumpers and runners than in controls. Discussion: Advantageous mechanical properties related to tendon spring-like function are observed in elite athletes whose sport require effective utilization of elastic energy. However, the mechanisms underpinning the better tendon capacity of some athletes to retain elastic energy could not be ascribed to
Wiesinger, Hans-Peter; Rieder, Florian; Kösters, Alexander; Müller, Erich; Seynnes, Olivier R
Introduction: During running and jumping activities, elastic energy is utilized to enhance muscle mechanical output and efficiency. However, training-induced variations in tendon spring-like properties remain under-investigated. The present work extends earlier findings on sport-specific profiles of tendon stiffness and cross-sectional area to examine whether years of distinct loading patterns are reflected by tendons' ability to store and return energy. Methods:Ultrasound scans were performed to examine the morphological features of knee extensor and plantar flexor muscle-tendon units in elite ski jumpers, distance runners, water polo players, and sedentary controls. Tendon strain energy and hysteresis were measured with combined motion capture, ultrasonography, and dynamometry. Results: Apart from the fractional muscle-to-tendon cross-sectional area ratio being lower in the knee extensors of ski jumpers (-31%) and runners (-33%) than in water polo players, no difference in the considered muscle-tendon unit morphological features was observed between groups. Similarly, no significant difference in tendon energy storage or energy return was detected between groups. In contrast, hysteresis was lower in the patellar tendon of ski jumpers (-33%) and runners (-30%) compared to controls, with a similar trend for the Achilles tendon (significant interaction effect and large effect sizes η(2) = 0.2). Normalized to body mass, the recovered strain energy of the patellar tendon was ~50% higher in ski jumpers than in water polo players and controls. For the Achilles tendon, recovered strain energy was ~40% higher in ski jumpers and runners than in controls. Discussion: Advantageous mechanical properties related to tendon spring-like function are observed in elite athletes whose sport require effective utilization of elastic energy. However, the mechanisms underpinning the better tendon capacity of some athletes to retain elastic energy could not be ascribed to intrinsic or
El Domiaty, M A; Zoair, M M; Sheta, A A
Entrapment neuropathy in the forearm is not uncommon. Surgical interference for nerve decompression should be preceded by accurate diagnosis of the exact cause and site of the nerve entrapment. The aim of the present study was to investigate the prevalence of accessory heads of the flexor pollicis longus and flexor digitorum profundus muscles (FPLah) and (FDPah) in Egyptians and their topographical relationship with both the median nerve and its anterior interosseous branch. A total of 42 upper limbs of embalmed cadavers, 36 from males and 6 from females, were examined to elucidate the prevalence of both the FPLah and the FDPah muscles, their origin, insertion, nerve supply and morphology. The distribution of these two muscles in the right and left male and female upper limbs and their relationship to the anterior interosseous and median nerves were recorded. The total lengths of both accessory muscles and the lengths of their fleshy bellies and tendons were also measured. The FPLah was found to be present more frequently (61.9%) than it was absent, whereas the FDPah was observed in only 14.24% of the specimens examined. The combination of the accessory muscles in the same forearm was noticed in 9.52% of cases. As regards side, the FPLah appeared in 77.7% of the right forearms and in 50% of the left, while the FDPah was found in only 25% of the left forearms. The accessory muscles showed no single morphology, as the FPLah appeared fusiform in 53.8%, slender in 30.8% and voluminous fusiform in 15.4%, while the FDPah was slender in 66.6% and triangular in 33.3% of specimens. The FPLah arose mainly from the under surface of flexor digitorum superficialis, while the FDPah took its origin from the under surface of flexor digitorum superficialis or from the medial epicondyle. The insertion of the FPLah was mainly into the upper third of the FPL tendon, while the FDPah tendon joined the tendons of the flexor digitorum profundus muscle to the index or middle and ring
Cortes, Daniel H.; Suydam, Stephen M.; Silbernagel, Karin Grävare; Buchanan, Thomas S.; Elliott, Dawn M.
Viscoelastic mechanical properties are frequently altered after tendon injuries and during recovery. Therefore, non-invasive measurements of shear viscoelastic properties may help evaluate tendon recovery and compare the effectiveness of different therapies. The objectives of this study are to present an elastography method to measure localized viscoelastic properties of tendon and to present initial results in healthy and injured human Achilles and semitendinosus tendons. The technique used an external actuator to generate the shear waves in the tendon at different frequencies and plane wave imaging to measure shear wave displacements. For each of the excitation frequencies, maps of direction specific wave speeds were calculated using Local Frequency Estimation. Maps of viscoelastic properties were obtained using a pixel wise curve-fit of wave speed and frequency. The method was validated by comparing measurements of wave speed in agarose gels to those obtained using magnetic resonance elastography. Measurements in human healthy Achilles tendons revealed a pronounced increase in wave speed as function of frequency that highlights the importance of tendon viscoelasticity. Additionally, the viscoelastic properties of the Achilles tendon were larger than those reported for other tissues. Measurements in a tendinopathic Achilles tendon showed that it is feasible to quantify local viscoeasltic properties. Similarly, measurement in the semitendinosus tendon showed a substantial differences in viscoelastic properties between the healthy and contralateral tendons. Consequently, this technique has the potential of evaluating localized changes in tendon viscoelastic properties due to injury and during recovery in a clinical setting. PMID:25796414
Buda, Roberto; Castagnini, Francesco; Pagliazzi, Gherardo; Giannini, Sandro
Chronic Achilles tendon lesions (CATLs) ensue from a neglected acute rupture or a degenerated tendon. Surgical treatment is usually required. The current English literature (PubMed) about CATLs was revised, and particular emphasis was given to articles depicting CATL classification. The available treatment algorithms are based on defect size. We propose the inclusion of other parameters, such as tendon degeneration, etiology, and time from injury to surgery. Partial lesions affecting less than (I stage) or more than (II stage) half of the tendon should be treated conservatively for healthy tendons, within 12 weeks of injury. In II stage complex cases, an end-to-end anastomosis is required. Complete lesions inferior to 2 cm should be addressed by an end-to-end anastomosis, with a tendon transfer in the case of tendon degeneration. Lesions measuring 2 to 5 cm require a turndown flap and a V-Y tendinous flap in the case of a good-quality tendon; degenerated tendons may require a tendon transfer. Lesions larger than 5 cm should be treated using two tendon transfers and V-Y tendinous flaps. A proper algorithm should be introduced to calibrate the surgical procedures. In addition to tendon defect size, tendon degeneration, etiology of the lesion, and time from injury to surgery are crucial factors that should be considered in the surgical planning.
Shim, Vickie B; Fernandez, Justin W; Gamage, Prasad B; Regnery, Camille; Smith, David W; Gardiner, Bruce S; Lloyd, David G; Besier, Thor F
Achilles tendon injuries including rupture are one of the most frequent musculoskeletal injuries, but the mechanisms for these injuries are still not fully understood. Previous in vivo and experimental studies suggest that tendon rupture mainly occurs in the tendon mid-section and predominantly more in men than women due to reasons yet to be identified. Therefore we aimed to investigate possible mechanisms for tendon rupture using finite element (FE) analysis. Specifically, we have developed a framework for generating subject-specific FE models of human Achilles tendon. A total of ten 3D FE models of human Achilles tendon were generated. Subject-specific geometries were obtained using ultrasound images and a mesh morphing technique called Free Form Deformation. Tendon material properties were obtained by performing material optimization that compared and minimized difference in uniaxial tension experimental results with model predictions. Our results showed that both tendon geometry and material properties are highly subject-specific. This subject-specificity was also evident in our rupture predictions as the locations and loads of tendon ruptures were different in all specimens tested. A parametric study was performed to characterize the influence of geometries and material properties on tendon rupture. Our results showed that tendon rupture locations were dependent largely on geometry while rupture loads were more influenced by tendon material properties. Future work will investigate the role of microstructural properties of the tissue on tendon rupture and degeneration by using advanced material descriptions.
Thorpe, Chavaunne T; Riley, Graham P; Birch, Helen L; Clegg, Peter D; Screen, Hazel R C
Tendon is composed of rope-like fascicles bound together by interfascicular matrix (IFM). The IFM is critical for the function of energy storing tendons, facilitating sliding between fascicles to allow these tendons to cyclically stretch and recoil. This capacity is required to a lesser degree in positional tendons. We have previously demonstrated that both fascicles and IFM in energy storing tendons have superior fatigue resistance compared with positional tendons, but the effect of ageing on the fatigue properties of these different tendon subunits has not been determined. Energy storing tendons become more injury-prone with ageing, indicating reduced fatigue resistance, hence we tested the hypothesis that the decline in fatigue life with ageing in energy storing tendons would be more pronounced in the IFM than in fascicles. We further hypothesised that tendon subunit fatigue resistance would not alter with ageing in positional tendons. Fascicles and IFM from young and old energy storing and positional tendons were subjected to cyclic fatigue testing until failure, and mechanical properties were calculated. The results show that both IFM and fascicles from the SDFT exhibit a similar magnitude of reduced fatigue life with ageing. By contrast, the fatigue life of positional tendon subunits was unaffected by ageing. The age-related decline in fatigue life of tendon subunits in energy storing tendons is likely to contribute to the increased risk of injury in aged tendons. Full understanding of the mechanisms resulting in this reduced fatigue life will aid in the development of treatments and interventions to prevent age-related tendinopathy.
Schiele, Nathan R.; von Flotow, Friedrich; Tochka, Zachary L.; Hockaday, Laura A.; Marturano, Joseph E.; Thibodeau, Jeffrey J.; Kuo, Catherine K.
Tendon injuries are common and heal poorly. Strategies to regenerate or replace injured tendons are challenged by an incomplete understanding of normal tendon development. Our previous study showed that embryonic tendon elastic modulus increases as a function of developmental stage. Inhibition of enzymatic collagen crosslink formation abrogated increases in tendon elastic modulus at late developmental stages, but did not affect increases in elastic modulus of early stage embryonic tendons. Here, we aimed to identify potential contributors to the mechanical properties of these early stage embryonic tendons. We characterized tendon progenitor cells in early stage embryonic tendons, and the influence of actin cytoskeleton disruption on tissue elastic modulus. Cells were closely packed in embryonic tendons, and did not change in density during early development. We observed an organized network of actin filaments that seemed contiguous between adjacent cells. The actin filaments exhibited a crimp pattern with a period and amplitude that matched the crimp of collagen fibers at each developmental stage. Chemical disruption of the actin cytoskeleton decreased tendon tissue elastic modulus, measured by atomic force microscopy. Our results demonstrate that early developmental stage embryonic tendons possess a well organized actin cytoskeleton network that contributes significantly to tendon tissue mechanical properties. PMID:25721681
Schiele, Nathan R; von Flotow, Friedrich; Tochka, Zachary L; Hockaday, Laura A; Marturano, Joseph E; Thibodeau, Jeffrey J; Kuo, Catherine K
Tendon injuries are common and heal poorly. Strategies to regenerate or replace injured tendons are challenged by an incomplete understanding of normal tendon development. Our previous study showed that embryonic tendon elastic modulus increases as a function of developmental stage. Inhibition of enzymatic collagen crosslink formation abrogated increases in tendon elastic modulus at late developmental stages, but did not affect increases in elastic modulus of early stage embryonic tendons. Here, we aimed to identify potential contributors to the mechanical properties of these early stage embryonic tendons. We characterized tendon progenitor cells in early stage embryonic tendons, and the influence of actin cytoskeleton disruption on tissue elastic modulus. Cells were closely packed in embryonic tendons, and did not change in density during early development. We observed an organized network of actin filaments that seemed contiguous between adjacent cells. The actin filaments exhibited a crimp pattern with a period and amplitude that matched the crimp of collagen fibers at each developmental stage. Chemical disruption of the actin cytoskeleton decreased tendon tissue elastic modulus, measured by atomic force microscopy. Our results demonstrate that early developmental stage embryonic tendons possess a well organized actin cytoskeleton network that contributes significantly to tendon tissue mechanical properties.
Jeon, Byung-Joon; Lee, Jung-Il; Kim, Jin Soo; Lee, Dong Chul; Lee, Kyung Jin
Background The purpose of this study was to identify comprehensive hand injury patterns in different pediatric age groups and to assess their risk factors. Methods This retrospective study was conducted among patients younger than 16-year-old who presented to the emergency room of a general hospital located in Gyeonggi-do, Republic of Korea, and were treated for an injury of the finger or hand from January 2010 to December 2014. The authors analyzed the medical records of 344 patients. Age was categorized according to five groups. Results A total of 391 injury sites of 344 patients were evaluated for this study. Overall and in each group, male patients were in the majority. With regard to dominant or non-dominant hand involvement, there were no significant differences. Door-related injuries were the most common cause in the age groups of 0 to 3, 4 to 6, and 7 to 9 years. Sport/recreational activities or physical conflict injuries were the most common cause in those aged 10 to 12 and 13 to 15. Amputation and crushing injury was the most common type in those aged 0 to 3 and 4 to 6 years. However, in those aged 10 to 12 and 13 to 15, deep laceration and closed fracture was the most common type. With increasing age, closed injuries tended to increase more sharply than open injuries, extensor tendon rupture more than flexor injuries, and the level of injury moved proximally. Conclusions This study provides a comprehensive overview of the epidemiology of hand injuries in the pediatric population. PMID:26848449
Asai, Shuji; Otsuru, Satoru; Candela, Maria Elena; Cantley, Leslie; Uchibe, Kenta; Hofmann, Ted J; Zhang, Kairui; Wapner, Keith L; Soslowsky, Louis J; Horwitz, Edwin M; Enomoto-Iwamoto, Motomi
To study the cellular mechanism of the tendon repair process, we used a mouse Achilles tendon injury model to focus on the cells recruited to the injured site. The cells isolated from injured tendon 1 week after the surgery and uninjured tendons contained the connective tissue progenitor populations as determined by colony-forming capacity, cell surface markers, and multipotency. When the injured tendon-derived progenitor cells (inTPCs) were transplanted into injured Achilles tendons, they were not only integrated in the regenerating area expressing tenogenic phenotype but also trans-differentiated into chondrogenic cells in the degenerative lesion that underwent ectopic endochondral ossification. Surprisingly, the micromass culture of the inTPCs rapidly underwent chondrogenic differentiation even in the absence of exogenous bone morphogenetic proteins or TGFβs. The cells isolated from human ruptured tendon tissues also showed connective tissue progenitor properties and exhibited stronger chondrogenic ability than bone marrow stromal cells. The mouse inTPCs contained two subpopulations one positive and one negative for CD105, a coreceptor of the TGFβ superfamily. The CD105-negative cells showed superior chondrogenic potential in vitro and induced larger chondroid degenerative lesions in mice as compared to the CD105-positive cells. These findings indicate that tendon progenitor cells are recruited to the injured site of tendons and have a strong chondrogenic potential and that the CD105-negative population of these cells would be the cause for chondroid degeneration in injured tendons. The newly identified cells recruited to the injured tendon may provide novel targets to develop therapeutic strategies to facilitate tendon repair.
Koyama, H; Murakami, K; Suzuki, T; Suzaki, K
Hip flexor spasticity, which is often associated with central nervous system (CNS) diseases, is a major impediment in rehabilitation. In order to cope with this problem, lumbar nerve blocking techniques developed by Meelhuysen and major and minor psoas muscle blocking techniques developed by Awad have been used in combination with physical therapies. Based on these techniques, we conducted major and minor psoas muscle phenol block (motor point block or intramuscular nerve block) under ultrasonic monitoring. Phenol block was conducted in nine patients with cerebral infarction (13 blocking procedures) and three with spinal cord injuries (six blocking procedures) while keeping them in a lateral position with the operation side upside. The beginning of the femoral nerves and part of the lumbar artery were visualized by ultrasound in some patients. As a result of the improvement of hip flexor spasticity, the range of hip joint motion (determined by the Mundale technique, prone hip extension and Thomas test) improved shortly after blocking. When physical therapy was conducted after blocking, improvement of skin care management was observed in eight cases, ability to keep in a stable sitting position in nine, improvement of a standing posture in three, increases in the ability to walk in two and alleviation of pain in three. Although nerve block is reported to result in hematoma, decreases in muscle force, pain, cystic/rectal disorders and hypogonadism, we have observed no such complication in our patients.
Zhang, Kairui; Zhang, Sheng; Li, Qianqian; Yang, Jun; Dong, Weiqiang; Wang, Shengnan; Cheng, Yirong; Al-Qwbani, Mohammed; Wang, Qiang; Yu, Bin
Highlights: • Celecoxib has no effects on TDSCs cell proliferation in various concentrations. • Celecoxib reduced mRNAs levels of tendon associated transcription factor. • Celecoxib reduced mRNAs levels of main tendon associated collagen. • Celecoxib reduced mRNAs levels of tendon associated molecules. - Abstract: NSAIDs are often ingested to reduce the pain and improve regeneration of tendon after tendon injury. Although the effects of NSAIDs in tendon healing have been reported, the data and conclusions are not consistent. Recently, tendon-derived stem cells (TDSCs) have been isolated from tendon tissues and has been suggested involved in tendon repair. Our study aims to determine the effects of COX-2 inhibitor (celecoxib) on the proliferation and tenocytic differentiation of TDSCs. TDSCs were isolated from mice Achilles tendon and exposed to celecoxib. Cell proliferation rate was investigated at various concentrations (0.1, 1, 10 and 100 μg/ml) of celecoxib by using hemocytometer. The mRNA expression of tendon associated transcription factors, tendon associated collagens and tendon associated molecules were determined by reverse transcription-polymerase chain reaction. The protein expression of Collagen I, Collagen III, Scleraxis and Tenomodulin were determined by Western blotting. The results showed that celecoxib has no effects on TDSCs cell proliferation in various concentrations (p > 0.05). The levels of most tendon associated transcription factors, tendon associated collagens and tendon associated molecules genes expression were significantly decreased in celecoxib (10 μg/ml) treated group (p < 0.05). Collagen I, Collagen III, Scleraxis and Tenomodulin protein expression were also significantly decreased in celecoxib (10 μg/ml) treated group (p < 0.05). In conclusion, celecoxib inhibits tenocytic differentiation of tendon-derived stem cells but has no effects on cell proliferation.
distal tendon. Although these findings overlap with those seen in tendinopathy , the presence of bone marrow edema at the radial tuberosity and fluid in...the bicipitoradial bursa suggests a partial tear rather than tendinopathy .3 When the distal biceps tendon tear is complete, MR imaging shows
Veljkovic, Andrea; Lansang, Edward; Lau, Johnny
Flexible forefoot deformities, such as hallux varus, clawed hallux, hammer toes, and angular lesser toe deformities, can be treated effectively with tendon transfers. Based on the presentation of the flexible forefoot deformities, tendon transfers can be used as the primary treatment or as adjuncts to bony procedures when there are components of fixed deformities.
Beck, Travis W; Ye, Xin; Wages, Nathan P
The purpose of this study was to compare the electromyographic (EMG) intensity patterns after unilateral concentric vs. eccentric exercise in the dominant (DOM) and nondominant (NONDOM) forearm flexors. Twenty-six men (mean ± SD: age, 24.0 ± 3.7 years) volunteered to perform a maximal isometric muscle action of the DOM and NONDOM forearm flexors before (PRE) and immediately after (POST) a series of maximal concentric isokinetic or maximal eccentric isokinetic muscle actions of the DOM forearm flexors. The concentric isokinetic and eccentric isokinetic muscle actions were performed on separate days that were randomly ordered. However, in both cases, the subjects performed 6 sets of 10 maximal muscle actions. A bipolar surface EMG signal was detected from the biceps brachii of the DOM and NONDOM limbs during the PRE and POST isometric muscle actions. The signals were then analyzed with a wavelet analysis, and the resulting intensity patterns were classified with a paired pattern classification procedure. The results indicated that the EMG intensity patterns could be correctly classified into their respective PRE vs. POST categories with an accuracy rate that was significantly better than random (20 of 26 patterns = 76.9% accuracy) but only for the DOM limb following the eccentric muscle actions. All other classifications were not significantly better than random. These findings indicated that eccentric exercise had a significant influence on the muscle activation pattern for the forearm flexors. It is possible that the muscle damage resulting from eccentric exercise affects muscle spindle or golgi tendon organ or both activity, thereby altering the muscle activation pattern.
Gajendran, Varun K; Bishop, Julius A
Terrible triad elbow injuries, consisting of fractures of the radial head and coronoid with ulnohumeral dislocation, are challenging to treat. They require a comprehensive understanding of the complex anatomy of the elbow to effectively treat all of the pathology and create a stable, congruent joint. The authors present a case of a terrible triad injury with avulsion of the triceps and flexor-pronator mass after a low-energy fall in a young patient. Although most terrible triad fracture-dislocations can be successfully treated with coronoid fixation, radial head fixation or replacement, and repair of the lateral collateral ligament complex, this case involved a completely circumferential injury to the elbow. The coronoid and anterior capsule were disrupted anteriorly, the radial head and lateral collateral ligament complex were disrupted laterally, the triceps was disrupted posteriorly, and the flexor-pronator mass was disrupted medially. Although the authors prefer to address most terrible triad injuries through a lateral approach, they suspected a circumferential injury preoperatively and elected to use a single posterior incision to address all of the pathology conveniently. This injury required treatment of all disrupted structures, because the elbow remained unstable until the triceps and flexor-pronator mass avulsions were ultimately repaired. With any elbow fracture-dislocation, surgeons should look for evidence of additional injuries that do not fit the commonly described patterns, because they may necessitate modifications to the treatment plan. Given the relatively common complications of stiffness and instability despite modern surgical techniques, additional injuries may further compromise functional outcomes unless they are addressed properly.
