”قالوا سبحانك لا علم لنا إلا ما علمتنا إنك أنت العليم الحكيم“ :”قالوا سبحانك لا علم لنا إلا ما علمتنا إنك أنت العليم الحكيم“ بسم الله الرحمن الرحيم صدق الله العظيم سورة البقرة "الآية - 32"


Overuse Tendinitis :Overuse Tendinitis Mohamed hosni abdel hakiem


Definition :Definition Inflammation of tendon occurring usually at its point of insertion into bone or at the point of muscular origin. The inflammation can extend to adjacent bursal tissue. It is usually related to repetitive activity or trauma, but can be without obvious cause.


Anatomical consideration :Anatomical consideration Anatomy of a normal tendon: At the myotendinous junction, tendinous collagen fibrils are inserted into deep recesses formed by myocyte processes allowing the tension generated by intracellular contractile proteins of muscle fibers to be transmitted to the collagen fibrils.


Slide 6:Tendons vary in shape and size from the small fibrous strings that form the tendons of the lumbrical muscles to the large fibrous cords that from the Achilles tendons. In any shape or size however,they join muscle to bone. They transmit the force of muscle contraction to bone. They consist of three parts, the substance of the tendon itself, the muscle tendon junction, and the bone insertion. Connective tissues surrounding tendons allow low friction gliding and access for blood vessels to the tendon substance.


Blood and lymphatic supply :Blood and lymphatic supply Tendons recive thier blood supply from three main sources:the intrinsic systems at the myotendinous junction and osteotendinous juncation , and the extrinsic system through the paratenon or the synovial sheath. The ratio of blood supply from the intrinsic systems to that from the extrinsic system varies from tendon to tendon.


: Small arterioles from adjacent muscle ramify longitudinally between their fascicles, anastomosing freely, accompanied by venae comitantes and lymphatic vessels. Lymphatics pass along blood vessels and drain into regional lymph nodes. This longitudinal plexus is augmented by small vessels from adjacent loose connective tissue or synovial sheaths.


Nerve Supply :Nerve Supply Tendon innervation originates from cutaneous, muscular, and peritendinous nerve trunks. At the myotendinous junction, nerve fibers cross and enter the endotenon septa. Nerve fibers from rich plexuses in the paratenon, and branches penetrate the epitenon. Most nerve fibers do not actually enter the main body of the tendon but terminate as nerve endings on its surface.


Histological Anatomy of Tendons :Histological Anatomy of Tendons Tendons are formed of dense connective tissue which differs from the loose connective tissue mainly in the great prepondrance of the fibers over the cellular and amorphous components. where the fibers are oriented parallel to one another or in some other consistent pattern it is called dense regular connective tissue.


Slide 11:The main cell type of dense fibrous tissue (fibroblasts), and main macromolecular component of dense fibrous tissue matrix (collagen fibers). Healthy tendons are brilliant white in color and have a fibroelastic texture. Tendons demonstrate marked variation In form; they can be rounded cords, straplike bands, or flattened ribbons.


Slide 12:The oxygen consumption of tendons and ligaments is 7.5 times lower than that of skeletal muscles . The low metabolic rate and well-developed anaerobic energy-generation capacity are essential to carry loads and maintain tension for long periods, reducing the risk of ischemia and subsequent necrosis. However, a low metabolic rate results in slow healing after injury.


Slide 13:The ground substance of the extracellular matrix network surrounding the collagen and the tenocytes is composed of proteoglycans, glycosaminoglycans, glycoproteins, and several other small molecules.


Biology and Biomechanics of Tendons :Biology and Biomechanics of Tendons The primary function of the tendon is to transmit muscle force to the skeletal system, and to do this with a limited amount of elongation. On gross examination, tendons are composed of dense connective tissues with closely packed, parallel collagenous fiber bundles with a glistening white appearance.


Biology and Biomechanics of Tendons :Biology and Biomechanics of Tendons Under microscopic examination, these tissues are seen to contain a meshwork of interlacing fibers, flattened and oval cells, and ground substance. Polarized light microscopy demonstrates an undulating pattern to the collagen fibers, and specialized stains can differentiate the fibrous elements as well as ground substance and fibroblast in the interfibrillar spaces.


