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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003ETendinosis is a common health concern that may be resistant to treatment, making it important to consider the best approaches. This article reviews the options for treating tendinosis.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Einterventional radiology\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eultrasonography\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eorthopaedic procedures\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Esoft tissue disorders\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \n         \u003Cp id=\u0022p-2\u0022\u003ETendinosis is a common health concern that may be resistant to treatment, making it important to consider the best approaches. In this session, 3 presenters reviewed the options for treating tendinosis.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ETENDON FENESTRATION FOR TENDINOSIS\u003C\/h2\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EJon A. Jacobson, MD, University of Michigan Health System, Ann Arbor, Michigan, USA, reviewed the procedure and outcomes for tendon fenestration as a treatment for tendinosis, a condition in which there is degeneration and possible microtears in a tendon without inflammation. In tendinosis, the tendon is hypoechoic and swollen; it may have anechoic clefts with tears or hyperemia. Tendon fenestration is an approach in which a needle is passed through the affected areas to disrupt the tendinosis. It can cause bleeding, the release of growth factors, and stimulate healing.\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EAt least 10 days prior to fenestration, it is important for patients to discontinue any nonsteroidal anti-inflammatory drugs (NSAIDs) to allow inflammation and healing to occur. However, Dr Jacobson does not recommend the discontinuation of aspirin for a cardiovascular event because of the trade-off of risks and benefits. Using ultrasound (US) guidance, a 20- to 22-gauge needle is passed through the tendon 20 to 30 times to cover the entire abnormality, pulling out the needle from the tendon (but not through the skin) when redirection is needed.\u003C\/p\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EContraindications have not been well defined, but some recommend caution with recent steroid injections (\u0026lt; 3 months prior), bleeding disorders, infections, or tendon tears that are \u0026gt; 50% of tendon thickness [Chiavaras MM, Jacobson JA. \u003Cem\u003ESemin Musculoskelet Radiol.\u003C\/em\u003E 2013]. Following the procedure, Dr Jacobson recommends that patients rest; NSAIDs and ice should be avoided for 2 weeks. Some physicians recommend additional restrictions such as a knee brace.\u003C\/p\u003E\n         \u003Cp id=\u0022p-6\u0022\u003EDr Jacobson then summarized the literature on fenestration and the associated techniques for tendinosis (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E). While the research is relatively limited, overall, most of the literature suggests improvement and that patients tolerate the procedure well. He noted that corticosteroids do not appear to help and interfere with inflammatory processes [McShane JM et al. \u003Cem\u003EJ Ultrasound Med.\u003C\/em\u003E 2008]. More data are needed concerning associated procedures such as platelet-rich plasma (PRP), whole blood injection, hyperosmolar dextrose, and prolotherapy. In the future, it will be important to learn more about which patients benefit, the appropriate timing, and the optimal number of treatments.\u003C\/p\u003E\n         \u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/16492\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/16492\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16492\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-7\u0022 class=\u0022first-child\u0022\u003ESummary of Studies on Tendon Fenestration\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EPRP FOR TENDINOSIS\u003C\/h2\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EKenneth S. Lee, MD, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA, addressed the associated treatment of PRP in more detail, including a review of the current literature and uses for PRP therapy. Although there can be variability in its preparation, PRP is defined in the literature as platelet count with 1 000 000 per \u03bcL.\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003ETendinosis is a substantial, common health issue [Woodwell DA, Cherry DK. \u003Cem\u003EAdv Data.\u003C\/em\u003E 2004] that can be difficult to treat; it is responsible for a high percentage of athletic injuries. The purpose of PRP therapy is to encourage healing and remodeling, which disrupts the progression of degenerative tendinosis (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E). Although conservative management is sufficient to relieve pain and return function in about 80% of patients, healing takes time and the tendon remains vulnerable [Wilson JJ, Best TM. \u003Cem\u003EAm Fam Physician.\u003C\/em\u003E 2005]. There is limited, inconsistent evidence about the best approaches for treatment.