The tibialis posterior tendon is the largest and anteriormost tendon in the medial ankle. It produces plantar flexion and supination of the ankle and stabilizes the plantar vault. Sonographic assessment of this tendon is done with high-frequency, linear-array transducers; an optimal examination requires transverse retromalleolar, longitudinal retromalleolar, and distal longitudinal scans, as well as dynamic studies. Disorders of the posterior tibial tendon include chronic tendinopathy with progressive rupture, tenosynovitis, acute rupture, dislocation and instability, enthesopathies. The most common lesion is a progressive "chewing gum" lesion that develops in a setting of chronic tendinopathy; it is usually seen in overweight women over 50 years of age with valgus flat feet. Medial ankle pain must also be carefully investigated, and the presence of instability assessed with dynamic maneuvers (forced inversion, or dorsiflexion) of the foot. Sonography plays an important role in the investigation of disorders involving the posterior tibial tendon.
Liu, N. R.; Zhang, X. Z.; Qiu, Y. S.; Chen, R.
The aim of this study was to examine the characteristics of skeletal muscle fibers in tail tendons, explore the content of intrinsic components at different depths and ascertain the optimum excitation wavelength, which will help to establish a relationship between diagnosis and therapy and the tendon injury. A multiphoton microscopic imaging system was used to achieve the images and spectra via an imaging mode and a Lambda mode, respectively. This work demonstrates that the skeletal muscle fibers of the tail tendon are in good order. Second harmonic generation (SHG) and two-photon excited fluorescence (TPEF) signals originating from certain intrinsic components are varied with depth, and the SHG/TPEF intensity ratios are varied at different excitation wavelengths. Below 800 nm is the optimum for cell TPEF, while above 800 nm is the optimum for SHG. With the development of imaging techniques, a nonlinear optical imaging system will be helpful to represent the functional behaviors of tissue related to tendon injury.
Huang, Alice H; Riordan, Timothy J; Wang, Lingyan; Eyal, Shai; Zelzer, Elazar; Brigande, John V; Schweitzer, Ronen
The muscles that govern hand motion are composed of extrinsic muscles that reside within the forearm and intrinsic muscles that reside within the hand. We find that the extrinsic muscles of the flexor digitorum superficialis (FDS) first differentiate as intrinsic muscles within the hand and then relocate as myofibers to their final position in the arm. This remarkable translocation of differentiated myofibers across a joint is dependent on muscle contraction and muscle-tendon attachment. Interestingly, the intrinsic flexor digitorum brevis (FDB) muscles of the foot are identical to the FDS in tendon pattern and delayed developmental timing but undergo limited muscle translocation, providing strong support for evolutionary homology between the FDS and FDB muscles. We propose that the intrinsic FDB pattern represents the original tetrapod limb and that translocation of the muscles to form the FDS is a mammalian evolutionary addition.
LaCroix, Andrew S; Duenwald-Kuehl, Sarah E; Lakes, Roderic S; Vanderby, Ray
Tendon is a highly specialized, hierarchical tissue designed to transfer forces from muscle to bone; complex viscoelastic and anisotropic behaviors have been extensively characterized for specific subsets of tendons. Reported mechanical data consistently show a pseudoelastic, stress-vs.-strain behavior with a linear slope after an initial toe region. Many studies report a linear, elastic modulus, or Young's modulus (hereafter called elastic modulus) and ultimate stress for their tendon specimens. Individually, these studies are unable to provide a broader, interstudy understanding of tendon mechanical behavior. Herein we present a metaanalysis of pooled mechanical data from a representative sample of tendons from different species. These data include healthy tendons and those altered by injury and healing, genetic modification, allograft preparation, mechanical environment, and age. Fifty studies were selected and analyzed. Despite a wide range of mechanical properties between and within species, elastic modulus and ultimate stress are highly correlated (R(2) = 0.785), suggesting that tendon failure is highly strain-dependent. Furthermore, this relationship was observed to be predictable over controlled ranges of elastic moduli, as would be typical of any individual species. With the knowledge gained through this metaanalysis, noninvasive tools could measure elastic modulus in vivo and reasonably predict ultimate stress (or structural compromise) for diseased or injured tendon.
Tendon injuries are a common cause of morbidity and a significant health burden on society. Tendons are structural tissues connecting muscle to bone and are prone to tearing and tendinopathy, an overuse or degenerative condition that is characterized by failed healing and cellular depletion. Current treatments, for tendon tear are conservative, surgical repair or surgical scaffold reconstruction. Tendinopathy is treated by exercises, injection therapies, shock wave treatments or surgical tendon debridement. However, tendons usually heal with fibrosis and scar tissue, which has suboptimal tensile strength and is prone to reinjury, resulting in lifestyle changes with activity restriction. Preclinical studies show that cell therapies have the potential to regenerate rather than repair tendon tissue, a process termed tenogenesis. A number of different cell lines, with varying degrees of differentiation, have being evaluated including stem cells, tendon derived cells and dermal fibroblasts. Even though cellular therapies offer some potential in treating tendon disorders, there have been few published clinical trials to determine the ideal cell source, the number of cells to administer, or the optimal bioscaffold for clinical use. PMID:22448174
Introductory textbooks commonly state that Golgi tendon organs (GTOs) are responsible for a reflex response that inhibits a muscle producing dangerously high tension (autogenic inhibition). Review of the relevant data from animal studies demonstrates that there is wide variability in the magnitude of, and even the presence of, GTO autogenic effects among locomotor hindlimb muscles, and that data on GTO effects under conditions of voluntary maximal muscle activation are lacking. A single available study on GTO function in humans, during a moderate contraction, surprisingly shows a reduction in autogenic inhibition during muscle-force production. Further, it is not possible to find experimental evidence supporting the idea that strength training may produce a decrease in GTO mediated autogenic inhibition, allowing greater muscle activation levels and hence greater force production.
Kieny, M; Chevallier, A
The aim of this study performed in the embryonic chick wing is to test the ability of the tendons to form and develop in the absence of the muscle bellies. The experiments were performed on 2-day chick embryos by destroying a portion of the somitic mesoderm by local X-irradiation. The irradiated part included the wing somite level 15-20 and extended three somites (or presumptive somites) in front and two to six presumptive somites in the rear of the wing somite levels. The wings of the operated side were examined histologically 3-8 days after the X-irradiation. The radio-destruction of the somitic mesoderm totally inhibited or severely impaired the development of the forearm muscles. But, despite the absence of the flexor and extensor muscles the differentiation of the distal manus tendons could be observed. This differentiation occurred at the same time and in the same positions as in controls. However, these tendons were transient structures. They disappeared within three days after their individuation. Two mechanisms that progressed in proximo-distal direction were involved in their resorption: cellular dislocation and cell death. We conclude that tendons start to develop autonomously from the muscle bulks, but for their maintenance and further development they require connexion to a muscle belly.
Slane, Laura Chernak; Thelen, Darryl G.
The goal of the current study was to investigate the fidelity of a 2D ultrasound elastography method for the measurement of tendon motion and strain. Ultrasound phantoms and ex vivo porcine flexor tendons were cyclically stretched to 4% strain while cine ultrasound radiofrequency (RF) data and video data were simultaneously collected. 2D ultrasound elastography was used to estimate tissue motion and strain from RF data, and surface tissue motion and strain were separately estimated using digital image correlation (DIC). There were strong correlations (R2 > 0.97) between DIC and RF measurements of phantom displacement and strain, and good agreement in estimates of peak phantom strain (DIC: 3.5 ± 0.2%; RF: 3.7 ± 0.1%). For tendon, elastographic estimates of displacement profiles also correlated well with DIC measurements (R2 > 0.92), and exhibited similar estimated peak tendon strain (DIC: 2.6 ± 1.4%; RF: 2.2 ± 1.3%). Elastographic tracking with B-Mode images tended to under-predict peak strain for both the phantom and tendon. This study demonstrates the capacity to use quantitative elastographic techniques to measure tendon displacement and strain within an ultrasound image window. The approach may be extendible to in vivo use on humans, which would allow for the non-invasive analysis of tendon deformation in both normal and pathological states. PMID:24388164
Tearing and inflammation of the tendons of the shoulder muscles can occur in sports which require the ... pitching, swimming, and lifting weights. Most often the shoulder will heal if a break is taken from ...
... the eyeball. A tendon serves to move the bone or structure. A ligament is a fibrous connective tissue which attaches bone to bone, and usually serves to hold structures together and keep them stable.
Lui, Tun Hing
Loose bodies of the posterior ankle can occur either at the posterior recess of the ankle or subtalar joint or at the posterior ankle extra-articular space. Loose bodies at the extra-articular space can be a result of tenosynovial chondromatosis of the tendons of the posterior ankle, especially the flexor hallucis longus tendon. Endoscopic removal of loose bodies of the posterior ankle extra-articular space is indicated for symptomatic cases that are not improved by conservative treatment. It is contraindicated if there is active infection at the planned portal sites or the surgeon is not familiar with the technique of posterior ankle endoscopy. Systematic assessment of the different parts of the posterior ankle will minimize the risk of loose body retention.
Lutti Guerra de Aguiar Zink, Frederico; Glória Mendonça, Danilo; Kelly Bittar, Cintia; Luís Amim Zabeu, José; Salomão, Osny; Egydio de Carvalho Junior, Antonio; Tarso Torquato, Marcelo; Cerqueira de Moraes Filho, Décio
Objective To demonstrate the results obtained from foot and ankle tendon reconstructions using the tendon of the semitendinosus muscle. The clinical results, the patient's degree of satisfaction and complications in the graft donor and recipient areas were evaluated. Methods This was a retrospective study in which the medical files of 38 patients who underwent this surgical procedure between 2006 and 2010 were surveyed. The functional results from this technique, the complications in the donor and recipient areas and the patients’ degree of satisfaction were evaluated. Results Three patients presented complications in the recipient area (skin necrosis); one patient showed complications in the donor area (pain and insensitivity); and all patients had satisfactory functional results, with complete range of motion. Conclusion The semitendinosus muscle is a good option for treatments for foot and ankle tendon injuries. PMID:26229856
Dyment, Nathaniel A.; Galloway, Jenna L.
Understanding the molecular and cellular mechanisms underlying tissue turnover and repair are essential towards addressing pathologies in aging, injury and disease. Each tissue has distinct means of maintaining homeostasis and healing after injury. For some, resident stem cell populations mediate both of these processes. These stem cells, by definition, are self renewing and give rise to all the differentiated cells of that tissue. However, not all organs fit with this traditional stem cell model of regeneration, and some do not appear to harbor somatic stem or progenitor cells capable of multilineage in vivo reconstitution. Despite recent progress in tendon progenitor cell research, our current knowledge of the mechanisms regulating tendon cell homeostasis and injury response is limited. Understanding the role of resident tendon cell populations is of great importance for regenerative medicine based approaches to tendon injuries and disease. The goal of this review is to bring to light our current knowledge regarding tendon progenitor cells and their role in tissue maintenance and repair. We will focus on pressing questions in the field and the new tools, including model systems, available to address them. PMID:26389023
Chung, U S; Kim, J H; Seo, W S; Lee, K H
We evaluated the clinical outcome of tendon reconstruction using tendon graft or tendon transfer and the parameters related to clinical outcome in 51 wrists of 46 patients with rheumatoid arthritis with finger extensor tendon ruptures. At a mean follow-up of 5.6 years, the mean metacarpophalangeal (MP) joint extension lag was 8 degrees (range, 0-45) and the mean visual analogue satisfaction scale was 74 (range, 10-100). Clinical outcome did not differ significantly between tendon grafting and tendon transfer. The MP joint extension lag correlated with the patient's satisfaction score, but the pulp-to-palm distance did not correlate with patient satisfaction. We conclude that both tendon grafting and tendon transfer are reliable reconstruction methods for ruptured finger extensor tendons in rheumatoid hands.
Murchison, Nicholas D; Price, Brian A; Conner, David A; Keene, Douglas R; Olson, Eric N; Tabin, Clifford J; Schweitzer, Ronen
The scleraxis (Scx) gene, encoding a bHLH transcription factor, is expressed in the progenitors and cells of all tendon tissues. To determine Scx function, we produced a mutant null allele. Scx-/- mice were viable, but showed severe tendon defects, which manifested in a drastically limited use of all paws and back muscles and a complete inability to move the tail. Interestingly, although the differentiation of all force-transmitting and intermuscular tendons was disrupted, other categories of tendons, the function of which is mainly to anchor muscles to the skeleton, were less affected and remained functional, enabling the viability of Scx-/- mutants. The force-transmitting tendons of the limbs and tail varied in the severity to which they were affected, ranging from dramatic failure of progenitor differentiation resulting in the loss of segments or complete tendons, to the formation of small and poorly organized tendons. Tendon progenitors appeared normal in Scx-/- embryos and a phenotype resulting from a failure in the condensation of tendon progenitors to give rise to distinct tendons was first detected at embryonic day (E)13.5. In the tendons that persisted in Scx-/- mutants, we found a reduced and less organized tendon matrix and disorganization at the cellular level that led to intermixing of tenocytes and endotenon cells. The phenotype of Scx-/- mutants emphasizes the diversity of tendon tissues and represents the first molecular insight into the important process of tendon differentiation.
Rineer, Craig A; Ruch, David S
Lateral and medial epicondylitis are common causes of elbow pain in the general population, with the lateral variety being more common than the medial by a ratio reportedly ranging from 4:1 to 7:1. Initially thought to be an inflammatory condition, epicondylitis has ultimately been shown to result from tendinous microtearing followed by an incomplete reparative response. Numerous nonoperative and operative treatment options have been employed in the treatment of epicondylitis, without the emergence of a single, consistent, universally accepted treatment protocol. Tendon ruptures about the elbow are much less frequent, but result in more significant disability and loss of function. Distal biceps tendon ruptures typically occur in middle-aged males as a result of an event that causes a sudden, eccentric contraction of the biceps. Triceps tendon ruptures are exceedingly rare but usually have a similar etiology with a forceful eccentric contraction of the triceps that causes avulsion of the tendon from the olecranon. The diagnosis of these injuries is not always readily made. Complete ruptures of the biceps or triceps tendons have traditionally been treated surgically with good results. With regard to biceps ruptures, there continues to be debate about the best surgical approach, as well as the best method of fixation of tendon to bone. This article is not meant to be an exhaustive review of the broad topics of elbow tendinopathy and tendon ruptures, but rather is a review of recently published information on the topics that will assist the clinician in diagnosis and management of these conditions.
Chamberlain, Connie S.; Duenwald-Kuehl, Sarah E.; Okotie, Gregory; Brounts, Sabrina H.; Baer, Geoffrey S.; Vanderby, Ray
The purpose of this study was to explore whether a new ultrasound-based technique correlates with mechanical and biological metrics that describe the tendon healing. Achilles tendons in 32 rats were unilaterally transected and allowed to heal without repair. At 7, 9, 14, or 29 days post-injury, tendons were collected and examined for healing via ultrasound image analysis, mechanical testing, and immunohistochemistry. Consistent with previous studies, we observe that the healing tendons are mechanically inferior (ultimate stress, ultimate load, and normalized stiffness) and biologically altered (cellular and ECM factors) compared to contralateral controls with an incomplete recovery over healing time. Unique to this study, we report: 1) Echo intensity (defined by gray-scale brightness in the ultrasound image) in the healing tissue is related to stress and normalized stiffness. 2) Elongation to failure is relatively constant so that tissue normalized stiffness is linearly correlated with ultimate stress. Together, 1 and 2 suggest a method to quantify mechanical compromise in healing tendons. 3) The amount and type of collagen in healing tendons associates with their strength and normalized stiffness as well as their ultrasound echo intensity. 4) A significant increase of periostin in the healing tissues suggests an important but unexplored role for this ECM protein in tendon healing. PMID:23149902
Shearn, J T; Kinneberg, K R; Dyment, N A; Galloway, M T; Kenter, K; Wylie, C; Butler, D L
The tissue engineering field has made great strides in understanding how different aspects of tissue engineered constructs (TECs) and the culture process affect final tendon repair. However, there remain significant challenges in developing strategies that will lead to a clinically effective and commercially successful product. In an effort to increase repair quality, a better understanding of normal development, and how it differs from adult tendon healing, may provide strategies to improve tissue engineering. As tendon tissue engineering continues to improve, the field needs to employ more clinically relevant models of tendon injury such as degenerative tendons. We need to translate successes to larger animal models to begin exploring the clinical implications of our treatments. By advancing the models used to validate our TECs, we can help convince our toughest customer, the surgeon, that our products will be clinically efficacious. As we address these challenges in musculoskeletal tissue engineering, the field still needs to address the commercialization of products developed in the laboratory. TEC commercialization faces numerous challenges because each injury and patient is unique. This review aims to provide tissue engineers with a summary of important issues related to engineering tendon repairs and potential strategies for producing clinically successful products.
Common sports, involving raising the arms above the head, i.e., throwing, racquet games and swimming, often result in rotator cuff tendinitis. During the throwing motion, the humeral head and its overlying biceps tendon and rotator cuff must pass rapidly under the coraco-acromial arch. Damage to these structures can occur by several mechanism. First, an increase in the size of the structures passing underneath the arch may lead to impingement. This can occur either by way of hypertrophy of the musculotendinous cuff or by way of inflammation of the cuff. Second, a decreased space available underneath the arch secondary to osteophyte formation of the acromion and fibrosis of the subacromial space may lead to impingement. Third, weakness or incompetence of the rotator cuff allows the humerus to ride up and impinge on the coracoacromial arch with motion of the shoulder. Tendinitis can be combined with increased laxity of the glenohumeral joint and/or acquired instability due to a labral tear. Prevention of overuse injuries is a cornerstone of our treatment concept. The muscle tendon unit requires passive and neuromuscular facilitated streching after warming-up exercises. Muscular imbalance and weakness are prevented by balanced eccentric strenthening with particular attention to the external rotators and scapular muscles. Knowledge of the mechanics of the pitching motion, tennis serve, swimming stroke, etc. is of paramount importance in the prevention of injuries. As the onset of shoulder problems contributes to a particularly fatiguing situation, extreme fatique performance severity should be avoided. Every effort must be made to apply conservative treatment when overuse problems arise in the athlete's shoulder.(ABSTRACT TRUNCATED AT 250 WORDS)
Landvater, S J; Renström, P A
Achilles tendon ruptures can be treated nonsurgically in the nonathletic or low-end recreational athletic patient, particularly those more than 50 years of age, provided the treating physician does not delay in the diagnosis and treatment (preferably less than 48 hrs and possibly less than 1 week). The patient should be advised of the higher incidence of re-rupture of the tendon when treated nonsurgically. Surgical treatment is recommended for patients who are young and athletic. This is particularly true because the major criticism of surgical treatment has been the complication rate, which has decreased to a low level and to a mild degree, usually not significantly affecting the repair over time. Surgical treatment in these individuals seems to be superior not only in regard to re-rupture but also in assuring the correct apposition of the tendon ends and in placing the necessary tension on the tendon to secure appropriate orientation of the collagen fibers. This in turn allows them to regain full strength, power, endurance, and an early return to sports. Surgery is also recommended for late diagnosed ruptures where there is significant lengthening of the tendon. Surgical technique should involve a medial incision to avoid the sural nerve, absorbable suture, and augmentation with fascia or tendon where there is a gap or late rupture. Postoperatively, the immobilization should be 7 to 10 days in a splint. A walking boot with early motion in plantar flexion or a short leg cast with the tendon under slight tension should thereafter be used for 4 to 5 weeks. An early and well-supervised rehabilitation program should be initiated to restore the patient to the preinjury activity level.
Skovgaard, Dorthe; Svensson, Rene B; Scheijen, Jean; Eliasson, Pernilla; Mogensen, Pernille; Hag, Anne Mette F; Kjær, Michael; Schalkwijk, Casper G; Schjerling, Peter; Magnusson, Stig P; Couppé, Christian
Advanced Glycation Endproducts (AGEs) accumulate in long-lived tissue proteins like collagen in bone and tendon causing modification of the biomechanical properties. This has been hypothesized to raise the risk of orthopedic injury such as bone fractures and tendon ruptures. We evaluated the relationship between AGE content in the diet and accumulation of AGEs in weight-bearing animal Achilles tendon. Two groups of mice (C57BL/6Ntac) were fed with either high-fat diet low in AGEs high-fat diet (HFD) (n = 14) or normal diet high in AGEs (ND) (n = 11). AGE content in ND was six to 50-fold higher than HFD The mice were sacrificed at week 40 and Achilles and tail tendons were carefully excised to compare weight and nonweight-bearing tendons. The amount of the AGEs carboxymethyllysine (CML), methylglyoxal-derived hydroimidazolone (MG-H1) and carboxyethyllysine (CEL) in Achilles and tail tendon was measured using ultraperformance liquid chromatography tandem mass spectrometry (UPLC-MS/MS) and pentosidine with high-pressure liquid chromatography (HPLC) with fluorescent detection. AGEs in Achilles tendon were higher than in tail tendon for CML (P < 0.0001), CEL (P < 0.0001), MG-H1 and pentosidine (for both ND and HFD) (P < 0.0001). The AGE-rich diet (ND) resulted in an increase in CML (P < 0.0001), MG-H1 (P < 0.001) and pentosidine (P < 0.0001) but not CEL, in Achilles and tail tendon. This is the first study to provide evidence for AGE accumulation in injury-prone, weight-bearing Achilles tendon associated with intake of an AGE-rich diet. This indicates that food-derived AGEs may alter tendon properties and the development of tendon injuries.