Age- Related Change of Mechanical Properties: :Age- Related Change of Mechanical Properties: Aging should have some, If not significant, influence on the mechanical properties of tendons. Unfortunately, not many reports in the literature deal with this subject. The stress-strain behavior of tendon as a function of age was examined.


Basic stress- strain or load deformation curve for tendon. :Basic stress- strain or load deformation curve for tendon.


Pathology of Tendinits :Pathology of Tendinits The pathogenesis of tendinits is difficult to define precisely Different hypotheses have been postulated with accorespondingly large number of alternative therapeutic propoaals. At first view, the prime factor may be repetitive stress of the groups of muscles involved, respectively of the extensors of the hand and the wrist.


Pathology of Tendinits :Pathology of Tendinits In fact the etiology is multifactorial and includes a cluster of causes Tendon injuries can occur in atheletes and workers whose tasks involve reptitive, high-force hand activities, but the early pathophysiologic processes of tendinopathy are not well known.


Pathology of Tendinits :Pathology of Tendinits Significantly, a review of the reported histologic findings in biopsy specimens take from patients with "chronic tendinitis syndrome" showed that they were all similar.


Pathology of Tendinits :Pathology of Tendinits All specimens contained demonstrated areas with various degrees of tendon degeneration, such as the loss of the normal collagen architecture, ranging from splaying of fibers to amorphic areas, the loss of cellularity in these areas, and the complete absence of the classic inflammatory response.


Pathology of Tendinits :Pathology of Tendinits Adolescent and young adult athletes showed a morphologic change in the fibroblasts adjacent to these areas of degeneration. The fibroblasts become more plump or rounded and granularity increased within the nucleus. These changes suggest an increased metabolic rate but there is no noticeable increase in collagen production.


Etiology :Etiology Tendon injuries appear to have a multi-factorial aetiology. Certain factors may be more important in one patient than in another. For instance, in the young athlete with otherwise healthy tendons, the repetitive mechanical overload from exercise may be the predominant factor, whereas in the aging patient with pre-existing tendon degeneration exercise may merely be the "permissive factor" that allows the problem to become symptomatic.


Extrinsic Factors: :Extrinsic Factors: 1-Repetitive mechanical load and training errors: A-Sudden increase in mileage: zero miles per week increased to 45miles per week. B-Inadequate stretching program: -Exercises for wrong muscles.


Extrinsic Factors: :Extrinsic Factors: -Too many exercises to be effective. -Use of exercises that produce injuries. -No stretching program. 2.Eguimpent problems:


Extrinsic Factors: :Extrinsic Factors: A- Footwear: -Using shoe after it is too worn out. -Lack of proper shoe for particular activity. -Shock absorption. -Inadequate care of the shoe gear.


Extrinsic Factors: :Extrinsic Factors: Surface geometer: -Hills. -Roads. -Tracks. Surface composition: -Sand. -Grass. -Concrete. -Tracks.


Extrinsic Factors: :Extrinsic Factors: C-Racquet size 3.Miscellaneous A-Weather conditions. -Snow. -Rain. -Too cold or too hot. B-Altitude


Intrinsic factors: :Intrinsic factors: 1.Anatomic factors: A-Malalignment eg.: -Equinus deformity of lower extremity. -Varus deformities of foot and leg. -Limb length discrepancies.


Intrinsic factors: :Intrinsic factors: -Miscellaneous pronatory conditions. B-Inflexibility. C-Muscle weakness. D-Muscle imbalance. E- Decreased vasculatrity. 2.Psyschological/ emotional/ social.


Age related factors: :Age related factors: 1.Tendon degeneration. 2.Decreased Healing response. 3.Increased tendon stiffness. 4.Decreased vascularity.


systemic factors: :systemic factors: 1.Inflammatory enthesopathy. 2.Quniolone- Tendinopathy.