\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/53\/24\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Tendinosis Model\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-263255488\u0022 data-figure-caption=\u0022Tendinosis Model\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/53\/24\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/53\/24\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/53\/24\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16401\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-11\u0022 class=\u0022first-child\u0022\u003ETendinosis Model\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EReproduced with permission from KS Lee, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-12\u0022\u003ECurrent US-guided therapies include steroids, percutaneous needle tenotomy (fenestration), prolotherapy, and PRP therapy. PRP therapy has become more common and is used for lateral epicondylitis, patellar tendinosis, and plantar fasciopathy, among others. The benefits arise from the interplay of concentrated growth factors (eg, platelet-derived growth factor, transforming growth factor-\u03b2, and basic fibroblast growth factor) in a relatively hypovascular area.\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EPRP is recommended for chronic overuse injuries, injuries that do not respond to conservative therapy, cases in which surgery is unwanted or inappropriate, and for accelerating return to play for athletes with acute injuries. There is generally a single injection followed by immobilization for 24 to 72 hours and then a gradual increase in activity after a month. Although the procedure is safe, pain medication may be required following injection. NSAIDs should be avoided as they interfere with healing. Although one study indicated that PRP was significantly more effective (\u003Cem\u003EP\u003C\/em\u003E \u0026lt; .001) than steroid treatment [Peerbooms JC et al. \u003Cem\u003EAm J Sports Med.\u003C\/em\u003E 2010], another study did not find PRP to be more effective than saline after 1 year [de Vos RJ et al. \u003Cem\u003EJAMA.\u003C\/em\u003E 2010]. Preliminary data from a pilot randomized controlled trial of 44 patients with plantar fasciopathy suggested significantly greater improvements in visual analog score for pain in patients treated with PRP vs steroids (\u003Cem\u003EP\u003C\/em\u003E \u0026lt; .001).\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EDr Lee concluded by emphasizing the importance of studying tendinosis due to the prevalence of the problem, and the markedly increasing use of PRP despite larger randomized controlled trials. A standard of care needs to be established.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-4\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EOTHER TREATMENTS FOR TENDINOSIS\u003C\/h2\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EConcluding the session, Mary M. Chiavaras, MD, PhD, McMaster University, Hamilton, Ontario, Canada, presented an overview of treatments for tendinosis. She first reviewed the IMPROVE randomized controlled trial [Chiavaras MM et al. \u003Cem\u003EAcad Radiol.\u003C\/em\u003E 2014] that is comparing PRP, whole blood, fenestration, and physical therapy. Factors influencing the best approach for a particular patient include the type of pathology, goals of the patient, type of patient (eg, athlete or nonathlete), and legality.\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003ETreatments can be noninvasive, percutaneous minimally invasive, or surgical. Noninvasive treatments are commonly used and can be effective in many cases. For the acute phase, it is important to modify risk factors (eg, stop the injury). Many patients try to minimize inflammation, but inflammation is important in healing. In the chronic phase, healing has failed and degeneration has occurred; NSAIDs are not helpful. The most common intervention is eccentric exercise [Frizziero A et al. \u003Cem\u003EBr Med Bull.\u003C\/em\u003E 2014], which may promote remodeling and collagen cross-link formation while decreasing pain mediators [Maffulli N et al. \u003Cem\u003EJ Bone Joint Surg Am.\u003C\/em\u003E 2010]. Some other noninvasive interventions include deep-friction tissue massage, low-intensity laser therapy, therapeutic ultrasonography, and extracorporal shockwave therapy.\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EPercutaneous minimally invasive procedures include a wide range of possibilities, such as PRP and fenestration; some illegal approaches have been tried (eg, deer antler dust). Corticosteroids have risks such as increased risk of tendon rupture, fat atrophy, depigmentation, and elevated glucose levels [Moon HJ et al. \u003Cem\u003EAm J Phys Med Rehabil.\u003C\/em\u003E 2014; McMahon SE et al. \u003Cem\u003EActa Orthop Belg.\u003C\/em\u003E 2013]. Corticosteroids should not be injected into tendons.\u003C\/p\u003E\n         \u003Cp id=\u0022p-18\u0022\u003EProlotherapy involves the injection of an irritant, such as hyperosmolar dextrose, which may cause an inflammatory response, the release of growth factors, and healing [Rabago D et al. \u003Cem\u003EAm J Phys Med Rehabil.\u003C\/em\u003E 2013; Distel LM, Best TM. \u003Cem\u003EPM R.\u003C\/em\u003E 2010]. Finally, ultrasonic percutaneous tenotomy is a new treatment that involves a US Food and Drug Administration\u2013approved device that is used to remove pathological tissue and that produced improvements in one study [Barnes DE et al. \u003Cem\u003EJ Shoulder Elbow Surg.\u003C\/em\u003E 2015].\u003C\/p\u003E\n         \u003Cp id=\u0022p-19\u0022\u003EProf Chiavaras concluded by highlighting the importance of trying physical therapy first, using caution with steroids, and considering fenestration if physical therapy was not sufficient.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2015 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/53\/24.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzlsn2\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzlsn2\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzlsn2\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}