Knott, C; Schmidt, H M
At a greater number of humid preparated human hands, all the ligamentous supports of the digital tendon sheath were exposed and their dimensions were determined. The osteofibrous channels, which contain the long flexor tendons of the digits, were bounded on the one hand by transversely concave shaft areas of the phalanges and the palmar ligaments and on the other side by the fibrous parts of the tendon sheath. From the second to the 5th finger, it has a regular extension of length, which begins proximal at the heads of the metacarpal bones and runs distal to the base of the nail phalanx. In some cases, there is a continuous communication between the digital tendon sheath of the little finger and the carpal synovial sheath. The tendon sheath of the flexor pollicis longus muscle in comparison with it is always in an open communication with the radial synovial sac of the wrist. At the fibrous supports of the digital tendon sheath, one can find constant and inconstant ligamentous structures. Regular shaped ligaments consist of annular fibers (A1 to A5). The proximal complex of fiber supports is a formation of the A1 and A2 ligaments. The band A1 can be divided into 2 ligaments both of roughly equal length, which lay between the head of the metacarpal bone and the base of the proximal phalanx. The strongest fibrous support of the whole digital tendon sheath represents the band A2. It is attached to the midth of the proximal phalanx and increases in strength from proximal to distal. The middle length varies between 6.7 mm at the thumb and 18.7 mm at the middle finger. The distal margin is strengthened by fibrocartilage tissue to be in accordance with the important function as a pulley. The annular band A4 forms the distal supporting complex height above the shaft of the middle phalanx. At the 2nd to the 5th finger it is, with a middle length of 6 to 7 mm, very much shorter than A2 and restrains first of all the tendon of the flexor digitorum profundus muscle. In the area
Connors, G. Patrick
Many baseball players suffer from shoulder injuries related to the rotator cuff muscles. These injuries may be classified as muscular strain, tendonitis or tenosynovitis, and impingement syndrome. Treatment varies from simple rest to surgery, so it is important to be seen by a physician as soon as possible. In order to prevent these injuries, the…
... ency/article/007678.htm Steroid injections - tendon, bursa, joint To use the sharing features on this page, ... often painful. It can be injected into a joint, tendon, or bursa. Description Your health care provider ...
Rempel, D; Serina, E; Klinenberg, E; Martin, B J; Armstrong, T J; Foulke, J A; Natarajan, S
The design of the force-displacement characteristics or 'feel' of keyboard keyswitches has been guided by preference and performance data; there has been very little information on how switch 'feel' alters muscle activity or applied force. This is a laboratory-based repeated measures design experiment to evaluate the effect of computer keyboard keyswitch design on applied finger force and muscle activity during a typing task. Ten experienced typists typed on three keyboards which differed in keyswitch make force (0.34, 0.47 and 1.02 N) while applied fingertip force and finger flexor electromyograms were recorded. The keyboard testing order was randomized and subjects typed on each keyboard for three trials, while data was collected for a minimum of 80 keystrokes per trial. No differences in applied fingertip force or finger flexor EMG were observed during typing on keyboards with switch make force of 0.34 or 0.47 N. However, applied fingertip force increased by approximately 40% (p < 0.05) and EMG activity increased by approximately 20% (p < 0.05) when the keyswitch make force was increased from 0.47 to 1.02 N. These results suggest that, in order to minimize the biomechanical loads to forearm tendons and muscles of keyboard users, keyswitches with a make force of 0.47 N or less should be considered over switches with a make force of 1.02 N.
Gerus, Pauline; Rao, Guillaume; Berton, Eric
Neuromusculoskeletal models are a common method to estimate muscle forces. Developing accurate neuromusculoskeletal models is a challenging task due to the complexity of the system and large inter-subject variability. The estimation of muscles force is based on the mechanical properties of tendon-aponeurosis complex. Most neuromusculoskeletal models use a generic definition of the tendon-aponeurosis complex based on in vitro test, perhaps limiting their validity. Ultrasonography allows subject-specific estimates of the tendon-aponeurosis complex's mechanical properties. The aim of this study was to investigate the influence of subject-specific mechanical properties of the tendon-aponeurosis complex on a neuromusculoskeletal model of the ankle joint. Seven subjects performed isometric contractions from which the tendon-aponeurosis force-strain relationship was estimated. Hopping and running tasks were performed and muscle forces were estimated using subject-specific tendon-aponeurosis and generic tendon properties. Two ultrasound probes positioned over the muscle-tendon junction and the mid-belly were combined with motion capture to estimate the in vivo tendon and aponeurosis strain of the medial head of gastrocnemius muscle. The tendon-aponeurosis force-strain relationship was scaled for the other ankle muscles based on tendon and aponeurosis length of each muscle measured by ultrasonography. The EMG-driven model was calibrated twice - using the generic tendon definition and a subject-specific tendon-aponeurosis force-strain definition. The use of subject-specific tendon-aponeurosis definition leads to a higher muscle force estimate for the soleus muscle and the plantar-flexor group, and to a better model prediction of the ankle joint moment compared to the model estimate which used a generic definition. Furthermore, the subject-specific tendon-aponeurosis definition leads to a decoupling behaviour between the muscle fibre and muscle-tendon unit in agreement with
Soons, J; Rakhorst, H A; Ruettermann, M; Luijsterburg, A J M; Bos, P K; Zöphel, O T
A total of seven patients (six men and one woman) with a defect in the Achilles tendon and overlying soft tissue underwent reconstruction using either a composite radial forearm flap (n = 3) or an anterolateral thigh flap (n = 4). The Achilles tendons were reconstructed using chimeric palmaris longus (n = 2) or tensor fascia lata (n = 2) flaps or transfer of the flexor hallucis longus tendon (n = 3). Surgical parameters such as the rate of complications and the time between the initial repair and flap surgery were analysed. Function was measured objectively by recording the circumference of the calf, the isometric strength of the plantar flexors and the range of movement of the ankle. The Achilles tendon Total Rupture Score (ATRS) questionnaire was used as a patient-reported outcome measure. Most patients had undergone several previous operations to the Achilles tendon prior to flap surgery. The mean time to flap surgery was 14.3 months (2.1 to 40.7). At a mean follow-up of 32.3 months (12.1 to 59.6) the circumference of the calf on the operated lower limb was reduced by a mean of 1.9 cm (sd 0.74) compared with the contralateral limb (p = 0.042). The mean strength of the plantar flexors on the operated lower limb was reduced to 88.9% of that of the contralateral limb (p = 0.043). There was no significant difference in the range of movement between the two sides (p = 0.317). The mean ATRS score was 72 points (sd 20.0). One patient who had an initial successful reconstruction developed a skin defect of the composite flap 12 months after free flap surgery and this resulted in recurrent infections, culminating in transtibial amputation 44 months after reconstruction. These otherwise indicate that reconstruction of the Achilles tendon combined with flap cover results in a successful and functional reconstruction.
The Effect of Sodium Hyaluronate on Ligamentation and Biomechanical Property of Tendon in Repair of Achilles Tendon Defect with Polyethylene Terephthalate Artificial Ligament: A Rabbit Tendon Repair Model
Li, Shengkun; Jiang, Jia; Chen, Shiyi
The Achilles tendon is the most common ruptured tendon of human body. Reconstruction with polyethylene terephthalate (PET) artificial ligament is recommended in some serious cases. Sodium hyaluronate (HA) is beneficial for the healing of tendon injuries. We aimed to determine the effect of sodium hyaluronate in repair of Achilles tendon defect with PET artificial ligament in an animal tendon repair model. Sixteen New Zealand White rabbits were divided into two groups. Eight rabbits repaired with PET were assigned to PET group; the other eight rabbits repaired with PET along with injection of HE were assigned to HA-PET group. All rabbits were sacrificed at 4 and 8 weeks postoperatively for biomechanical and histological examination. The HA-PET group revealed higher biomechanical property compared with the PET group. Histologically, more collagen tissues grew into the HA-PET group compared with PET group. In conclusion, application of sodium hyaluronate can improve the healing of Achilles tendon reconstruction with polyethylene terephthalate artificial ligament. PMID:28105436
Ihrke, Chris A. (Inventor); Reich, David M. (Inventor); Bridgwater, Lyndon (Inventor); Linn, Douglas Martin (Inventor); Askew, Scott R. (Inventor); Diftler, Myron A. (Inventor); Platt, Robert (Inventor); Hargrave, Brian (Inventor); Valvo, Michael C. (Inventor); Abdallah, Muhammad E. (Inventor); Permenter, Frank Noble (Inventor); Mehling, Joshua S. (Inventor)
A humanoid robot includes a robotic hand having at least one finger. An actuation system for the robotic finger includes an actuator assembly which is supported by the robot and is spaced apart from the finger. A tendon extends from the actuator assembly to the at least one finger and ends in a tendon terminator. The actuator assembly is operable to actuate the tendon to move the tendon terminator and, thus, the finger.
Amadio, Peter C
Finger flexor tendon rehabilitation has come a long way, but further advances are possible. Ideally, a healing tendon should move, but under the minimum load necessary to achieve motion. It is possible to design suture repairs that minimize the friction between tendon and sheath while simultaneously maintaining adequate strength to provide a wide margin of safety during therapy. A looped, four-strand modified Kessler repair is a good example of this type of high-strength, low-friction repair. At the same time, rehabilitation methods can also be optimized. A new modified synergistic motion protocol is described in which wrist flexion and finger extension is alternated with wrist and metacarpophalangeal joint extension and finger interphalangeal joint flexion. Based on evidence from basic science studies, the authors hypothesize that this new protocol will deliver more effective proximal tension on the tendon repair than either passive flexion/active extension or synergistic protocols, and may be useful in patients who are not ready for, or are not reliable with, active motion or place and hold protocols. The scientific basis for these new methods is reviewed, and the concept of the "safe zone" for tendon loading, in which tendon motion occurs without gapping of the repair site, is developed.
The purpose of this study was to quantify strain and elongation of the long head of the biceps femoris (BFlh) and the semitendinosus (ST) tendon/aponeurosis. Forty participants performed passive knee extension trials from 90° of knee flexion to full extension (0°) followed by ramp isometric contractions of the knee flexors at 0°, 45° and 90° of knee flexion. Two ultrasound probes were used to visualize the displacement of BFlh and ST tendon/aponeurosis. Three-way analysis of variance designs indicated that: (a) Tendon/aponeurosis (passive) elongation and strain were higher for the BFlh than the ST as the knee was passively extended (p<0.05), (b) contraction at each angular position was accompanied by a smaller BFlh tendon/aponeurosis (active) strain and elongation than the ST at higher levels of effort (p<0.05) and (c) combined (passive and active) strain was significantly higher for the BFlh than ST during ramp contraction at 0° but the opposite was observed for the 45° and 90° flexion angle tests (p<0.05). Passive elongation of tendon/aponeurosis has an important effect on the tendon/aponeurosis behavior of the hamstrings and may contribute to a different loading of muscle fibers and tendinous tissue between BFlh and ST.
JONES, M.; ABRAHAMS, P. H.; SAÑUDO, J. R.; CAMPILLO, M.
In 1813 Gantzer described 2 accessory muscles in the human forearm which bear his name (Wood, 1868; Macalister, 1875; Testut, 1884; Le Double, 1897). The more frequent of the 2 accessory muscles or ‘accessorius ad pollicem’ was found to arise from the coronoid process of the ulna, coursing distally to attach into the flexor pollicis longus muscle (flexor pollicis longus accessory head, FPLah). The less frequently observed or ‘accessorius ad flexorem profundum digitorum’ was again found to arise from the coronoid process and course to join into the flexor digitorum profundus (flexor digitorum profundus accessory head, FDPah). Since their initial description, they have been examined in further detail by a number of authors (Wood, 1868; Macalister, 1875; Le Double, 1897; Dykes & Anson, 1944; Mangini, 1960; Malhotra et al. 1982; Dellon & McKinnon, 1987; Kida, 1988). These studies, most of them focusing on the FPLah, all show different results of prevalence, origin, insertion, relations and nerve supply. We undertook this study with the aim of providing a more accurate account of the detailed morphology of both accessory muscles because of the above-mentioned inconsistent anatomical descriptions and the lack of information as to important aspects such as vascular supply, morphology (shape and length) and the coexistence of both accessory heads. PMID:9419002
Gehwolf, Renate; Wagner, Andrea; Lehner, Christine; Bradshaw, Amy D.; Scharler, Cornelia; Niestrawska, Justyna A.; Holzapfel, Gerhard A.; Bauer, Hans-Christian; Tempfer, Herbert; Traweger, Andreas
Acute and chronic tendinopathies remain clinically challenging and tendons are predisposed to degeneration or injury with age. Despite the high prevalence of tendon disease in the elderly, our current understanding of the mechanisms underlying the age-dependent deterioration of tendon function remains very limited. Here, we show that Secreted protein acidic and rich in cysteine (Sparc) expression significantly decreases in healthy-aged mouse Achilles tendons. Loss of Sparc results in tendon collagen fibrillogenesis defects and Sparc−/− tendons are less able to withstand force in comparison with their respective wild type counterparts. On the cellular level, Sparc-null and healthy-aged tendon-derived cells exhibited a more contracted phenotype and an altered actin cytoskeleton. Additionally, an elevated expression of the adipogenic marker genes PPARγ and Cebpα with a concomitant increase in lipid deposits in aged and Sparc−/− tendons was observed. In summary, we propose that Sparc levels in tendons are critical for proper collagen fibril maturation and its age-related decrease, together with a change in ECM properties favors lipid accretion in tendons. PMID:27586416
Tijs, Chris; van Dieën, Jaap H.; Baan, Guus C.; Maas, Huub
Force transmission between rat ankle plantar-flexors has been found for physiological muscle lengths and relative positions, but only with all muscles maximally activated. The aims of this study were to assess intermuscular mechanical interactions between ankle plantar-flexors during (i) fully passive conditions, (ii) excitation of soleus (SO), (iii) excitation of lateral gastrocnemius (LG), and (iv) during co-activation of SO, and LG (SO&LG). We assessed effects of proximal lengthening of LG and plantaris (PL) muscles (i.e., simulating knee extension) on forces exerted at the distal SO tendon (FSO) and on the force difference between the proximal and distal LG+PL tendons (ΔFLG+PL) of the rat. LG+PL lengthening increased FSO to a larger extent (p = 0.017) during LG excitation (0.0026 N/mm) than during fully passive conditions (0.0009 N/mm). Changes in FSO in response to LG+PL lengthening were lower (p = 0.002) during SO only excitation (0.0056 N/mm) than during SO&LG excitation (0.0101 N/mm). LG+PL lengthening changed ΔFLG+PL to a larger extent (p = 0.007) during SO excitation (0.0211 N/mm) than during fully passive conditions (0.0157 N/mm). In contrast, changes in ΔFLG+PL in response to LG+PL lengthening during LG excitation (0.0331 N/mm) were similar (p = 0.161) to that during SO&LG excitation (0.0370 N/mm). In all conditions, changes of FSO were lower than those of ΔFLG+PL. This indicates that muscle forces were transmitted not only between LG+PL and SO, but also between LG+PL and other surrounding structures. In addition, epimuscular myofascial force transmission between rat ankle plantar-flexors was enhanced by muscle activation. However, the magnitude of this interaction was limited. PMID:27708589
Zhang, Jianying; Middleton, Kellie K; Fu, Freddie H; Im, Hee-Jeong; Wang, James H-C
Platelet-rich plasma (PRP) containing hepatocyte growth factor (HGF) and other growth factors are widely used in orthopaedic/sports medicine to repair injured tendons. While PRP treatment is reported to decrease pain in patients with tendon injury, the mechanism of this effect is not clear. Tendon pain is often associated with tendon inflammation, and HGF is known to protect tissues from inflammatory damages. Therefore, we hypothesized that HGF in PRP causes the anti-inflammatory effects. To test this hypothesis, we performed in vitro experiments on rabbit tendon cells and in vivo experiments on a mouse Achilles tendon injury model. We found that addition of PRP or HGF decreased gene expression of COX-1, COX-2, and mPGES-1, induced by the treatment of tendon cells in vitro with IL-1β. Further, the treatment of tendon cell cultures with HGF antibodies reduced the suppressive effects of PRP or HGF on IL-1β-induced COX-1, COX-2, and mPGES-1 gene expressions. Treatment with PRP or HGF almost completely blocked the cellular production of PGE2 and the expression of COX proteins. Finally, injection of PRP or HGF into wounded mouse Achilles tendons in vivo decreased PGE2 production in the tendinous tissues. Injection of platelet-poor plasma (PPP) however, did not reduce PGE2 levels in the wounded tendons, but the injection of HGF antibody inhibited the effects of PRP and HGF. Further, injection of PRP or HGF also decreased COX-1 and COX-2 proteins. These results indicate that PRP exerts anti-inflammatory effects on injured tendons through HGF. This study provides basic scientific evidence to support the use of PRP to treat injured tendons because PRP can reduce inflammation and thereby reduce the associated pain caused by high levels of PGE2.
Aspenberg, Per; Schepull, Thorsten
Summary Background healing after rupture of the Achilles tendon can be described in terms of mechanical properties of the new-formed tissue, constituting the tendon callus. In previous human studies, the elastic modulus and the density remained almost constant during 3 months after mobilization started, and then improved up to one year. So far, time-dependent deformation of the healing human tendon has not been reported. Methods in a series of 16 patients, operated with Achilles tendon suture, we implanted tantalum beads into the tendon and measured the distance between them repeatedly during 3 min of constant loading, using an ordinary image intensifier. The patients unloaded their leg for 30 min before the test. To avoid bias, all images were investigated in a randomized and blinded order. Results total strain during 3 min of constant loading at 7 weeks post injury amounted to 5%, and at 19 weeks to 3%. About half of the strain, after the loading was applied, occurred during the second and third min. Considerable strain also occurred just before loading, when the patient was told that a load would be applied, but before this was actually done. Conclusion the measurements were crude, and this study should be seen as a pilot. Still, visco-elastic properties seem to dominate the mechanical behavior the healing Achilles tendon from start of mobilization to 19 weeks, at least when tested after 30 min rest. This deserves further studies with more precise methods. PMID:26605187
Zhang, Xinzhi; Bogdanowicz, Danielle; Erisken, Cevat; Lee, Nancy M; Lu, Helen H
Rotator cuff tears represent the most common shoulder injuries in the United States. The debilitating effect of this degenerative condition coupled with the high incidence of failure associated with existing graft choices underscores the clinical need for alternative grafting solutions. The 2 critical design criteria for the ideal tendon graft would require the graft to not only exhibit physiologically relevant mechanical properties but also be able to facilitate functional graft integration by promoting the regeneration of the native tendon-to-bone interface. Centered on these design goals, this review will highlight current approaches to functional and integrative tendon repair. In particular, the application of biomimetic design principles through the use of nanofiber- and nanocomposite-based scaffolds for tendon tissue engineering will be discussed. This review will begin with nanofiber-based approaches to functional tendon repair, followed by a section highlighting the exciting research on tendon-to-bone interface regeneration, with an emphasis on implementation of strategic biomimicry in nanofiber scaffold design and the concomitant formation of graded multi-tissue systems for integrative soft-tissue repair. This review will conclude with a summary and discussion of future directions.
Yucesoy, Can A; Baan, Guus; Huijing, Peter A
The goal of the present study was to test the hypothesis that epimuscular myofascial force transmission occurs between deep flexor muscles of the rat and their antagonists: previously unstudied mechanical effects of length changes of deep flexors on the anterior crural muscles (i.e., extensor digitorum longus (EDL), as well as tibialis anterior and extensor hallucis longus muscle complex (TA+EHL) and peroneal (PER) muscles were assessed experimentally. These muscles or muscle groups were kept at constant length, whereas, distal length changes were imposed on deep flexor (DF) muscles before performing isometric contractions. Distal forces of all muscle-tendon complexes were measured simultaneously, in addition to EDL proximal force. Distal lengthening of DF caused substantial significant effects on its antagonistic muscles: (1) increase in proximal EDL total force (maximally 19.2%), (2) decrease in distal EDL total (maximally 8.4%) and passive (maximally 49%) forces, (3) variable proximo-distal total force differences indicating net proximally directed epimuscular myofascial loads acting on EDL at lower DF lengths and net distally directed loads at higher DF lengths, (4) decrease in TA+EHL total (maximally 50%) and passive (maximally 66.5%) forces and (5) decrease in PER total force (maximally 51.3%). It is concluded that substantial inter-antagonistic epimuscular myofascial force transmission occurs between deep flexor, anterior crural and peroneal muscles. In the light of our present results and recently reported evidence on inter-antagonistic interaction between anterior crural, peroneal and triceps surae muscles, we concluded that epimuscular myofascial force transmission is capable of causing major effects within the entire lower leg of the rat. Implications of such large scale myofascial force transmission are discussed and expected to be crucial to muscle function in healthy, as well as pathological conditions.