Clinical picture :Clinical picture The history of patients with a chronic tendon problem can vary widely, because of the wide spectrum of aetiologic factors that may be involved. The role of repetitive and/ or intense mechanical overload can be determined by careful inquiry about changes in work, sport, and other activities, not only in the days leading up to the first symptoms but also in the preceding weeks or even months.


Clinical picture :Clinical picture The physical examinations may yield the definitive diagnosis, Peritendinitis and tenosynovitis results in visible or palpable swelling of the tendon sheath, sometimes accompanied by crepitus or symptoms of triggering. In other forms of tendinopathy, the tendon will be point tendon to direct palpation.


Clinical picture :Clinical picture In insertional tendinopothy deep palpation of the bone tendon junction tissue is usually located on the deep joint side of the tendon. Testing the tendon in tension (similar to muscle strength testing) often reveals surprisingly little pain compared with direct palpation.


Clinical picture :Clinical picture In some location, like the shoulder, direct palpation may be difficult. Indirect pressure on the affected tendon through the impingement maneuver in shoulder can indicate a chronic rotator cuff tendon problem. Restriction of joint motion also can be present.


Clinical picture :Clinical picture Routines radiographs are often not conclusive during the initial visit if involvement of the tendon or tendon sheath is evident. When there is doubt, radiographs are appropriate to eliminate the possibility of problem such as degenerative arthritis of the adjacent joint or a stress fracture near the tendon and traction spurs at the bone- tendon junction support the diagnosis of tendinopathy.


Clinical picture :Clinical picture In cases that are complex or that do not respond to treatment, more sophisticated imaging techniques can be helpful. Technetium bone scanning can be positive in active insertional tendinopathy.


Clinical picture :Clinical picture Evaluation of the tendon can also be accomplished through diagnostic ultrasound. Enlargement of the tendon, degenerative lesions and partial or complete tears can be documented by experienced ultrason-grapher.


Clinical picture :Clinical picture Also ultrasound is used to localize the calcium deposits as a preoperative mapping of these deposits to facilitate localization during arthroscopic surgery for calcifying tendonitis.


Clinical picture :Clinical picture Magnetic resonance (MR) imaging will allow evaluation of the tendon as well as the surrounding structure, such as the adjacent joint. However the degree of tendon involvement depicted by MR imaging does not always correlate with the clinical Symptoms.


Treatment :Treatment Non Surgical Treatment: Correction of external factors. Physical Therapy. Cytokines and Growth Factors Gene Therapy. Tissue Engineering with Mesenchymal Stem Cells.


Treatment :Treatment Mobilization and Mechanical Loading. Role of Heparin. Crytherapy. Asclerosing agent. Non steroidal Anti-inflammatory Drugs. Corticosteroid therapy.


Treatment :Treatment Surgical treatment: If symptoms and functional impairments continue beyond 4 to 6 months after the start of treatment, surgery can be considered, weighing the potential side effects against the level of severity symptoms. Many patients will be able to mange the problem well with only modest changes in their lifestyle and will not require further invasive treatment.


Specific Conditions :Specific Conditions Bicipital tendinitis:


Iliotibial Band Friction Sydrome (ITBFS): :Iliotibial Band Friction Sydrome (ITBFS): Tendinosis about the hip (Snapping hip). Internal snapping hip. External Snapping hip.


Achilles tendinitis: :Achilles tendinitis:


Tendinitis of the Rotator Cuff: :Tendinitis of the Rotator Cuff: Sub acute tendinitis. Chronic tendinitis. Cuff Disruption.


Tendinitis of the Elbow: :Tendinitis of the Elbow: Lateral Tendinitis of the Elbow. Medial Tendinitis of the elbow. Medial tennis elbow.


Trigger Finger (Digital tenovaginitis): :Trigger Finger (Digital tenovaginitis): Infantile trigger thumb. De Quervain's disease (stenosing tenovaginitis).


Iliopsoas Bursitis. :Iliopsoas Bursitis. Trochanteric Bursitis. Gluteus Medius Tendinitis. Adductor Longus Strain or Tendinitis.


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