1684 272 86.1 13.9 Type of Injury Stress Fracture Tendonitis Arthritis Bursitis Fasciitis Pinched Nerve Strain Sprain Pain Shin...StressFracture Tendonitis Arthritis Bursitis Fasciitis Pinched Nerve Strain Sprain Shin Splints Abrasion/Cut Pain (unknown cause) Concussion...b. Side of body injured: Right Left Not Applicable c. Injury type: StressFracture Tendonitis Arthritis Bursitis Fasciitis Pinched
Moon, Hyun-Ju; Goo, Bong-Oh; Kwon, Hae-Yeon; Jang, Jun-Hyeok
[Purpose] The purpose of this study was to identify changes in the thicknesses of the cervical flexors according to eye coordination during deep cervical flexor training. [Subjects and Methods] Twenty normal adults were randomly selected, and during their deep cervical flexor training and eye tracking, the thicknesses of the longus colli and the sternocleidomastoid were measured using ultrasonic waves. [Results] The thickness of the longus colli statistically significantly increased when deep cervical flexor training and eye coordination were performed simultaneously. However, the thickness of the sternocleidomastoid did not show statistically significant differences according to eye coordination. [Conclusion] Eye coordination during deep cervical flexor training is likely to increase the thickness of the longus colli selectively. PMID:26834355
Tendon injuries are prevalent and problematic, especially among young and otherwise healthy individuals. The inherently slow innate healing process combined with the inevitable scar tissue formation compromise functional recovery, imposing the need for the development of therapeutic strategies. The limited number of low activity/reparative capacity tendon-resident cells has directed substantial research efforts towards the exploration of the therapeutic potential of various stem cells in tendon injuries and pathophysiologies. Severe injuries require the use of a stem cell carrier to enable cell localisation at the defect site. The present study describes advancements that injectable carriers, tissue grafts, anisotropically orientated biomaterials, and cell-sheets have achieved in preclinical models as stem cell carriers for tendon repair. PMID:25157898
Melvin, Alan; Litsky, Alan; Mayerson, Joel; Witte, David; Melvin, David; Juncosa-Melvin, Natalia
A coupling mechanism that can permanently fix a forcefully contracting muscle to a bone anchor or any totally inert prosthesis would meet a serious need in orthopaedics. Our group developed the OrthoCoupler™ device to satisfy these demands. The objective of this study was to test OrthoCoupler’s performance in vitro and in vivo in the goat semitendinosus tendon model. For in vitro evaluation, 40 samples were fatigue-tested, cycling at 10 load levels, n=4 each. For in vivo evaluation, the semitendinosus tendon was removed bilaterally in 8 goats. Left sides were reattached with an OrthoCoupler, and right sides were reattached using the Krackow stitch with #5 braided polyester sutures. Specimens were harvested 60 days post-surgery and assigned for biomechanics and histology. Fatigue strength of the devices in vitro was several times the contractile force of the semitendinosus muscle. The in vivo devices were built equivalent to two of the in vitro devices, providing an additional safety factor. In strength testing at necropsy, suture controls pulled out at 120.5 ± 68.3 N, whereas each OrthoCoupler was still holding after the muscle tore, remotely, at 298±111.3N (mean ± SD)(p<0.0003). Muscle tear strength was reached with the fiber-muscle composite produced in healing still soundly intact. This technology may be of value for orthopaedic challenges in oncology, revision arthroplasty, tendon transfer, and sports-injury reconstruction. PMID:19639642
Wang, Xiao-Tian; Rosenberg, Zehava Sadka; Mechlin, Michael B; Schweitzer, Mark E
Diseases of the peroneal tendons and superior peroneal retinaculum (SPR) are frequently underdiagnosed causes of lateral ankle pain and instability. Common diseases include tenosynovitis, rupture, and dislocation of the peroneal tendons as well as injuries to the SPR. Many anatomic variants, such as a flat or convex retromalleolar fibular groove, hypertrophy of the peroneal tubercle, an accessory peroneus quartus muscle, a low-lying peroneus brevis muscle belly, or an os peroneum, may be associated with or predispose to lateral ankle disease. Magnetic resonance (MR) imaging is excellent for detecting soft-tissue and bone variants and abnormalities related to the lateral ankle. Knowledge of the MR imaging appearances of these entities aids radiologists in making the precise diagnosis of disorders of the peroneal tendons and SPR. Pitfalls and normal variants of the peroneal tendons, including magic angle phenomenon, pseudosubluxation of the peroneus brevis tendon, a bifurcated or mildly crescentic peroneus brevis tendon, insertion of the peroneus quartus tendon into the peroneus brevis tendon, and the presence of an os peroneum are important to recognize. It is also useful to be familiar with the MR imaging appearances of SPR injuries, which can be an overlooked but treatable cause of lateral ankle pain and instability.
Burk, Janina; Erbe, Ina; Berner, Dagmar; Kacza, Johannes; Kasper, Cornelia; Pfeiffer, Bastian; Winter, Karsten; Brehm, Walter
The use of decellularized tendon tissue as a scaffold for tendon tissue engineering provides great opportunities for future clinical and current research applications. The aim of this study was to assess the effect of repetitive freeze-thaw cycles and two different detergents, t-octyl-phenoxypolyethoxyethanol (Triton X-100) and sodium dodecyl sulfate (SDS), on decellularization effectiveness and cytocompatibility in large tendons. Freshly collected equine superficial and deep digital flexor tendons were subjected to decellularization according to four different protocols (1 and 2: freeze-thaw cycles combined with either Triton X-100 or SDS; 3 and 4: Triton X-100 or SDS). Decellularization effectiveness was assessed based on the reduction of vital cell counts, histologically visible nuclei, and DNA content. Transmission electron microscopy was performed to evaluate cellular and extracellular matrix integrity. Further, cytocompatibility of scaffolds that had been decellularized according to the protocols including freeze-thaw cycles (protocols 1 and 2) was assessed by seeding the scaffolds with superparamagnetic iron oxide labeled mesenchymal stromal cells and monitoring the cells histologically and by magnetic resonance imaging for two weeks. Decellularization was significantly more effective when using the protocols including freeze-thaw cycles, leaving only roughly 1% residual nuclei and 20% residual DNA, whereas samples that had not undergone additional freeze-thaw cycles contained roughly 20% residual nuclei and 40% residual DNA. No morphological extracellular matrix alterations due to decellularization could be observed. Scaffolds prepared by both protocols including freeze-thaw cycles were cytocompatible, but the cell distribution into the scaffold tended to be better in scaffolds that had been decellularized using freeze-thaw cycles combined with Triton X-100 instead of SDS.
Knobloch, K; Thermann, H; Hüfner, T
Achilles tendon ruptures are one end of a continuum starting with the healthy Achilles tendon via the thickened and painful tendinopathic Achilles tendon with neovascularisation to the complete tendon rupture. Often times chinolone antibiotics, cortisone therapy and valgus foot axis are associated risk factors. Incidence of Achilles tendon ruptures is estimated to be 10/100 000 per year with a mean age of 35-40 years. Physical activity is encountered in 75 % cases of Achilles tendon ruptures. Running is associated with Achilles tendinopathy as the predominant overuse injury in an analysis among 291 athletes with 10 million kilometers exposure. The Achilles tendinopathic rate was 0.016/1000 km differentiated in 0.008/1000 km mid-portion tendinopathy and 0.005/1000 km insertional tendinopathy. Achilles tendinopathy in running overuse injuries is followed by runner's knee (0.013/1000 km), shin splint (0.0104/1000 km) and plantar fasciitis (0.0054/1000 km). Dynamic ultrasound in 20 degrees plantar flexion is of utmost importance for therapeutic decision making. With an adaptation rate of 75 % or more of the ruptured tendon in 20 degrees plantar flexion and a high patient's compliance we perform an early functional conservative treatment regimen in Achilles tendon ruptures. In almost all other cases the percutaneous Achilles tendon repair is indicated, where nervus suralis lesions have to be appreciated. The vulnerable zone is 10-12 cm proximal to the calcaneus at the lateral border of the Achilles tendon with the sural nerve in close proximity with the tendon. Early functional rehabilitation is not associated with a higher risk of rerupture but with improved subjective assessments and should therefore be advocated.
Ciarletta, Pasquale; Dario, Paolo; Micera, Silvestro
Understanding the functional relationship between the viscoelasticity and the morphology of soft collagenous tissues is fundamental for many applications in bioengineering science. This work presents a pseudo-hyperelastic constitutive theory aiming at describing the time-dependant hysteretic response of tendons subjected to uniaxial tensile loads. A macroscopic tendon is modeled as a composite homogeneous tissue with the anisotropic reinforcement of collagen type I fibrils. The tissue microstructure is considered as an adaptive network of fibrillar units connected in temporary junctions. The processes of breakage and reformation of active fibrils are thermally activated, and are occurring at random times. An internal softening variable and a dissipation energy function account for the adaptive arrangement of the fibrillar network in the pseudo-hyperelastic model. Cyclic uniaxial tensile tests have been performed in vitro on porcine flexor digital tendons. The theoretical predictions fit accurately the experimental stress-strain data both for the loading and the unloading processes. The hysteresis behavior reflects the improvement in the efficiency and performance of the motion of the muscle-tendon unit at high strain rates. The results of the model demonstrate the microstructural importance of proteoglycans in determining the functional viscoelastic adaptability of the macroscopic tendon.
Dundar, Umit; Kusbeci, Özge Yilmaz; Ulasli, Alper Murat; Toy, Ozgur; Oruc, Serdar
Abstract Introduction In Parkinson’s disease (PD), a resting tremor of the thumb may affect the flexor pollicis longus (FPL) and influence hand functions. We investigated the relationship between FPL tendon thickness and hand function in PD patients and compared these characteristics with those in healthy controls. Methods The hand grip and pinch strengths were measured. The participants completed the Duruöz hand index, the Sollerman’s hand function test, and the Nine Hole Peg Test. The thickness of the FPL tendon was measured using ultrasonography Results The FPL tendon was thicker in PD patients but was not associated with tremor severity. In PD patients, despite functional performance of the hands are impaired and grip strength is decreased, pinch strengths are preserved. FPL thickness was not correlated with grip and pinch strengths. Conclusion The thicker FPL tendon may be associated with greater pinch and grip strengths and manual dexterity in healthy individuals. The presence of tremor is associated with a thicker FPL tendon. PMID:28352760
Longo, Umile Giuseppe; Lamberti, Alfredo; Petrillo, Stefano; Maffulli, Nicola; Denaro, Vincenzo
Tissue engineering techniques using novel scaffold materials offer potential alternatives for managing tendon disorders. Tissue engineering strategies to improve tendon repair healing include the use of scaffolds, growth factors, cell seeding, or a combination of these approaches. Scaffolds have been the most common strategy investigated to date. Available scaffolds for tendon repair include both biological scaffolds, obtained from mammalian tissues, and synthetic scaffolds, manufactured from chemical compounds. Preliminary studies support the idea that scaffolds can provide an alternative for tendon augmentation with an enormous therapeutic potential. However, available data are lacking to allow definitive conclusion on the use of scaffolds for tendon augmentation. We review the current basic science and clinical understanding in the field of scaffolds and tissue engineering for tendon repair. PMID:22190961
Majewski, Martin; Porter, Ryan M.; Betz, Oliver B.; Betz, Volker M.; Clahsen, Harald; Flückiger, Rudolf; Evans, Christopher H.
Tendon rupture is a common injury. Inadequate endogenous repair often leaves patients symptomatic, with tendons susceptible to re-rupture. Administration of certain growth factors improves tendon healing in animal models, but their delivery remains a challenge. Here we evaluated the delivery of TGF-β1 to tendon defects by the implantation of genetically modified muscle grafts. Rat muscle biopsies were transduced with recombinant adenovirus encoding TGF-β1 and grafted onto surgically transected Achilles tendons in recipient animals. Tissue regenerates were compared to those of controls by biomechanical testing as well as histochemical and immunohistochemical analyses. Healing was greatly accelerated when genetically modified grafts were implanted into tendon defects, with the resulting repair tissue gaining nearly normal histological appearance as early as 2 weeks postoperatively. This was associated with decreased deposition of type III collagen in favour of large fibre bundles indicative of type I collagen. These differences in tendon composition coincided with accelerated restoration of mechanical strength. Tendon thickness increased in gene-treated animals at weeks 1 and 2, but by week 8 became significantly lower than that of controls suggesting accelerated remodelling. Thus localised TGF-β1 delivery via adenovirus-modified muscle grafts improved tendon healing in this rat model and holds promise for clinical application. PMID:22354460
Mersmann, F; Bohm, S; Schroll, A; Boeth, H; Duda, G N; Arampatzis, A
There is evidence that a non-uniform adaptation of muscle and tendon in young athletes results in increased tendon stress during mid-adolescence. The present longitudinal study investigated the development of the morphological and mechanical properties of muscle and tendon of volleyball athletes in a time period of 2 years from mid-adolescence to late adolescence. Eighteen elite volleyball athletes participated in magnetic resonance imaging and ultrasound-dynamometry sessions to determine quadriceps femoris muscle strength, vastus lateralis, medialis and intermedius morphology, and patellar tendon mechanical and morphological properties in mid-adolescence (16 ± 1 years) and late adolescence (18 ± 1 years). Muscle strength, anatomical cross-sectional area (CSA), and volume showed significant (P < 0.05) but moderate increases of 13%, 6%, and 6%, respectively. The increase of patellar tendon CSA (P < 0.05) was substantially greater (27%) and went in line with increased stiffness (P < 0.05; 25%) and reduced stress (P < 0.05; 9%). During late adolescence, a pronounced hypertrophy of the patellar tendon led to a mechanical strengthening of the tendon in relation to the functional and morphological development of the muscle. These adaptive processes may compensate the unfavorable relation of muscle strength and tendon loading capacity in mid-adolescence and might have implications on athletic performance and tendon injury risk.
Hase, Eiji; Minamikawa, Takeo; Sato, Katsuya; Takahashi, Mitsuhiko; Yasui, Takashi
Tendon rupture is a trauma difficult to recover the condition before injury. In previous researches, tensile test and staining method have been widely used to elucidate the mechanism of the repair process from the viewpoints of the mechanical property and the histological findings. However, since both methods are destructive and invasive, it is difficult to obtain both of them for the same sample. If both the mechanical property and the histological findings can be obtained from the same sample, one may obtain new findings regarding mechanisms of tendon repairing process. In this paper, we used second-harmonic-generation (SHG) microscopy, showing high selectivity and good image contrast to collagen molecules as well as high spatial resolution, optical three-dimensional sectioning, deep penetration, and without additional staining. Since SHG light intensity sensitively reflects the structural maturity of collagen molecule and its aggregates, it will be a good indicator for the repairing degree of the ruptured tendon. From comparison of SHG images between the 4-weeks-repaired tendon and the sound tendon in the animal model, we confirmed that SHG light intensity of the repaired tendon was significantly lower than that of the sound tendon, indicating that the collagen structure in the repaired tendon is still immature. Furthermore, we performed both SHG imaging and the tensile test for the same sample, and confirmed a correlation between them. This result shows a potential of SHG light for an indicator of the histological and mechanical recovery of the ruptured tendon.
Matthews, P B; Cody, F W; Richardson, H C; MacDermott, N
Vibration was applied to the tendon of flexor carpi radialis while recording the EMG of the wrist flexors in 29 Parkinsonian patients. Cessation of the vibration led to a small short-latency (approximately 25 ms) reduction in the level of activity which did not differ in magnitude from the normal. Moreover, there was no sign of any subsequent long-latency reduction of activity. Thus the maintained tonic activity of Parkinsonian muscles seems unlikely to be due to an enhancement of the tonic reflex actions of the Ia afferents, especially via the short-latency pathway. In addition, the findings argue against reduction of either Ia or Ib firing being responsible for the delayed excitatory "Westphal" (or "shortening") response that may occur in parkinsonism on allowing a muscle to shorten; this was never found on terminating vibration, even when present on muscle release.
Wei, Anthony S.; Callaci, John J.; Juknelis, Dainius; Marra, Guido; Tonino, Pietro; Freedman, Kevin B.; Wezeman, Frederick H.
Background Subacromial corticosteroid injections are commonly used in the nonoperative management of rotator cuff disease. The effects of corticosteroid injection on injured rotator cuff tendons have not been studied. Our aims were to characterize the acute response of rotator cuff tendons to injury through the analysis of the type-III to type-I collagen expression ratio, a tendon injury marker, and to examine the effects of corticosteroid on this response. Methods Sixty Sprague-Dawley rats were randomly assigned to four groups: control, tendon injury, steroid treatment, and tendon injury and steroid treatment. Six rats served as sham controls. Unilateral tendon injuries were created with full-thickness defects across 50% of the total width of the infraspinatus tendon, 5 mm from its humeral insertion. Steroid treatment with a single dose of methylprednisolone (0.6 mg/kg), equivalent to that given to humans, was injected into the subacromial space under direct visualization. Steroid treatment followed the creation of an injury in the rats in the injury and steroid treatment group. At one, three, and five weeks after the injury, the total RNA isolated from tendons was quantified with real-time polymerase chain reaction with use of primers for type-I and type-III collagen and ribosomal 18s RNA. Results The type-III to type-I collagen expression ratio remained at baseline at all time-points in the control and sham groups. At one week, the type-III to type-I collagen expression ratio increased more than fourfold above the control level in the tendon injury group (p = 0.017) and the tendon injury and steroid treatment group (p = 0.003). The ratio remained greater than twofold above the control at three weeks in both groups (p = 0.003 and p = 0.037) and returned to baseline at five weeks. Interestingly, the group that had steroid treatment only showed an increase of >4.5-fold (p = 0.001) in the type-III to type-I collagen expression ratio, without structural injury to the
... of them are in your arm; the humerus, radius and ulna. Your arms are also made up of muscles, joints, tendons and other connective tissue. Injuries to any of these parts of the arm can occur during sports, a fall or an accident. Types of arm injuries ...
... For Parents MORE ON THIS TOPIC Medial Epicondylitis Repetitive Stress Injuries Dealing With Sports Injuries What Happens If You Keep Playing Sports When You're Injured? Sports Center Strains and Sprains Safety Tips: Baseball Safety Tips: Tennis ...
Sayegh, Eli T.; Sandy, John D.; Virk, Mandeep S.; Romeo, Anthony A.; Wysocki, Robert W.; Galante, Jorge O.; Trella, Katie J.; Plaas, Anna; Wang, Vincent M.
There exists a range of surgical and non-surgical approaches to the treatment of both acute and chronic tendon injuries. Despite surgical advances in the management of acute tears and increasing treatment options for tendinopathies, strategies frequently are unsuccessful, due to impaired mechanical properties of the treated tendon and/or a deficiency in progenitor cell activities. Hence, there is an urgent need for effective therapeutic strategies to augment intrinsic and/or surgical repair. Such approaches can benefit both tendinopathies and tendon tears which, due to their severity, appear to be irreversible or irreparable. Biologic therapies include the utilization of scaffolds as well as gene, growth factor, and cell delivery. These treatment modalities aim to provide mechanical durability or augment the biologic healing potential of the repaired tissue. Here, we review the emerging concepts and scientific evidence which provide a rationale for tissue engineering and regeneration strategies as well as discuss the clinical translation of recent innovations. PMID:26753125
Smith, Lester; Xia, Younan; Galatz, Leesa M.; Genin, Guy M.; Thomopoulos, Stavros
Injuries to connective tissues are painful and disabling and result in costly medical expenses. These injuries often require re-attachment of an unmineralized connective tissue to bone. The uninjured tendon/ligament-to-bone insertion (enthesis) is a functionally graded material that exhibits a gradual transition from soft tissue (i.e., tendon or ligament) to hard tissue (i.e., mineralized bone) through a fibrocartilaginous transition region. This transition is believed to facilitate force transmission between the two dissimilar tissues by ameliorating potentially damaging interfacial stress concentrations. The transition region is impaired or lost upon tendon/ligament injury and is not regenerated following surgical repair or natural healing, exposing the tissue to risk of re-injury. The need to regenerate a robust tendon-to-bone insertion has led a number of tissue engineering repair strategies. This review treats the tendon-to-bone insertion site as a tissue structure whose primary role is mechanical and discusses current and emerging strategies for engineering the tendon/ligament-to-bone insertion in this context. The focus lies on strategies for producing mechanical structures that can guide and subsequently sustain a graded tissue structure and the associated cell populations. PMID:22185608
Veronesi, Francesca; Salamanna, Francesca; Tschon, Matilde; Maglio, Melania; Nicoli Aldini, Nicolo; Fini, Milena
Tendon injuries are a noteworthy morbidity but at present there are few effective scientifically proven treatments. In recent decades, a number of new strategies including tissue engineering with mesenchymal stem cells (MSCs) have been proposed to enhance tendon healing. Although MSCs are an interesting and promising approach, many questions regarding their use in tendon repair remain unanswered. This descriptive overview of the literature of the last decade explores the in vivo studies on tendon healing, in small and large animal models, which used MSCs harvested from different tissues, and the state of the art in clinical applications. It was observed that there are still doubts about the optimum amount of MSCs to use and their source and the type of scaffolds to deliver the cells. Thus, further studies are needed to determine the best protocol for MSC use in tendon healing. Copyright © 2016 John Wiley & Sons, Ltd.
Spoor, C F; Badoux, D M
A hitherto-unknown atavistic muscle in the dog initiated a review of the literature on the homologies and nomenclature of the forelimb flexors in carnivores and man. A consequence is that we recommend a revision of the nomenclature in the Nomina Anatomica Veterinaria (Ithaca, New York, 1983) so that it is in agreement with the Nomina Anatomica (Wilkins, Baltimore, 1983). This revision mainly consists of the incorporation of the terms M. palmaris longus and Mm. flexores breves manus.
Hase, E.; Sato, K.; Yonekura, D.; Minamikawa, T.; Takahashi, M.
Objectives This study aimed to evaluate the histological and mechanical features of tendon healing in a rabbit model with second-harmonic-generation (SHG) imaging and tensile testing. Materials and Methods A total of eight male Japanese white rabbits were used for this study. The flexor digitorum tendons in their right leg were sharply transected, and then were repaired by intratendinous stitching. At four weeks post-operatively, the rabbits were killed and the flexor digitorum tendons in both right and left legs were excised and used as specimens for tendon healing (n = 8) and control (n = 8), respectively. Each specimen was examined by SHG imaging, followed by tensile testing, and the results of the two testing modalities were assessed for correlation. Results While the SHG light intensity of the healing tendon samples was significantly lower than that of the uninjured tendon samples, 2D Fourier transform SHG images showed a clear difference in collagen fibre structure between the uninjured and the healing samples, and among the healing samples. The mean intensity of the SHG image showed a moderate correlation (R2 = 0.37) with Young’s modulus obtained from the tensile testing. Conclusion Our results indicate that SHG microscopy may be a potential indicator of tendon healing. Cite this article: E. Hase, K. Sato, D. Yonekura, T. Minamikawa, M. Takahashi, T. Yasui. Evaluation of the histological and mechanical features of tendon healing in a rabbit model with the use of second-harmonic-generation imaging and tensile testing. Bone Joint Res 2016;5:577–585. DOI: 10.1302/2046-3758.511.BJR-2016-0162.R1. PMID:27881441
Butcher, M T; Chase, P B; Hermanson, J W; Clark, A N; Brunet, N M; Bertram, J E A
Equine digital flexor muscles have independent tendons but a nearly identical mechanical relationship to the main joint they act upon. Yet these muscles have remarkable diversity in architecture, ranging from long, unipennate fibers ("short" compartment of DDF) to very short, multipennate fibers (SDF). To investigate the functional relevance of the form of the digital flexor muscles, fiber contractile properties were analyzed in the context of architecture differences and in vivo function during locomotion. Myosin heavy chain (MHC) isoform fiber type was studied, and in vitro motility assays were used to measure actin filament sliding velocity (V(f)). Skinned fiber contractile properties [isometric tension (P(0)/CSA), velocity of unloaded shortening (V(US)), and force-Ca(2+) relationships] at both 10 and 30°C were characterized. Contractile properties were correlated with MHC isoform and their respective V(f). The DDF contained a higher percentage of MHC-2A fibers with myosin (heavy meromyosin) and V(f) that was twofold faster than SDF. At 30°C, P(0)/CSA was higher for DDF (103.5 ± 8.75 mN/mm(2)) than SDF fibers (81.8 ± 7.71 mN/mm(2)). Similarly, V(US) (pCa 5, 30°C) was faster for DDF (2.43 ± 0.53 FL/s) than SDF fibers (1.20 ± 0.22 FL/s). Active isometric tension increased with increasing Ca(2+) concentration, with maximal Ca(2+) activation at pCa 5 at each temperature in fibers from each muscle. In general, the collective properties of DDF and SDF were consistent with fiber MHC isoform composition, muscle architecture, and the respective functional roles of the two muscles in locomotion.
Gililland, Jeremy M.; Webber, Nicholas P.; Jones, Kevin B.; Randall, R. Lor; Aoki, Stephen K.
Patellar tendon-related pain is common in the athletic patient. When it occurs in skeletally mature patients participating in running, jumping, or kicking sports, the diagnosis of jumper’s knee patellar tendonitis is usually made. If patellar tendon pain is associated with a mass, the differential diagnosis should be broadened to include crystalline arthropathy. This article presents a case of a highly athletic 45-year-old man with a history of gout, anterior knee pain, and an enlarging mass in the region of the patellar tendon. Conservative management failed, and an excisional biopsy found it to be an intra-tendinous gouty tophus. To our knowledge, only 1 report exists documenting a patellar tendon mass secondary to gout, and no case report exists documenting this problem in an athlete. The interplay between athletics and gout has not been well described. Despite the long-term protective nature of fitness, transient elevations in uric acid associated with athletic endeavors may contribute acutely to manifestations of gout in some athletes. Resultant intra- or extra-articular pathology may present as, and easily be mistaken for, a sports-related injury. Without appropriate medical management, tophaceous deposition may continue to occur and treatment of the resultant mass may require surgical intervention. PMID:21410111
Jose, Jean; O'Donnell, Kevin; Lesniak, Bryson
Ganglion cysts have been previously described throughout the body, most commonly about the wrist, hand, knee, ankle, and feet. When symptomatic, they may interfere with joint mechanics, resulting in snapping, catching, and locking. Intratendinous ganglion cysts lack a synovial epithelial lining and are thought to develop from the mucoid degeneration of connective tissue caused by chronic irritation, chronic repetitive injury, and chronic ischemia. On magnetic resonance imaging, ganglion cysts originating from tendons, ligaments, tendon sheaths, menisci, or joint capsules appear as well-defined lobulated masses that follow simple or complex fluid signal intensity on all pulse sequences, with enhancing walls and internal septations on post-contrast images. There may be appreciable degeneration and partial tearing of the structure of origin, particularly if associated with tendons. On ultrasonography, they present as hypoechoic masses, with internal septations and lobulations of varying sizes, without significant vascularity on power or color Doppler sampling. A thin fluid neck extending from the structure of origin (tail sign), when present, is a reliable sign of a ganglion cyst. This article describes a sonographically guided technique to treat symptomatic ganglion cysts within the patellar tendon. Complete evacuation of the ganglion cyst, with disappearance of the tail sign, is considered the determining factor for a successful procedure. A similar technique can be used for the treatment of other symptomatic intratendinous ganglion cysts elsewhere in the body. To our knowledge, symptomatic intratendinous ganglion cysts within the patellar tendon and their treatment have not been previously reported.
Rosenbaum, Yoseph A; Awan, Hisham M
Hand and wrist injuries in athletes are common, representing between 3 and 25% of all sports injuries. As many as a quarter of all sports injuries involve the hand or wrist. We review the recent literature regarding acute hand injuries in athletes based on the structures involved - bone, muscle/tendon, ligament, and neurovascular - including diagnosis and pathophysiology of these injuries, focusing on athlete-specific facets of treatment, and when available, opinions on return to play.
Waugh, C M; Korff, T; Fath, F; Blazevich, A J
Children develop lower levels of muscle force, and at slower rates, than adults. Although strength training in children is expected to reduce this differential, a synchronous adaptation in the tendon must be achieved to ensure forces continue to be transmitted to the skeleton with efficiency while minimizing the risk of strain-related tendon injury. We hypothesized that resistance training (RT) would alter tendon mechanical properties in children concomitantly with changes in force production characteristics. Twenty prepubertal children (age 8.9 ± 0.3 yr) were equally divided into control (nontraining) and experimental (training) groups. The training group completed a 10-wk RT intervention consisting of 2-3 sets of 8-15 plantar flexion contractions performed twice weekly on a recumbent calf-raise machine. Achilles tendon properties (cross-sectional area, elongation, stress, strain, stiffness, and Young's modulus), electromechanical delay (EMD; time between the onset of muscle activity and force), rate of force development (RFD; slope of the force-time curve), and rate of electromyographic (EMG) increase (REI; slope of the EMG time curve) were measured before and after RT. Tendon stiffness and Young's modulus increased significantly after RT in the experimental group only (∼29% and ∼25%, respectively); all other tendon properties were not significantly altered, although there were mean decreases in both peak tendon strain and strain at a given force level (14% and 24%, respectively; not significant) which may have implications for tendon injury risk and muscle fiber mechanics. A decrease of ∼13% in EMD was found after RT for the experimental group, which paralleled the increase in tendon stiffness (r = -0.59); however, RFD and REI were unchanged. The present data show that the Achilles tendon adapts to RT in prepubertal children and is paralleled by a change in EMD, although the magnitude of this change did not appear to be sufficient to influence RFD. These
Kusnezov, Nicholas; Rensing, Nicholas
Fracture of the calcaneal tuberosity with a concomitant Achilles tendon rupture presents a difficult challenge for the treating surgeon. The ultimate goal of treatment is to restore function of both the gastrocnemius-soleus complex and the Achilles tendon. This particular subset of fractures occurs often in diabetics and elderly patients with osteoporosis making fixation of the displaced fragment rather complex. If the Achilles tendon disruption is only discovered later once the fracture is healed, subsequent management is difficult with surgical treatment being more morbid. While this is a rare injury, the consequences of a missed chronic Achilles tendon disruption are severe with significant dysfunction. It is therefore important to have a high index of suspicion for concomitant injury and to be prepared for dual fixation. We present a novel hybrid surgical fixation technique, which may be used in this instance. PMID:28357147
Vallone, Ganfranco; Vittorio, Tarallo
Complete rupture of the Achilles tendon is relatively rare, but it is an injury of considerable clinical relevance. A common cause of non-traumatic tendon rupture is local corticosteroid infiltration. Corticosteroid injections may start a degenerative process resulting in partial rupture and subsequent complete rupture of the tendon due to a direct toxic effect, because corticosteroids inhibit production of extracellular matrix collagen and also because of poor local vascularization. This paper describes the case of a patient who presented with complete rupture of the Achilles tendon shortly after administration of local corticosteroid injections in the treatment of deep retrocalcaneal bursitis. This confirms that corticosteroid treatment which is not correctly and accurately administered may be a factor contributing to major injury. It demonstrates that the physician must take all necessary precautions when administering corticosteroid infiltration. It is particularly important that corticosteroid injection is performed under ultrasound guidance which permits visualization of the needle tip and therefore exact identification of the injection site.
More than 30 years ago, Frank and Fuortes proposed that the synaptic effectiveness of muscle spindle afferents associated with spinal motoneurones could be diminished by the activation of nerves from flexor muscles. Since that time, research has focused on disclosing the mode of operation and the spinal pathways involved in this presynaptic inhibitory control. Initially, it was assumed that the same last-order interneurones mediated presynaptic inhibition of both muscle spindle and tendon organ afferent fibres. More recent evidence indicates that the synaptic effectiveness of these two groups of afferents is controlled by separate sets of GABAergic interneurones synapsing directly with the intraspinal terminals of the afferent fibres. This unique arrangement allows for selective control of the information on muscle length or muscle tension, despite the convergence of muscle spindle and tendon organ afferents on second-order interneurones.
Dunn, Jennifer A; Sinnott, K Anne; Rothwell, Alastair G; Mohammed, Khalid D; Simcock, Jeremy W
After cervical spinal cord injury, the loss of upper limb function is common. This affects an individual's ability to perform activities of daily living and participate in previous life roles. There are surgical procedures that can restore some of the upper limb function lost after cervical spinal cord injury. Tendon transfer surgery has been performed in the tetraplegic population since the early 1970s. The goals of surgery are to provide a person with tetraplegia with active elbow extension, wrist extension (if absent), and sufficient pinch and/or grip strength to perform activities of daily living without the need for adaptive equipment or orthoses. These procedures are suitable for a specific group, usually with spinal cord impairment of C4-8, with explicit components of motor and sensory loss. Comprehensive team assessments of current functioning, environment, and personal circumstances are important to ensure success of any procedure. Rehabilitation after tendon transfer surgery involves immobilization for tendon healing followed by specific, targeted therapy based on motor learning and goal-orientated training. Outcomes of tendon transfer surgery are not limited to the improvements in an individual's strength, function, and performance of activities but have much greater life affects, especially with regard to well-being, employment, and participation. This article will provide an overview of the aims of surgery, preoperative assessment, common procedures, postoperative rehabilitation strategies, and outcomes based on clinical experience and international published literature.
Hu, Yejun; Le, Huihui; Jin, Zhangchu; Chen, Xiao; Yin, Zi; Shen, Weiliang; Ouyang, Hongwei
Tendon/ligament injury is one of the most common impairments in sports medicine. The traditional treatments of damaged tissue repair are unsatisfactory, especially for athletes, due to lack of donor and immune rejection. The strategy of tissue engineering may break through these limitations, and bring new hopes to tendon/ligament repair, even regeneration. Silk is a kind of natural biomaterials, which has good biocompatibility, wide range of mechanical properties and tunable physical structures; so it could be applied as tendon/ligament tissue engineering scaffolds. The silk-based scaffold has robust mechanical properties; combined with other biological ingredients, it could increase the surface area, promote more cell adhesion and improve the biocompatibility. The potential clinical application of silk-based scaffold has been confirmed by in vivo studies on tendon/ligament repairing, such as anterior cruciate ligament, medial collateral ligament, achilles tendon and rotator cuff. To develop novel biomechanically stable and host integrated tissue engineered tendon/ligament needs more further micro and macro studies, combined with product development and clinical application, which will give new hope to patients with tendon/ligament injury.
Kelm, J; Anagnostakos, K; Deubel, G; Schliessing, P; Schmitt, E
The rupture of the tendon of the M. tibialis ant. is a rare sport injury and has not been yet described in fencing. The lunge, the most common offensive movement in fencing, displays a high stress on the spanned tendons and ligaments over the ankle joint and led to the rupture of the pre-damaged tendon of our patient. Pain over the inner side of the foot should be assessed as knells of this tendon injury. The exact patient's history and the precise clinical investigation are adequate for diagnosing the rupture. Hereby, an absence of the tendon shape over the ankle joint and a distinct active deficit of the extension are presented in comparison to the other side where a gap in the tendon course is palpable. An x-ray is obligate, a sonography and a MRI are helpful for the operative planning. The surgical treatment is necessary for athletes. If possible, a primary tendon suture should be aimed, in case of a distal torn an osseous reinsertion should occur. An early functional, postoperative treatment with an orthesis should be rather preferred for athletes than an immobilization.
Brum, J.; Bernal, M.; Gennisson, J. L.; Tanter, M.
Non-invasive evaluation of the Achilles tendon elastic properties may enhance diagnosis of tendon injury and the assessment of recovery treatments. Shear wave elastography has shown to be a powerful tool to estimate tissue mechanical properties. However, its applicability to quantitatively evaluate tendon stiffness is limited by the understanding of the physics on the shear wave propagation in such a complex medium. First, tendon tissue is transverse isotropic. Second, tendons are characterized by a marked stiffness in the 400 to 1300 kPa range (i.e. fast shear waves). Hence, the shear wavelengths are greater than the tendon thickness leading to guided wave propagation. Thus, to better understand shear wave propagation in tendons and consequently to properly estimate its mechanical properties, a dispersion analysis is required. In this study, shear wave velocity dispersion was measured in vivo in ten Achilles tendons parallel and perpendicular to the tendon fibre orientation. By modelling the tendon as a transverse isotropic viscoelastic plate immersed in fluid it was possible to fully describe the experimental data (deviation<1.4%). We show that parallel to fibres the shear wave velocity dispersion is not influenced by viscosity, while it is perpendicularly to fibres. Elasticity (found to be in the range from 473 to 1537 kPa) and viscosity (found to be in the range from 1.7 to 4 Pa.s) values were retrieved from the model in good agreement with reported results.
Hamilton, C D; Glousman, R E; Jobe, F W; Brault, J; Pink, M; Perry, J
The medical collateral ligament is a common site of injury in baseball pitchers, causing substantial morbidity and loss of pitching time. Twenty-six skilled baseball pitchers with medial collateral ligament insufficiency were studied before surgery with high-speed cinematography and fine-wire electromyography of eight muscles around the elbow. Data from the pitchers with injured elbows were compared with data obtained from uninjured pitchers. The flexor carpi radialis muscle in the pitchers with medial collateral ligament deficiencies revealed significantly decreased firing during the acceleration and deceleration phase of the fastball when compared with that of the pitchers with normal elbows, and the flexor carpi radialis muscle was significantly depressed during the early cocking and deceleration phases. The extensor muscles revealed slightly increased activity in the injured elbows; however, this was not statistically significant. Although the muscles of the flexor pronator group (especially the flexor carpi ulnaris muscle and the flexor digitorum superficialis muscles) are anatomically positioned to provide dynamic stability of the elbow, they did not demonstrate increased electrical activity in pitchers with medial collateral ligament deficiencies. This finding suggests that the muscles on the medial side of the elbow do not supplant the role of the medial collateral ligament during the fastball pitch.
Cross, M J; Vandersluis, R; Wood, D; Banff, M
Complete rupture of the hamstring tendons in the adult is a rare injury. This report discusses complete rupture of the hamstring tendons in nine patients treated by late operative repair. All patients were referred from outside centers for a second opinion after failed nonoperative treatment. The diagnosis was made quite easily on clinical grounds and was confirmed at surgery. Surgical treatment in all cases consisted of reattachment of the hamstring tendons to the origin on the ischium, and in all cases it was necessary to perform neurolysis of the sciatic nerve. Good results were achieved in all cases, at follow-up all patients were satisfied with the surgery.
Tang, Jin Bo; Wu, Ya Fang; Cao, Yi; Chen, Chuan Hao; Zhou, You Lang; Avanessian, Bella; Shimada, Masaru; Wang, Xiao Tian; Liu, Paul Y.
Tendon injury during limb motion is common. Damaged tendons heal poorly and frequently undergo unpredictable ruptures or impaired motion due to insufficient innate healing capacity. By basic fibroblast growth factor (bFGF) or vascular endothelial growth factor (VEGF) gene therapy via adeno-associated viral type-2 (AAV2) vector to produce supernormal amount of bFGF or VEGF intrinsically in the tendon, we effectively corrected the insufficiency of the tendon healing capacity. This therapeutic approach (1) resulted in substantial amelioration of the low growth factor activity with significant increases in bFGF or VEGF from weeks 4 to 6 in the treated tendons (p < 0.05 or p < 0.01), (2) significantly promoted production of type I collagen and other extracellular molecules (p < 0.01) and accelerated cellular proliferation, and (3) significantly increased tendon strength by 68–91% from week 2 after AAV2-bFGF treatment and by 82–210% from week 3 after AAV2-VEGF compared with that of the controls (p < 0.05 or p < 0.01). Moreover, the transgene expression dissipated after healing was complete. These findings show that the gene transfers provide an optimistic solution to the insufficiencies of the intrinsic healing capacity of the tendon and offers an effective therapeutic possibility for patients with tendon disunion. PMID:26865366
Dave, V; Gandhi, S; Mehta, V; Kumar, A; Arora, J; Suri, R K; Rath, G
Extensor tendon injury is a frequent finding in clinical practice. During a routine dissection class of undergraduate medical students examining the extensor aspect of the right hand, they found an interesting pattern of extensor tendons. The extensor digitorum (ED) exhibited three tendons for the middle and ring fingers. The intermediate tendon of the ED was found to pass to the junctura connecting the tendons of the ring and middle fingers. Additionally the Extensor carpi ulnaris displayed two tendinus slips. The lateral slip was inserted on the base of fifth metacarpal as usual, whereas the medial slip divided into two strands- proximal and distal. Apart from the above findings in the current case specimen, there was an accessory muscle belly for the index finger and the extensor digiti minimi bifurcated into two tendinus slips which gained attachment to the dorsal digital expansion of the little finger. These accessory muscle bellies and tendons could possibly be utilized for tendon reconstructions such as repairs, tenoplasties or tendon transfers.
Tang, Jin Bo; Wu, Ya Fang; Cao, Yi; Chen, Chuan Hao; Zhou, You Lang; Avanessian, Bella; Shimada, Masaru; Wang, Xiao Tian; Liu, Paul Y
Tendon injury during limb motion is common. Damaged tendons heal poorly and frequently undergo unpredictable ruptures or impaired motion due to insufficient innate healing capacity. By basic fibroblast growth factor (bFGF) or vascular endothelial growth factor (VEGF) gene therapy via adeno-associated viral type-2 (AAV2) vector to produce supernormal amount of bFGF or VEGF intrinsically in the tendon, we effectively corrected the insufficiency of the tendon healing capacity. This therapeutic approach (1) resulted in substantial amelioration of the low growth factor activity with significant increases in bFGF or VEGF from weeks 4 to 6 in the treated tendons (p < 0.05 or p < 0.01), (2) significantly promoted production of type I collagen and other extracellular molecules (p < 0.01) and accelerated cellular proliferation, and (3) significantly increased tendon strength by 68-91% from week 2 after AAV2-bFGF treatment and by 82-210% from week 3 after AAV2-VEGF compared with that of the controls (p < 0.05 or p < 0.01). Moreover, the transgene expression dissipated after healing was complete. These findings show that the gene transfers provide an optimistic solution to the insufficiencies of the intrinsic healing capacity of the tendon and offers an effective therapeutic possibility for patients with tendon disunion.
Lui, Pauline Po Yee
Tendon injuries are a common cause of physical disability. They present a clinical challenge to orthopedic surgeons because injured tendons respond poorly to current treatments without tissue regeneration and the time required for rehabilitation is long. New treatment options are required. Stem cell-based therapies offer great potential to promote tendon regeneration due to their high proliferative, synthetic, and immunomodulatory activities as well as their potential to differentiate to the target cell types and undergo genetic modification. In this review, I first recapped the challenges of tendon repair by reviewing the anatomy of tendon. Next, I discussed the advantages and limitations of using different types of stem cells compared to terminally differentiated cells for tendon tissue engineering. The safety and efficacy of application of stem cells and their modified counterparts for tendon tissue engineering were then summarized after a systematic literature search in PubMed. The challenges and future research directions to enhance, optimize, and standardize stem cell-based therapies for augmenting tendon repair were then discussed.
de Castro Pochini, Alberto; Pochini, Alberto Castro; Ejnisman, Benno; Andreoli, Carlos Vicente; Monteiro, Gustavo Cara; Fleury, Anna Maria; Faloppa, Flavio; Cohen, Moises; Albertoni, Walter Manna
A powerlifting athlete ruptured his left tendon of the pectoralis major muscle while attempting to lift 160 kg in a Brazilian bench press championship. The injury seemed to occur in the concentric phase of exercise; however, the more common mechanism of rupture is during the eccentric phase. The tendon was reinserted to the humerus 3 weeks later with screws and washers. The athlete returned to competitive activities after 5 months. One year later he lifted 170 kg and won the national championship.
Yang, Jinjuan; Zhao, Qianjun; Wang, Kunfu; Liu, Hao; Ma, Caiyun; Huang, Hongmei; Liu, Yingjie
The lack of appropriate candidates of cell sources for cell transplantation has hampered efforts to develop therapies for tendon injuries, such as tendon rupture, tendonitis, and tendinopathy. Tendon-derived stem cells (TDSCs) are a type of stem cells which may be used in the treatment of tendon injuries. In this study, TDSCs were isolated from 5-mo-old Luxi Yellow fetal bovine and cultured in vitro and further analyzed for their biological characteristics using immunofluorescence and reverse transcription-polymerase chain reaction (RT-PCR) assays. It was found that primary TDSCs could be expanded for 42 passages in vitro maintaining proliferation. The expressions of stem cell marker nucleostemin and tenocyte-related markers, such as collagen I, collagen II, collagen III, and tenascin-C, were observed on different passage cells by immunofluorescence. The results from RT-PCR show that TDSCs were positive for collagen type I, CD44, tenascin-C, and collagen type III but negative for collagen type II. Meanwhile, TDSC passage 4 was successfully induced to differentiate into osteoblasts, adipocytes, and chondrocytes. Our results indicate that the fetal bovine TDSCs not only had strong self-renewal capacity but also possess the potential for multi-lineage differentiation. This study provides theoretical basis and experimental foundation for potential therapeutic application of the fetal bovine TDSCs in the treatment of tendon injuries.
Background Increased tendon production of the inflammatory mediator prostaglandin E2 (PGE2) has been suggested to be a potential etiologic agent in the development of tendinopathy. Repeated injection of PGE2 into tendon has been proposed as a potential animal model for studying treatments for tendinopathy. In contrast, nonsteroidal anti-inflammatory drugs (NSAIDs) which inhibit PGE2 production and are commonly prescribed in treating tendinopathy have been shown to impair the healing of tendon after acute injury in animal models. The contradictory literature suggests the need to better define the functional effects of PGE2 on tendon. Our objective was to characterize the effects of PGE2 injection on the biomechanical and biochemical properties of tendon and the activity of the animals. Our hypothesis was that weekly PGE2 injection to the rat patellar tendon would lead to inferior biomechanical properties. Methods Forty rats were divided equally into four groups. Three groups were followed for 4 weeks with the following peritendinous injection procedures: No injection (control), 4 weekly injections of saline (saline), 4 weekly injections of 800 ng PGE2 (PGE2-4 wks). The fourth group received 4 weekly injections of 800 ng PGE2 initially and was followed for a total of 8 weeks. All animals were injected bilaterally. The main outcome measurements included: the structural and material properties of the patellar tendon under tensile loading to failure, tendon collagen content, and weekly animal activity scores. Results The ultimate load of PGE2-4 wks tendons at 4 weeks was significantly greater than control or saline group tendons. The stiffness and elastic modulus of the PGE2 injected tendons at 8 weeks was significantly greater than the control or saline tendons. No differences in animal activity, collagen content, or mean fibril diameter were observed between groups. Conclusions Four weekly peritendinous injections of PGE2 to the rat patellar tendon were not found to
Morrison, William B
Basic sports-related injuries of the ankle include ligament tear, tendon degeneration and tear, bone bruise, fracture, impingement, osteochondral defect, and plantar fasciitis. This article discusses the magnetic resonance imaging appearance of these injuries.
Background We developed a single stretch injury model to create damage near the musculotendinous junction (MTJ) of the gastrocnemius muscle in mice. Our hypothesis was that magnitude of muscle injury could be controlled by stepped shortening of the Achilles tendon (AT) prior to a lengthening contraction. Increased shortening would result in a greater isometric torque deficit and morphological damage 24 hours post-injury. Methods Sixteen mice were randomly assigned to sham or injury predicated on stepped increases in AT shortening. The AT was exposed and placed in a customized stainless steel roller-clamp system to achieve a specific level of shortening; 0 mm (resting length), 0.7 mm or 1.4 mm. Plantar flexors were stimulated to tetany with a needle electrode and then actively lengthened at 450°/sec from neutral to 75° of dorsiflexion. Passive and isometric torques were measured pre- and immediately post-injury. Isometric torque was measured again 24 h post-injury. Peak isokinetic torque was recorded during eccentric injury. Results Injury resulted in decreased passive and immediate absolute isometric torque only when induced with AT shortening. The percentage of pre-injury isometric torque was significantly lower in the AT shortened groups immediately and 24 h post-injury, but was unaffected by the level of shortening. Relative isometric torque deficits were noted in the 0 mm group only 24 h post-injury. Peak isokinetic torque during injury was similar in all groups. Histological evaluation 24 h post-injury revealed increased morphological damage near the MTJ in the AT shortened groups. Conclusion Single stretch with AT shortening created morphological damage near the MTJ and isometric torque deficits immediately and 24 h post-injury, but the magnitude of damage could not be titrated with stepped increases in AT shortening. This model provides an opportunity to utilize transgenic mice in order to elucidate inflammatory mediators that promote
The mechanical properties of tendon play a fundamental role to passively transmit forces from muscle to bone, withstand sudden stretches, and act as a mechanical buffer allowing the muscle to work more efficiently. The use of non-invasive imaging methods for the assessment of human tendon's mechanical, structural, and biochemical properties in vivo is relatively young in sports medicine, clinical practice, and basic science. Non-invasive assessment of the tendon properties may enhance the diagnosis of tendon injury and the characterization of recovery treatments. While ultrasonographic imaging is the most popular tool to assess the tendon's structural and indirectly, mechanical properties, ultrasonographic elastography, and ultra-high field magnetic resonance imaging (UHF MRI) have recently emerged as potentially powerful techniques to explore tendon tissues. This paper highlights some methodological cautions associated with conventional ultrasonography and perspectives for in vivo human Achilles tendon assessment using ultrasonographic elastography and UHF MRI. PMID:27512376
Ahmed, Aisha S; Li, Jian; Abdul, Alim M D; Ahmed, Mahmood; Östenson, Claes-Göran; Salo, Paul T; Hewitt, Carolyn; Hart, David A; Ackermann, Paul W
Metabolic diseases such as diabetes mellitus type-II (DM-II) may increase the risk of suffering painful connective tissue disorders and tendon ruptures. The pathomechanisms, however, by which diabetes adversely affects connective tissue matrix metabolism and regeneration, still need better definition. Our aim was to study the effect of DM-II on expressional changes of neuro- and angiotrophic mediators and receptors in intact and healing Achilles tendon. The right Achilles tendon was transected in 5 male DM-II Goto-Kakizaki (GK) and 4 age-matched Wistar control rats. The left Achilles tendons were left intact. At week 2 post-injury, NGF, BDNF, TSP, and receptors TrkA, TrkB and Nk1 gene expression was studied by quantitative RT-PCR (qRT-PCR) and their protein distribution by immunohistochemistry in intact and injured tendons. The expression of tendon-related markers, Scleraxis (SCX) and Tenomodulin (TNMD), was evaluated by qRT-PCR in intact and injured tendons. Injured tendons of diabetic GK rats exhibited significantly down-regulated Ngf and Tsp1 mRNA and corresponding protein levels, and down-regulated Trka gene expression compared to injured Wistar controls. Intact tendons of DM-II GK rats displayed reduced mRNA levels for Ngf, Tsp1 and Trkb compared to corresponding intact non-diabetic tendons. Up-regulated Scx and Tnmd gene expression was observed in injured tendons of normal and diabetic GK rats compared to intact Wistar controls. However, these molecules were not up-regulated in injured DM-II GK rats compared to their corresponding controls. Our results suggest that DM-II has detrimental effects on neuro- and angiotrophic pathways, and such effects may reflect the compromised repair seen in diabetic Achilles tendon. Thus, novel approaches for regeneration of injured, including tendinopathic, and surgically repaired diabetic tendons may include therapeutic molecular modulation of neurotrophic pathways such as NGF and its receptors.
Ahmed, Aisha S.; Li, Jian; Abdul, Alim M. D.; Ahmed, Mahmood; Östenson, Claes-Göran; Salo, Paul T.; Hewitt, Carolyn; Hart, David A.; Ackermann, Paul W.
Metabolic diseases such as diabetes mellitus type-II (DM-II) may increase the risk of suffering painful connective tissue disorders and tendon ruptures. The pathomechanisms, however, by which diabetes adversely affects connective tissue matrix metabolism and regeneration, still need better definition. Our aim was to study the effect of DM-II on expressional changes of neuro- and angiotrophic mediators and receptors in intact and healing Achilles tendon. The right Achilles tendon was transected in 5 male DM-II Goto-Kakizaki (GK) and 4 age-matched Wistar control rats. The left Achilles tendons were left intact. At week 2 post-injury, NGF, BDNF, TSP, and receptors TrkA, TrkB and Nk1 gene expression was studied by quantitative RT-PCR (qRT-PCR) and their protein distribution by immunohistochemistry in intact and injured tendons. The expression of tendon-related markers, Scleraxis (SCX) and Tenomodulin (TNMD), was evaluated by qRT-PCR in intact and injured tendons. Injured tendons of diabetic GK rats exhibited significantly down-regulated Ngf and Tsp1 mRNA and corresponding protein levels, and down-regulated Trka gene expression compared to injured Wistar controls. Intact tendons of DM-II GK rats displayed reduced mRNA levels for Ngf, Tsp1 and Trkb compared to corresponding intact non-diabetic tendons. Up-regulated Scx and Tnmd gene expression was observed in injured tendons of normal and diabetic GK rats compared to intact Wistar controls. However, these molecules were not up-regulated in injured DM-II GK rats compared to their corresponding controls. Our results suggest that DM-II has detrimental effects on neuro- and angiotrophic pathways, and such effects may reflect the compromised repair seen in diabetic Achilles tendon. Thus, novel approaches for regeneration of injured, including tendinopathic, and surgically repaired diabetic tendons may include therapeutic molecular modulation of neurotrophic pathways such as NGF and its receptors. PMID:28122008
Moura, Diogo Lino; Marques, José Pedro; Lucas, Francisco Manuel; Fonseca, Fernando Pereira
Bilateral patellar tendon rupture is a rare entity, often associated with systemic diseases and patellar tendinopathy. The authors report a rare case of a 34-year-old man with simultaneous bilateral rupture of the patellar tendon caused by minor trauma. The patient is a retired basketball player with no past complaints of chronic knee pain and a history of steroid use. Surgical management consisted in primary end-to-end tendon repair protected temporarily with cerclage wiring, followed by a short immobilization period and intensive rehabilitation program. Five months after surgery, the patient was able to fully participate in sport activities.
Cherniak, Meir; Anglister, Lili; Lev-Tov, Aharon
The ability to improve motor function in spinal cord injury patients by reactivating spinal central pattern generators (CPGs) requires the elucidation of neurons and pathways involved in activation and modulation of spinal networks in accessible experimental models. Previously we reported on adrenoceptor-dependent sacral control of lumbar flexor motoneuron firing in newborn rats. The current work focuses on clarification of the circuitry and connectivity involved in this unique modulation and its potential use. Using surgical manipulations of the spinal gray and white matter, electrophysiological recordings, and confocal microscopy mapping, we found that methoxamine (METH) activation of sacral networks within the ventral aspect of S2 segments was sufficient to produce alternating rhythmic bursting (0.15-1 Hz) in lumbar flexor motoneurons. This lumbar rhythm depended on continuity of the ventral funiculus (VF) along the S2-L2 segments. Interrupting the VF abolished the rhythm and replaced it by slow unstable bursting. Calcium imaging of S1-S2 neurons, back-labeled via the VF, revealed that ∼40% responded to METH, mostly by rhythmic firing. All uncrossed projecting METH responders and ∼70% of crossed projecting METH responders fired with the concurrent ipsilateral motor output, while the rest (∼30%) fired with the contralateral motor output. We suggest that METH-activated sacral CPGs excite ventral clusters of sacral VF neurons to deliver the ascending drive required for direct rhythmic activation of lumbar flexor motoneurons. The capacity of noradrenergic-activated sacral CPGs to modulate the activity of lumbar networks via sacral VF neurons provides a novel way to recruit rostral lumbar motoneurons and modulate the output required to execute various motor behaviors.
Jeong, Siwoo; Lee, Dae-Yeon; Choi, Dong-Sung; Lee, Hae-Dong
The objectives of this study was to investigate the acute effects of various magnitudes of tendon strain on the mechanical properties of the human medial gastrocnemius (MG) in vivo during controlled heel-drop exercises. Seven male and seven female volunteers performed two different exercises executed one month apart: one was a heel-drop exercise on a block (HDB), and the other was a heel-drop exercise on level floor (HDL). In each regimen, the subjects completed a session of 150 heel-drop exercises (15 repetitions×10 sets; with a 30 s rest following each set). Before and immediately after the heel-drop exercise, the ankle plantar flexor torque and elongation of the MG were measured using a combined measurement system of dynamometry and ultrasonography and then the MG tendon strain and stiffness were evaluated in each subject. The tendon stiffness measured prior to the exercises was not significantly different between the two groups 23.7±10.6N/mm and 24.1±10.0N/mm for the HDB and HDL, respectively (p>.05). During the heel-drop exercise, it was found that the tendon strain during the heel-drop exercise on a block (8.4±3.7%) was significantly higher than the strain measured on the level floor (5.4±3.8%) (p<.05). In addition, the tendon stiffness following the heel-drop exercise on a block (32.3±12.2N/mm) was significantly greater than the tendon stiffness measured following the heel-drop exercise on the level floor (25.4±11.4N/mm) (p<.05). The results of this study suggest that tendon stiffness immediately following a heel-drop exercise depends on the magnitude of tendon strain.
Chernak, Laura A.; Thelen, Darryl G.
The purpose of this study was to evaluate the use of 2D ultrasound elastography to assess tendon tissue motion and strains under axial loading conditions. Four porcine flexor tendons were cyclically loaded to 4% peak strain using a servo hydraulic test system. An ultrasound transducer was positioned to image a longitudinal cross-section of the tendon during loading. Ultrasound radiofrequency (RF) data were collected at 63 frames per second simultaneously with applied force and crosshead displacement. A grid of nodes was manually positioned on an ultrasound image of the unloaded tendon. Small kernels (2 × 1 mm) centered at each node were then cross-correlated with search regions centered at corresponding nodal locations in the subsequent frame. Frame-to-frame nodal displacements were defined as the values that maximized the normalized cross-correlations. This process was repeated across all frames in the loading cycle, providing a measurement of the 2D trajectories of tissue motion through out the loading cycle. The high resolution displacement measures along the RF beam direction were spatially differentiated to estimate the transverse (relative to tend on fibers) tissue strains. The nodal displacements obtained using this method were very repeatable, with average along-fiber trajectories that were highly correlated (r2>0.98) with the prescribed crosshead displacements. The elastography transverse strains were also repeatable and were consistent with average transverse strains estimated via changes in tendon width. The apparent Poisson’s ratios (0.82-1.64) exceeded the incompressibility limit, but are comparable to values found for tendon in prior experimental and computational studies. The results demonstrate that 2D ultrasound elastography is a promising approach for noninvasively assessing localized tissue motion and strain patterns. PMID:22939179
Yang, Ying; Rupani, Asha; Weightman, Alan; Wimpenny, Ian; Bagnaninchi, Pierre; Ahearne, Mark
Tendons are load-bearing collagenous tissues consisting mainly of type I collagen and various proteoglycans (PGs) including decorin and versican. It is widely accepted that highly orientated collagen fibers in tendons a play critical role for transferring tensile stress and demonstrate birefringent optical properties. However, the influence that proteoglycans have on the optical properties of tendons is yet to be fully elucidated. Tendinopathy (defined as a syndrome of tendon pain, tenderness and swelling that affects the normal function of the tissue) is a common disease associated with sporting injuries or degeneration. PG's are the essential components of the tendon extracellular matrix; changes in their quantities and compositions have been associated with tendinopathy. In this study, polarization sensitive optical coherence tomography (PS-OCT) has been used to reveal the relationship between proteoglycan content/location and birefringent properties of tendons. Tendons dissected from freshly slaughtered chickens were imaged at regular intervals by PS-OCT and polarizing light microscope during the extraction of PGs or glycosaminoglycans using established protocols (guanidine hydrochloride (GuHCl) or proteinase K solution). The macroscopic and microscopic time lapsed images are complimentary; mutually demonstrating that there was a higher concentration of PG's in the outer sheath region than in the fascicles; and the integrity of the sheath affected extraction process and the OCT birefringence bands. Extraction of PGs using GuHCl disturbed the organization of local collagen bundles, which corresponded to a reduction in the frequency of birefringence bands and the band width by PS-OCT. The feature of OCT penetration depth helped us to define the heterogeneous distribution of PG's in tendon, which was complimented by polarizing light microscopy. The results provide new insight of tendon structure and also demonstrate a great potential for using PS-OCT as a
Ward, James P; Shreve, Mark C; Youm, Thomas; Strauss, Eric J
Distal biceps ruptures occur most commonly in middle-aged males and result from eccentric contraction of the biceps tendon. The injury typically presents with pain and a tearing sensation in the antecubital fossa with resultant weakness in flexion and supination strength. Physical exam maneuvers and diagnostic imaging aid in determining the diagnosis. Nonoperative management is reserved for elderly, low demand patients, while operative intervention is generally pursued for younger patients and can consist of nonanatomic repair to the brachialis or anatomic repair to the radial tuberosity. Anatomic repair through a one-incision or two-incision approach is commonplace, while the nonanatomic repairs are rarely performed. No clear advantage exists in operative management with a one-incision versus two-incision techniques. Chronic ruptures present a more difficult situation, and allograft augmentation is often necessary. Common complications after repair include transient nerve palsy, which often resolves, and heterotopic ossification. Despite these possible complications, most studies suggest that better patient outcomes are obtained with operative, anatomic reattachment of the distal biceps tendon.
Huisman, Elise S; Andersson, Gustav; Scott, Alexander; Reno, Carol R; Hart, David A; Thornton, Gail M
The aim of this study was: (i) to analyze the morphology and expression of extracellular matrix genes in six different regions of the Achilles tendon complex of intact normal rabbits; and (ii) to assess the effect of ovariohysterectomy (OVH) on the regional expression of these genes. Female New Zealand White rabbits were separated into two groups: (i) intact normal rabbits (n = 4); and (ii) OVH rabbits (n = 8). For each rabbit, the Achilles tendon complex was dissected into six regions: distal gastrocnemius (DG); distal flexor digitorum superficialis; proximal lateral gastrocnemius (PLG); proximal medial gastrocnemius; proximal flexor digitorum superficialis; and paratenon. For each of the regions, hematoxylin and eosin staining was performed for histological evaluation of intact normal rabbit tissues and mRNA levels for proteoglycans, collagens and genes associated with collagen regulation were assessed by real-time reverse transcription-quantitative polymerase chain reaction for both the intact normal and OVH rabbit tissues. The distal regions displayed a more fibrocartilaginous phenotype. For intact normal rabbits, aggrecan mRNA expression was higher in the distal regions of the Achilles tendon complex compared with the proximal regions. Collagen Type I and matrix metalloproteinase-2 expression levels were increased in the PLG compared to the DG in the intact normal rabbit tissues. The tendons from OVH rabbits had lower gene expressions for the proteoglycans aggrecan, biglycan, decorin and versican compared with the intact normal rabbits, although the regional differences of increased aggrecan expression in distal regions compared with proximal regions persisted. The tensile and compressive forces experienced in the examined regions may be related to the regional differences found in gene expression. The lower mRNA expression of the genes examined in the OVH group confirms a potential effect of systemic estrogen on tendon.
Kaux, Jean-François; Samson, Antoine; Crielaard, Jean-Michel
Summary Introduction recently, the viscoelastic properties of hyaluronic acid (HA) on liquid connective tissue have been proposed for the treatment of tendinopathies. Some fundamental studies show encouraging results on hyaluronic acid’s ability to promote tendon gliding and reduce adhesion as well as to improve tendon architectural organisation. Some observations also support its use in a clinical setting to improve pain and function. This literature review analyses studies relating to the use of hyaluronic acid in the treatment of tendinopathies. Methods this review was constructed using the Medline database via Pubmed, Scopus and Google Scholar. The key words hyaluronic acid, tendon and tendinopathy were used for the research. Results in total, 28 articles (in English and French) on the application of hyaluronic acid to tendons were selected for their relevance and scientific quality, including 13 for the in vitro part, 7 for the in vivo animal part and 8 for the human section. Conclusions preclinical studies demonstrate encouraging results: HA permits tendon gliding, reduces adhesions, creates better tendon architectural organisation and limits inflammation. These laboratory observations appear to be supported by limited but encouraging short-term clinical results on pain and function. However, controlled randomised studies are still needed. PMID:26958533
Brukner, Peter; Connell, David
Why do some hamstring and quadriceps strains take much longer to repair than others? Which injuries are more prone to recurrence? Intramuscular tendon injuries have received little attention as an element in ‘muscle strain’. In thigh muscles, such as rectus femoris and biceps femoris, the attached tendon extends for a significant distance within the muscle belly. While the pathology of most muscle injures occurs at a musculotendinous junction, at first glance the athlete appears to report pain within a muscle belly. In addition to the musculotendinous injury being a site of pathology, the intramuscular tendon itself is occasionally injured. These injuries have a variety of appearances on MRIs. There is some evidence that these injuries require a prolonged rehabilitation time and may have higher recurrence rates. Therefore, it is important to recognise the tendon component of a thigh ‘muscle strain’. PMID:26519522
Prabhu, Jagadish; Faqi, Mohammed Khalid; Alkhalifa, Fahad; Tayara, Bader Kamal; Awad, Rashad Khamis
Injuries to the pectoralis major muscle are relatively infrequent. The mechanism of injury is usually an eccentric shortening of the pectoralis major under heavy load, such as when performing a bench press exercise. We report a case that presented to us with a history of sudden pain in the left pectoral region while doing heavy bench press exercise. The patient sustained a type III D pectoralis muscle –tendon avulsion. Surgical repair was done through a bi-cortical tendon sliding technique using two cortical buttons. In this article we describe our modifications to the previously described surgical technique for the pectoralis major tendon repair using the EndoButton and tension – slide technique, aiming to overcome the possible complications. PMID:28217216
Zhang, Kairui; Asai, Shuji; Yu, Bin; Enomoto-Iwamoto, Motomi
Tendon injuries are common, and the damaged tendon often turns into scar tissue and never completely regains the original biomechanical properties. Previous studies have reported that the mRNA levels of inflammatory cytokines such as IL-1β are remarkably up-regulated in injured tendons. To examine how IL-1β impacts tendon repair process, we isolated the injured tendon-derived progenitor cells (inTPCs) from mouse injured Achilles tendons and studied the effects of IL-1β on the inTPCs in vitro. IL-1β treatment strongly reduced expression of tendon cell markers such as scleraxis and tenomodulin, and also down-regulated gene expression of collagen 1, collagen 3, biglycan and fibromodulin in inTPCs. Interestingly, IL-1β stimulated lactate production with increases in hexokinase II and lactate dehydrogenase expression and a decrease in pyruvate dehydrogenase. Inhibition of lactate production restored IL-1β-induced down-regulation of collagen1 and scleraxis expression. Furthermore, IL-1β significantly inhibited adipogenic, chondrogenic and osteogenic differentiation of inTPCs. Interestingly, inhibition of tenogenic and adipogenic differentiation was not recovered after removal of IL-1β while chondrogenic and osteogenic differentiation abilities were not affected. These findings indicate that IL-1β strongly and irreversibly impairs tenogenic potential and alters glucose metabolism in tendon progenitors appearing in injured tendons. Inhibition of IL-1β may be beneficial for maintaining function of tendon progenitor cells during the tendon repair process.
Aro, A A; Perez, M O; Vieira, C P; Esquisatto, M A M; Rodrigues, R A F; Gomes, L; Pimentel, E R
In recent years, the scientific community has undertaken research on plant extracts, searching for compounds with pharmacological activities that can be used in diverse fields of medicine. Calendula officinalis L. is known to have antioxidant, anti-inflammatory, antibacterial, and wound healing properties when used to treat skin burns. Therefore, the purpose of this study was to analyze the effects of C. officinalis on the initial phase of Achilles tendon healing. Wistar rats were separated in three groups: Calendula (Cal)-rats with a transected tendon were treated with topical applications of C. officinalis cream and then euthanized 7 days after injury; Control (C)-rats were treated with only vehicle after transection; and Normal (N)-rats without tenotomy. Higher concentrations of hydroxyproline (an indicator of total collagen) and non-collagenous proteins were observed in the Cal group in relation to the C group. Zymography showed no difference in the amount of the isoforms of metalloproteinase-2 and of metalloproteinase-9, between C and Cal groups. Polarization microscopy images analysis showed that the Cal group presented a slightly higher birefringence compared with the C group. In sections of tendons stained with toluidine blue, the transected groups presented higher metachromasy as compared with the N group. Immunocytochemistry analysis for chondroitin-6-sulfate showed no difference between the C and Cal groups. In conclusion, the topical application of C. officinalis after tendon transection increases the concentrations of collagen and non-collagenous proteins, as well as the collagen organization in the initial phase of healing.
Sun, Hui B.; Schaniel, Christoph; Leong, Daniel J.; Wang, James H-C.
In this review, we summarize the group discussions on Cell Biology & Mechanics from the 2014 ORS/ISMMS New Frontiers in Tendon Research Conference. The major discussion topics included: 1) the biology of tendon stem/progenitor cells (TSPCs) and the potential of stem cell-based tendon therapy using TSPCs and other types of stem cells, namely, embryonic and/or induced pluripotent stem cells (iPSCs), 2) the biological concept and potential impact of cellular senescence on tendon aging, tendon injury repair and the development of degenerative disease, and 3) the effects of tendon cells’ mechano-response on tendon cell fate and metabolism. For each topic, a brief overview is presented which summarizes the major points discussed by the group participants. The focus of the discussions ranged from current research progress, challenges and opportunities, to future directions on these topics. In the preparation of this manuscript, authors consulted relevant references as a part of their efforts to present an accurate view on the topics discussed. PMID:25728946
Konow, Nicolai; Roberts, Thomas J
During downhill running, manoeuvring, negotiation of obstacles and landings from a jump, mechanical energy is dissipated via active lengthening of limb muscles. Tendon compliance provides a 'shock-absorber' mechanism that rapidly absorbs mechanical energy and releases it more slowly as the recoil of the tendon does work to stretch muscle fascicles. By lowering the rate of muscular energy dissipation, tendon compliance likely reduces the risk of muscle injury that can result from rapid and forceful muscle lengthening. Here, we examine how muscle-tendon mechanics are modulated in response to changes in demand for energy dissipation. We measured lateral gastrocnemius (LG) muscle activity, force and fascicle length, as well as leg joint kinematics and ground-reaction force, as turkeys performed drop-landings from three heights (0.5-1.5 m centre-of-mass elevation). Negative work by the LG muscle-tendon unit during landing increased with drop height, mainly owing to greater muscle recruitment and force as drop height increased. Although muscle strain did not increase with landing height, ankle flexion increased owing to increased tendon strain at higher muscle forces. Measurements of the length-tension relationship of the muscle indicated that the muscle reached peak force at shorter and likely safer operating lengths as drop height increased. Our results indicate that tendon compliance is important to the modulation of energy dissipation by active muscle with changes in demand and may provide a mechanism for rapid adjustment of function during deceleration tasks of unpredictable intensity.
Aunon-Martin, Ismael; Prada-Canizares, Alfonso; Jimenez-Diaz, Veronica; Vidal-Bujanda, Carlos; Leon-Baltasar, Jose Luis
Introduction: The distal triceps tendon rupture is an uncommon injury. The acute treatment is well-defined, but when a delayed diagnosis is made or when a tendon retraction is present the alternatives or reconstruction are limited and sometimes complex. Case Presentation: In this case, we report on a 28-year-old man who presented with a chronic disruption of the distal triceps tendon with a gap of approximately 15 cm. The patient was diagnosed in another center with an inveterate breakage of the distal triceps tendon and was initially treated with an Achilles allograft that was complicated by a wound infection and required more than ten surgeries. Nearly 22 months after the initial trauma, and 12 months after the first surgery, we performed a reconstruction with an Achilles tendon allograft using the new technique of distal attachment. At the 12-month follow-up the patient presented a joint balance from -5º to 110º and presented with no pain. Conclusions: The use of an Achilles tendon allograft provides excellent results in complex distal triceps tendon ruptures. We report the use of a new technique to anchor a distal Achilles allograft. PMID:27148500
Reuther, Katherine E.; Thomas, Stephen J.; Tucker, Jennica J.; Yannascoli, Sarah M.; Caro, Adam C.; Vafa, Rameen P.; Liu, Stephen S.; Gordon, Joshua A.; Bhatt, Pankti R.; Kuntz, Andrew F.; Soslowsky, Louis J.
Shoulder tendon injuries are frequently seen in the presence of abnormal scapular motion, termed scapular dyskinesis. The cause and effect relationship between scapular dyskinesis and shoulder injury has not been directly defined. The objective of this study was to develop and use an animal model to examine the initiation and progression of pathological changes in the rotator cuff and biceps tendon. 60 male Sprague-Dawley rats were randomized into two groups: nerve transection (to induce scapular dyskinesis, SD) or sham nerve transection (control). The animals were sacrificed 4 and 8 weeks after surgery. Shoulder function and passive joint mechanics were evaluated over time. Tendon mechanical, histological, organizational, and compositional properties were evaluated at 4 and 8 weeks. Gross observation demonstrated alterations in scapular motion, consistent with scapular “winging”. Shoulder function, passive internal range of motion, and tendon mechanical properties were significantly altered. Histology results, consistent with tendon pathology (rounded cell shape and increased cell density), were observed and protein expression of collagen III and decorin was altered. This study presents a new model of scapular dyskinesis that can rigorously evaluate cause and effect relationships in a controlled manner. These results identify scapular dyskinesis as a causative mechanical mechanism for shoulder tendon pathology. PMID:25070580
Tucker, Jennica J; Riggin, Corinne N; Connizzo, Brianne K; Mauck, Robert L; Steinberg, David R; Kuntz, Andrew F; Soslowsky, Louis J; Bernstein, Joseph
Supraspinatus tears often result in the setting of chronic tendinopathy. However, the typical repair model utilizes an acute injury. In recognition of that distinction, our laboratory developed an overuse animal model; however it is unclear whether induced overuse is necessary in the repair model. We studied the repair properties of overuse-induced tendons compared to normal tendons. We hypothesized that histological and mechanical properties would not be altered between the overuse-induced and normal tendons 1 and 4 weeks after repair. Thirty-one adult male Sprague-Dawley rats were subjected to either overuse or cage activity for 4 weeks prior to bilateral supraspinatus tendon repair surgery. Rats were sacrificed at 1 and 4 weeks post-surgery and evaluated for histology and mechanics. Results at 1 week showed no clear histologic changes, but increased inflammatory protein expression in overuse tendons. At 4 weeks, percent relaxation was slightly increased in the overuse group. No other alterations in mechanics or histology were observed. Our results suggest that the effects of the surgical injury overshadow the changes evoked by overuse. Because clinically relevant mechanical parameters were not altered in the overuse group, we conclude that when examining tendons 4 weeks after repair in the classic rat supraspinatus model, inducing overuse prior to surgery is likely to be unnecessary.
Riemersma, D J; van den Bogert, A J; Jansen, M O; Schamhardt, H C
Strains in the superficial digital flexor tendon (SDFT), deep digital flexor tendon (DDFT), accessory ligament of the deep digital flexor muscle (inferior check ligament [ICL]) and the interosseus medius muscle (suspensory ligament [SL]) in the right forelimb of 5 ponies were measured using mercury-in-silastic strain gauges a few hours after implantation. Tendon strains were recorded at the walk with normal flat shoes, egg-bar shoes, a 7 degrees increased hoof angle accomplished by application of a heel-wedge and a 7 degrees decreased hoof angle using a toe-wedge, consecutively. Ground reaction forces were recorded with all 4 shoe types preoperatively and with flat shoes post operatively. The strain patterns of the SDFT, DDFT and SL showed a rapid increase at the beginning of the stance phase, followed by a plateau with a small incline or decline and a rapid decrease at the end of the stance phase. The SDFT had its maximal strain in the first half of the stance phase in all ponies. The DDFT and SL reached their maximal strain in the first half of the stance phase in 2 ponies and in the second half of the stance phase in the other 3 ponies. The ICL was strained maximally in the second half of the stance phase in all ponies. Averaged over all 5 ponies, the maximal strains in the SDFT, DDFT, ICL and SL with normal flat shoes were 2.4, 1.3, 5.4 and 3.7%, respectively. If an egg-bar was applied the mean peak strain in the DDFT was 0.13% lower and strain in the SL was 0.22% higher. With a heel-wedge, strain decreased in the DDFT and ICL (0.19% and 0.4%, respectively) and increased by 0.24% in the SL. A toe-wedge increased strain in the ICL by 0.8%. All changes mentioned were statistically significant (P < 0.1). The changes in tendon strain as a result of different types of shoeing correlated with changes in calculated torque's of the ground reaction force acting on the coffin joint.
Bojsen-Møller, Jens; Hansen, Philip; Aagaard, Per; Svantesson, Ulla; Kjaer, Michael; Magnusson, S Peter
The human triceps surae muscle-tendon complex is a unique structure with three separate muscle compartments that merge via their aponeuroses into the Achilles tendon. The mechanical function and properties of these structures during muscular contraction are not well understood. The purpose of the study was to investigate the extent to which differential displacement occurs between the aponeuroses of the medial gastrocnemius (MG) and soleus (Sol) muscles during plantar flexion. Eight subjects (mean +/- SD; age 30 +/- 7 yr, body mass 76.8 +/- 5.5 kg, height 1.83 +/- 0.06 m) performed maximal isometric ramp contractions with the plantar flexor muscles. The experiment was performed in two positions: position 1, in which the knee joint was maximally extended, and position 2, in which the knee joint was maximally flexed (125 degrees ). Plantarflexion moment was assessed with a strain gauge load cell, and the corresponding displacement of the MG and Sol aponeuroses was measured by ultrasonography. Differential shear displacement of the aponeurosis was quantified by subtracting displacement of Sol from that of MG. Maximal plantar flexion moment was 36% greater in position 1 than in position 2 (132 +/- 20 vs. 97 +/- 11 N.m). In position 1, the displacement of the MG aponeurosis at maximal force exceeded that of the Sol (12.6 +/- 1.7 vs. 8.9 +/- 1.5 mm), whereas in position 2 displacement of the Sol was greater than displacement of the MG (9.6 +/- 1.0 vs. 7.9 +/- 1.2 mm). The amount and "direction" of shear between the aponeuroses differed significantly between the two positions across the entire range of contraction, indicating that the Achilles tendon may be exposed to intratendinous shear and stress gradients during human locomotion.
de Souza Leao, Marcos George; Pampolha, Abelardo Gautama Moreira; Orlando Junior, Nilton
Objectives To evaluate knee function in patients undergoing reconstruction of the anterior cruciate ligament (ACL) using the central third of the patellar ligament or the medial flexor tendons of the knee, i.e. quadruple ligaments from the semitendinosus and gracilis (ST-G), by means of the Knee Society Score (KSS) and the Lysholm scale. Methods This was a randomized prospective longitudinal study on 40 patients who underwent arthroscopic ACL reconstruction between September 2013 and August 2014. They comprised 37 males and three females, with ages ranging from 16 to 52 years. The patients were numbered randomly from 1 to 40: the even numbers underwent surgical correction using the ST-G tendons and the odd numbers, using the patellar tendon. Functional evaluations were made using the KSS and Lysholm scale, applied in the evening before the surgical procedure and six months after the operation. Results From the statistical analysis, it could be seen that the patients’ functional capacity was significantly greater after the operation than before the operation. There was strong evidence that the two forms of therapy had similar results (p = >0.05), in all the comparisons. Conclusions The results from the ACL reconstructions were similar with regard to functional recovery of the knee and improvement of quality of life, independent of the type of graft. It was not possible to identify the best method of surgical treatment. The surgeon's clinical and technical experience and the patient are the factors that determine the choice of graft type for use in ACL surgery. PMID:27218084
Goldfarb, Charles A; Puri, Sameer K; Carlson, Michelle Gerwin
Hand and wrist injuries in the high-level athlete are challenging because they may be underestimated by the patient, family, and team, and return to play may be longer than desired. The needs of the player and the team must be balanced with the long-term functional ramifications of the injury. Four common soft-tissue sports injuries are flexor digitorum profundus avulsion, flexor pulley rupture, extensor carpi ulnaris dislocation, and thumb metacarpophalangeal joint ulnar collateral ligament injury. For each of these injuries, the assessment, treatment, and considerations for return to play should be individualized on the basis of the patient, the sport, and the timing of the injury.
Debarge, Romain; Philippot, Rémy; Viola, Jérémy; Besse, Jean Luc
The aim of this study was to evaluate the outcome of the percutaneous flexor tenotomy. We compared the results of two groups. The first group included 23 patients who underwent forefoot surgery without percutaneous flexor tenotomy, and the second group included 50 patients who underwent the same procedure combined with percutaneous flexor tenotomy for claw toe deformities, secondary to shortening metatarsal Scarf osteotomy. The average follow-up was 11.6 months. Three algoneurodystrophies were noted. No delayed wound healing was observed. Functional dissatisfaction rate (18% vs.17.4%) and toe pulp contact defect (12% vs. 8.7%) were not significantly different in the two groups. Toe grasping defect rate (10% vs. 4.3%) was superior in the tenotomy group. Five recurring claw toe deformities of the second toe were noted in the tenotomy group. Percutaneous flexor tenotomy is a simple, rapid, and efficient method to correct reducible secondary claw toe deformities. However, despite a significant postoperative loss of toe grasping function, no patient reported major dissatisfaction.
Behounek, J; Hrubina, M; Skoták, M; Krumpl, O; Zahálka, M; Dvorák, J; Fucík, M
PURPOSE OF THE STUDY To present the results of surgical repair of ruptures of the distal tendon of the biceps brachii muscle and thus show the adequacy of this treatment. MATERIAL Between 1987 and 2006, 19 patients had surgery for distal biceps tendon rupture. Only one side was affected in each patient. All patients were men between 28 and 69 years (average age, 47.5 years) at the time of injury (surgery). When the patients were evaluated at the end of 2007, 18 patients were included, because one died a year after surgery. METHODS The surgical repair always included a single-incision anatomical reattachment into the radial tuberosity. In 11 patients, a modified Mac Reynolds method with screw and washer fixation was used; in seven patients the insertion was fixed with Mitek anchors and, in one, it was sutured to the adjacent soft tissues. The average follow-up was 7 years (range, 1 to 20.5 years). The patients were evaluated for the cause of injury, their physical activity, age, dominance of the injured arm, surgical procedure and complications. RESULTS In 18 patients surgical repair was done early and, in one, at 16 days after injury. In all of them the tendon was detached from its site of insertion, but never torn. The intra-operative complications included, in one patient, bleeding owing to iatrogenic damage to a branch of the brachial artery, and difficult separation of the tendon due to its previous healed injury in another patient. Early post-operative complications included superficial skin necrosis in one patient and transient neurological deficit of the dorsal brand of the radial nerve and of the lateral cutaneous nerve of the forearm in two and one patient, respectively. The late complications were heterotropic ossification in three patients and screw migration in the one treated by the Mac Reynolds method. Excellent results were recorded in 11 patients (61 %), and good outcomes with a slight restriction of motion or muscle strength not limiting the
Tsiampa, Vassiliki A; Ignatiadis, Ioannis; Papalois, Apostolos; Givissis, Panayiotis; Christodoulou, Anastasios; Fridén, Jan
Improved tendon-to-tendon suturing techniques allow for consistent and immediate activation of transferred muscle after surgery. A pre-requisite for early training after tendon transfer surgery is sufficient mechanical integrity of the tendon-to-tendon attachment. This in vitro study compared the mechanisms and magnitudes of load-to-failure response of two different repair techniques (side-to-side running, n = 7) and weave sutures (n = 8) in sheep front foot tendons. Tensile tests were performed by placing pre-conditioned tendons in a testing machine and stretching at a constant speed to failure. The length of the tendons overlap was the same (50 mm) for both repair techniques. The results of the load to failure tests showed that the side-to-side repairs were significantly stronger than the weave repairs. The failure mechanisms were also different. While the side-to-side attachment failed by longitudinal separation of tendon material of the donor tendon but with the fibres locked to the running sutures attached to the recipient tendon, the weave repairs failed by knot slipping or by suture pullout from the tendon substance. It is concluded that use of the side-to-side repair technique can provide early active training of new motors that not only prevent the formation of adhesions but also facilitate the voluntary recruitment of motors powering new functions before immobilisation-related swelling and stiffness restrain muscle contractions.
Zheng, S; Robinson, E; Yeoman, S; Stewart, N; Crabbe, J; Rouse, J; McQueen, F M
Objective To investigate the role of early magnetic resonance imaging (MRI) of the wrist in predicting functional outcome in rheumatoid arthritis. Methods MRI scans of the dominant wrist were scored for synovitis, tendon inflammation, bone oedema, and erosion at first presentation (n = 42), at 1 year (n = 42), and at 6 years (n = 31). At 8 years, clinical reassessment (n = 28) was undertaken. Tendon function was graded 0–3 for movement, tendon sheath swelling, and pain on resistance at nine flexor and extensor tendons of the hand. Hand function was also assessed using the Sollerman grip test. The requirement for joint or tendon surgery by 8 years was determined by telephone survey in 39 of the original 42 patients. Results At 8 years, tendon function was highly correlated with hand function (Sollerman score, R = −0.51, p = 0.005) and global function (health assessment questionnaire score, R = 0.53, p = 0.004). Using a model incorporating baseline and 1 year MRI scores, the MRI bone oedema score was strongly predictive of tendon function at 8 years (χ22 = 15.3, p = 0.0005), as was the MRI bone erosion score (χ22 = 9.23, p = 0.01). Hand function was also predicted by the baseline MRI erosion score (p = 0.02). MRI variables did not predict the requirement for surgery, but patients who had surgery were more likely to show progression of MRI bone erosion scores between baseline and 1 year (p = 0.008). Conclusions Extensive MRI bone oedema and erosions at the wrist in early rheumatoid arthritis predict tendon dysfunction and impaired hand function in the medium term but not the requirement for joint or tendon surgery. PMID:16219706
... regularly play sports that involve a lot of repetitive jumping — like track and field (particularly high-jumping), basketball, volleyball, gymnastics, running, and soccer — can put a lot of strain on their knees. Jumper's knee can seem like a minor injury that isn't really that serious. Because of ...
Abdalla, Rene Jorge; Monteiro, Diego Antico; Dias, Leonardo; Correia, Dárcio Maurício; Cohen, Moisés; Forgas, Andrea
Objective: this study aims to compare the arthrometric and isokinetic examination results from two types of autologous grafts: the central third of the patellar ligament and a graft formed by the tendons of the semitendinosus and gracilis muscles, within the same rehabilitation protocol, six months after the surgery. Methods: the results from examinations carried out on 63 patients were analyzed. These patients were divided in two groups: one group of 30 patients who received a patellar tendon graft and another group of 33 patients who received a graft from the tendons of the semitendinosus and gracilis muscles. Both the grafts were attached in the same way, with Endobutton™ for suspensory fixation to the femur and a bioabsorbable interference screw for fixation in the tibial tunnel. Results: arthrometry 30 did not present any statistical difference between the two study groups. On the other hand, the isokinetic evaluation showed that the patellar tendon group had a larger mean peak torque of flexion and greater extension deficit, while the semitendinosus/gracilis group had a better mean flexion/extension ratio and greater percentage of flexion deficit. There was no statistically significant difference between the groups when measuring peak torque extension. Conclusion: therefore, when the patellar tendon was used, there was greater extensor deficit and, when the semitendinosus/gracilis tendons were used, there was greater flexor deficit. PMID:27004173
Stannard, J P; Bucknell, A L
Rupture of the triceps mechanism is an uncommon injury that has been recognized with increasing frequency in recent years. It has been proposed that such injuries commonly accompany fractures of the radial head and must be actively evaluated in the presence of such a fracture. We present a unique case of isolated rupture of the triceps tendon in an athlete who was lifting weights. This case was complicated by a history of olecranon bursitis that had been treated with numerous local steroid injections, as well as a history of anabolic steroid abuse. Both systemic steroids and local injections may predispose tendons to rupture. Triceps tendon ruptures may result in uniformly good to excellent results if recognized and treated surgically. This case also serves as a reminder of the risks of treating inflamed tissues with local steroid injections, especially in strength athletes who place high demands on their musculoskeletal structures. Finally, this case documents a second case of triceps mechanism rupture in an athlete who has abused anabolic steroids. A study by Hunter et al. suggests that oral steroid abuse may be associated with detrimental effects on the mechanical properties of connective tissue, demonstrating another negative effect of anabolic steroid use in athletes.
Konrad, A; Stafilidis, S; Tilp, M
The purpose of this study was to investigate the influence of a single static, ballistic, or proprioceptive neuromuscular facilitation (PNF) stretching exercise on the various muscle-tendon parameters of the lower leg and to detect possible differences in the effects between the methods. Volunteers (n = 122) were randomly divided into static, ballistic, and PNF stretching groups and a control group. Before and after the 4 × 30 s stretching intervention, we determined the maximum dorsiflexion range of motion (RoM) with the corresponding fascicle length and pennation angle of the gastrocnemius medialis. Passive resistive torque (PRT) and maximum voluntary contraction (MVC) were measured with a dynamometer. Observation of muscle-tendon junction (MTJ) displacement with ultrasound allowed us to determine the length changes in the tendon and muscle, respectively, and hence to calculate stiffness. Although RoM increased (static: +4.3%, ballistic: +4.5%, PNF: +3.5%), PRT (static: -11.4%, ballistic: -11.5%, PNF: -13,7%), muscle stiffness (static: -13.1%, ballistic: -20.3%, PNF: -20.2%), and muscle-tendon stiffness (static: -11.3%, ballistic: -10.5%, PNF: -13.7%) decreased significantly in all the stretching groups. Only in the PNF stretching group, the pennation angle in the stretched position (-4.2%) and plantar flexor MVC (-4.6%) decreased significantly. Multivariate analysis showed no clinically relevant difference between the stretching groups. The increase in RoM and the decrease in PRT and muscle-tendon stiffness could be explained by more compliant muscle tissue following a single static, ballistic, or PNF stretching exercise.
Finstein, Joseph L.; Cohen, Steven B.; Dodson, Christopher C.; Ciccotti, Michael G.; Marchetto, Paul; Pepe, Matthew D.; Deluca, Peter F.
Background: Complete triceps tendon ruptures are relatively rare in the general population but slightly more prevalent in professional football. One prior study found 11 complete ruptures over a 6-season period. Hypothesis: Triceps ruptures occur more commonly in football linemen due to forced elbow flexion during an eccentric contraction and may occur more commonly with the increasing size and speed of professional players. Surgical repair allows full return to sports, but with a lengthy recovery time. Study Design: Case series; Level of evidence, 4. Methods: A search of the National Football League Injury Surveillance System (NFLISS) found a total of 37 triceps tendon ruptures requiring surgical repair from the years 2000 to 2009. Data were obtained for setting of injury, player position, activity causing injury, play type, time of game when injury occurred, height, weight, body mass index (BMI), and number of days lost from football. Results: There were 37 players requiring surgical repair for triceps tendon ruptures over the 10-season period. The average height, weight, and BMI of the players were 75 inches, 292 pounds, and 36.5 kg/m2, respectively. The majority of players were linemen (86%): 16 defensive, 15 offensive, and 1 tight end. The injury took place while blocking or being blocked in 29 players (78%) and while tackling or being tackled in 5 players (14%). Players missed an average of 165 days (range, 49-318 days) from football as a result of their injury and surgery. Conclusion: Triceps tendon tears requiring surgical repair are more common in professional football players than in the general population and are occurring more commonly than previously reported. Surgical repair allows return to play. Clinical Relevance: Our study identifies the rate of triceps tendon tears requiring repair in the NFL according to position, identifying which players may be most at risk for this injury. PMID:26535394
Al-Otaibi, S T
Repetitive strain injury is a group of musculoskeletal disorders affecting muscles, tendons, nerves and blood vessels. These disorders could be attributed to occupational causes; however non-occupational causes should be excluded. The management of these cases required a multidisciplinary team approach.
Wang, Lin-Hwa; Lo, Kuo-Cheng; Jou, I-Ming; Kuo, Li-Chieh; Tai, Ta-Wei; Su, Fong-Chin
This study investigated the contribution of flexor muscles to the forearm through fatigue; therefore, the differences in forearm mechanisms on the pitching motion in fastball were analysed. Fifteen baseball pitchers were included in this study. Ultrasonographical examination of participants' ulnar nerve in the cubital tunnel with the elbow extended and at 45°, 90° and 120° of flexion was carried. A three-dimensional motion analysis system with 14 reflective markers attached on participants was used for motion data collection. The electromyography system was applied over the flexor carpi ulnaris, flexor carpi radialis and extensor carpi radialis muscles of the dominant arm. Flexor carpi ulnaris muscle activity showed a significant difference during the acceleration phase, with a peak value during fastball post-fatigue (P = 0.02). Significant differences in the distance between ulnar nerve and medial condyle on throwing arm and non-throwing arm were observed as the distance increased with the elbow movement from 0° to 120° of flexion (P = 0.01). The significant increase of the flexor carpi ulnaris muscle activity might be responsible for maintaining the stability of the wrist joint. The increased diameter might compress the ulnar nerve and cause several pathological changes. Therefore, fatigue in baseball pitchers still poses a threat to the ulnar nerve because the flexor carpi ulnaris and flexor carpi radialis all originate from the medial side of the elbow, and the swelling tendons after fatigue might be a key point.
Giombini, A; Innocenzi, L; Di Cesare, A; Di Salvo, W; Fagnani, F; Pigozzi, F
The aim of this study was to describe a case of a 27-year-old male elite waterpolo goalkeeper, who had a partial rupture of the distal biceps tendon of his dominant arm while he was trying to save a strong outside shot. Pain on the antecubital fossa was the chief complaint. Ultrasound and magnetic resonance imaging completed the instrumental set-up. This case had the resolution of the pain and impairment after 3 months of conservative treatment. At 1-year follow-up, the athlete is asymptomatic and the isokinetic test provided almost complete recovery of the strength for elbow flexors and supinators muscles.
Dyment, Nathaniel A; Hagiwara, Yusuke; Matthews, Brya G; Li, Yingcui; Kalajzic, Ivo; Rowe, David W
Unlike during embryogenesis, the identity of tissue resident progenitor cells that contribute to postnatal tendon growth and natural healing is poorly characterized. Therefore, we utilized 1) an inducible Cre driven by alpha smooth muscle actin (SMACreERT2), that identifies mesenchymal progenitors, 2) a constitutively active Cre driven by growth and differentiation factor 5 (GDF5Cre), a critical regulator of joint condensation, in combination with 3) an Ai9 Cre reporter to permanently label SMA9 and GDF5-9 populations and their progeny. In growing mice, SMA9+ cells were found in peritendinous structures and scleraxis-positive (ScxGFP+) cells within the tendon midsubstance and myotendinous junction. The progenitors within the tendon midsubstance were transiently labeled as they displayed a 4-fold expansion from day 2 to day 21 but reduced to baseline levels by day 70. SMA9+ cells were not found within tendon entheses or ligaments in the knee, suggesting a different origin. In contrast to the SMA9 population, GDF5-9+ cells extended from the bone through the enthesis and into a portion of the tendon midsubstance. GDF5-9+ cells were also found throughout the length of the ligaments, indicating a significant variation in the progenitors that contribute to tendons and ligaments. Following tendon injury, SMA9+ paratenon cells were the main contributors to the healing response. SMA9+ cells extended over the defect space at 1 week and differentiated into ScxGFP+ cells at 2 weeks, which coincided with increased collagen signal in the paratenon bridge. Thus, SMA9-labeled cells represent a unique progenitor source that contributes to the tendon midsubstance, paratenon, and myotendinous junction during growth and natural healing, while GDF5 progenitors contribute to tendon enthesis and ligament development. Understanding the mechanisms that regulate the expansion and differentiation of these progenitors may prove crucial to improving future repair strategies.
Ackermann, Paul W; Hart, David A
Painful and non-healing musculoskeletal disorders, eg. tendinopathy, pose a tremendous burden on society and the quality of life for patients. New advances in the understanding of connective tissue disorders such as tendinopathy reveal that common health problems such as obesity, atherosclerosis, hormonal dysfunctions and diabetes mellitus are closely linked to the metabolism of components of the musculoskeletal system, particularly tendons. As tendons function as multi-component "organ systems" (Muscle-TMJ-Tendon-Enthesis to Bone), tendons can be influenced directly, or indirectly via, for instance, alterations to muscle. However, this volume/set of chapters focus mainly on the tendon.Emerging findings in musculoskeletal research have established important new links in our understanding of tendon metabolism. Thereby, the function of the neuroendocrine/-immune axis, as well as supply of neuro-vascular factors, can be directly linked to the quality of tendon metabolism.Since some conditions, eg. atherosclerosis and diabetes mellitus, are more common in individuals as they age, and aging can also affect pain and tissue repair, convergence of such complications will potentially exert an increasingly significant impact on tendons as the demographics of many societies change with expanding percentages of the populations >60-65 years of age.Comorbidities related to metabolic dysfunction have to be identified early in patients with musculoskeletal disorders, such as acute tendon injuries or chronic tendinopathy, for therapeutic considerations regarding both operative and non-operative treatment protocols. Necessary interactions between researchers and clinicians with different subspecialties have to be initiated in order to optimize tissue metabolism for improved healing potentials.
Szebeszczyk, Janina; Straszecka, Joanna
The examination of Achilles tendon reflex is widely used as a simple, noninvasive clinical test in diagnosis and pharmacological therapy monitoring in such diseases as: hypothyroidism, hyperthyroidism, diabetic neuropathy, the lower limbs obstructive angiopathies and intermittent claudication. Presented Achilles tendon reflect measuring system is based on the piezoresistive sensor connected with the cylinder-piston system. To determinate the moment of Achilles tendon stimulation a detecting circuit was used. The outputs of the measuring system are connected to the PC-based data acquisition board. Experimental results showed that the measurement accuracy and repeatability is good enough for diagnostics and therapy monitoring purposes. A user friendly, easy-to-operate measurement system fulfills all the requirements related to recording, presentation and storing of the patients' reflexograms.
Fantry, Amanda; Lareau, Craig; Vopat, Bryan; Blankenhorn, Brad
Management of posterior malleolus fractures continues to be controversial, with respect to both need for fixation and fixation methods. Fixation methods include an open posterior approach to the ankle as well as percutaneous reduction and fixation with or without arthroscopy for visualization of the articular surface. Plain radiographs are unreliable in identifying fracture pattern and intraoperative reduction, making arthroscopy a valuable adjunct to posterior malleolus fracture management. In this article, we report a case of tibialis posterior tendon entrapment within a posterior malleolus fracture, as identified by arthroscopy and managed with open reduction. Tibialis posterior tendon entrapment within a posterior malleolus has not been previously reported. Ankle arthroscopy for posterior malleolus fractures provides an opportunity to identify soft-tissue or tendinous entrapment, articular surface reduction, and articular cartilage injuries unlikely to be identified with fluoroscopy alone and should be considered in reduction and fixation of posterior malleolus fractures.
Smith, R K W; Birch, H L; Goodman, S; Heinegård, D; Goodship, A E
Strain-induced tendinopathy is a common injury in both human and equine athletes, with increasing incidence associated with greater involvement in sport and an increasingly aged population. This paper reviews our studies on the abundant non-collagenous protein, cartilage oligomeric matrix protein (COMP), in equine tendons. Its variation between tendon type and site, age and exercise has provided an insight into how age and exercise influence tendon growth and maturation. Tendons can be broadly divided into two types, reflecting their different matrix composition and function: the energy-storing tendons used for weight-bearing and locomotion, which suffer a high incidence of strain-induced tendinopathy, and positional tendons involved in limb placement or manipulative skills. It would appear that while energy-storing tendon can respond to the mechanical forces applied to it during growth, there is no evidence that it can do so after skeletal maturity. Instead, cumulative fatigue damage causes degeneration at the molecular level, potentially weakening it and increasing the risk of clinical injury. Appropriate exercise regimes early in life may help to improve the quality of growing tendon, thereby reducing the incidence of injury during ageing or subsequent athletic career.
Wong, Jason K. F.; Metcalfe, Anthony D.; Wong, Richard; Bush, Jim; Platt, Chris; Garcon, Arnaud; Goldspink, Nick; McGrouther, Duncan A.; Ferguson, Mark W. J.
Repaired tendons may be complicated by progressive fibrosis, causing adhesion formation or tendon softening leading to tendon rupture and subsequent reduced range of motion. There are few therapies available which improve the gliding of damaged tendons in the hand. We investigate the role of Mannose 6-phosphate (M6P) in a 600 mM hypertonic solution (Adaprev) on tendon adhesion formation in vivo using a mouse model of severed tendon in conjunction with analysis of collagen synthesis, cellular proliferation and receptors involved in TGF beta signalling. Cytotoxicity was assessed by measuring tissue residency, mechanical strength and cell viability of tendons after treatment with Adaprev. To elicit potential modes of action, in vitro and ex vivo studies were performed investigating phosphorylation of p38, cell migration and proliferation. Adaprev treatment significantly (p<0.05) reduced the development of adhesions and improved collagen organisation without reducing overall collagen synthesis following tendon injury in vivo. The bioavailability of Adaprev saw a 40% reduction at the site of administration over 45 minutes and tendon fibroblasts tolerated up to 120 minutes of exposure without significant loss of cell viability or tensile strength. These favourable effects were independent of CI-MPR and TGF-β signalling and possibly highlight a novel mechanism of action related to cellular stress demonstrated by phosphorylation of p38. The effect of treatment reduced tendon fibroblast migration and transiently halted tendon fibroblast proliferation in vitro and ex vivo. Our studies demonstrate that the primary mode of action for Adaprev is potentially via a physical, non-chemical, hyperosmotic effect. PMID:25383548
Massoud, Elsayed Ibraheem Elsayed
Tendon ruptures remain a significant musculoskeletal injury. Despite advances in surgical techniques and procedures, traditional repair techniques maintain a high incidence of rerupture or tendon elongation. Mechanical loading and biochemical signaling both control tissue healing. This has led some researchers to consider using a technique based on tension regulation at the suture line for obtaining good healing. However, it is unknown how they interact and to what extent mechanics control biochemistry. This review will open the way for understanding the interplay between mechanical loading and the process of tendon healing. PMID:24147258
Conrad, Megan O; Gadhoke, Bani; Scheidt, Robert A; Schmit, Brian D
Sensory stimulation of wrist musculature can enhance stability in the proximal arm and may be a useful therapy aimed at improving arm control post-stroke. Specifically, our prior research indicates tendon vibration can enhance stability during point-to-point arm movements and in tracking tasks. The goal of the present study was to investigate the influence of forearm tendon vibration on endpoint stability, measured at the hand, immediately following forward arm movements in an unstable environment. Both proximal and distal workspaces were tested. Ten hemiparetic stroke subjects and 5 healthy controls made forward arm movements while grasping the handle of a two-joint robotic arm. At the end of each movement, the robot applied destabilizing forces. During some trials, 70 Hz vibration was applied to the forearm flexor muscle tendons. 70 Hz was used as the stimulus frequency as it lies within the range of optimal frequencies that activate the muscle spindles at the highest response rate. Endpoint position, velocity, muscle activity and grip force data were compared before, during and after vibration. Stability at the endpoint was quantified as the magnitude of oscillation about the target position, calculated from the power of the tangential velocity data. Prior to vibration, subjects produced unstable, oscillating hand movements about the target location due to the applied force field. Stability increased during vibration, as evidenced by decreased oscillation in hand tangential velocity.
Conrad, Megan O.; Gadhoke, Bani; Scheidt, Robert A.; Schmit, Brian D.
Sensory stimulation of wrist musculature can enhance stability in the proximal arm and may be a useful therapy aimed at improving arm control post-stroke. Specifically, our prior research indicates tendon vibration can enhance stability during point-to-point arm movements and in tracking tasks. The goal of the present study was to investigate the influence of forearm tendon vibration on endpoint stability, measured at the hand, immediately following forward arm movements in an unstable environment. Both proximal and distal workspaces were tested.