By Dr. Bert Fields

Photo of Daniela Hantuchova by Sasho

As a busy sports medicine physician I see an increasing number of patients pursuing unproven and often expensive treatments before they have tried established therapies with stronger evidence.  One example of this is a recent patient who saw advertising for a cold laser that they purchased from an internet site. The patient showed no progress with his tennis elbow until we saw him in the office and gave him a series of eccentric exercises and other standard treatment which quickly started a reversal of his problem.

In my opinion marketing and news stories which exaggerate the benefits of unproven therapies are leading patients to make bad choices.  Particularly for tendon injuries, patients are purchasing unproven devices or seeking injections with substances like platelet rich plasma or stem cells before they have done any established treatment.

Related BJSM Articles

Lotta Willberg, Kerstin Sunding, Magnus Forssblad, Martin Fahlström, Håkan Alfredson. 2011. Sclerosing polidocanol injections or arthroscopic shaving to treat patellartendinopathy/jumper’s knee? A randomised controlled study . Br J Sports Med 2011;45:411-415.

A van der Plas, S de Jonge,  R J de Vos, H J L van der Heide, J A N Verhaar, A Weir,  J L Tol. 2011. A 5-year follow-up study of Alfredson’s heel-drop exercise programme in chronic midportion Achilles tendinopathy. Br J Sports Med 2012;46:214-218 Published Online First: 10 November 2011. (FREE ONLINE!)

Mathijs van Ark, Johannes Zwerver,  Inge van den Akker-Scheek. 2011. Injection treatments for patellar tendinopathy. Br J Sports Med 2011;45:1068-1076 Published Online First: 3 May 2011. 

R J de Vos, A Weir, J L Tol, J A N Verhaar, H Weinans, H T M van Schie. 2011. No effects of PRP on ultrasonographic tendon structure and neovascularisation in chronic midportion Achilles tendinopathy. Br J Sports Med 2011;45:387-392 Published Online First: 3 November 2010

Bert Fields, MD is a professor for the UNC School of Medicine and directs the sports medicine fellowship at Cone Health system in Greensboro, NC.  He is a past president of AMSSM.

For more information: www.ists2012.com

More information, and call for abstracts coming soon!

Contact: alex.scott@ubc.ca

Just a quick post (it’s the weekend and BJSM editors never work on weekends).

One of the pioneers of the science of sedentary behavior, Professor Neville Owen, alerted BJSM to this comprehensive paper  (not open access, sorry!) – great one to bring you up to speed in this field. What is sedentary behaviour? It’s too much sitting as opposed to too little physical activity. A problem in its own right. Kills ya!

Neville’s editorial raising this for BJSM readers was in 2009 (we like to be cutting edge )

Click on these separate links for other related material:

* List of great papers: February 2009 (focus on sedentary behaviour)

* List of great papers: January 2009 (focus on how clinicians can get folks to be physically active)

* Another paper cited in Garland’s recent review was When will we treat physical activity as a legitimate medical therapy…even though it does not come in a pill? by Tim Church and Steven Blair. Click here for that one. 

That’s it for today. And if you haven’t done 30/60 minutes of accumluated physical activity today what are you doing reading this? (in the most respectful way possible )

 Great cartoon for that Feb BJSM issue by Malcolm Willett

A commonly overlooked diagnosis of lateral hip pain is gluteal tendinopathy. The relative emphasis on ‘trochanteric bursitis’ compared with tendinopathy is likely reversed. The tendinopathy is much more prevalent that the ‘bursitis’ according to MR studies of the regions.

At surgery for total hip arthroplasty, surgeons often find major tears in the gluteus medius (Bunker and colleagues, 1997, among others). More recent MR studies have highlighted this pathology.

Have you ever wondered why ‘strengthening exercises’ are helpful in treatment of  lateral hip pain? This would be counterintuitive for a ‘bursitis’ but perfectly logical for a tendinopathy.

The take home message: Please consider gluteal tendinopathy in the patient who presents with lateral hip pain. It occurs across the ages – from the active sports person to the older person in whom it can be mistakenly diagnosed as ‘hip OA’!  Wouldn’t it be terrible if someone were to undergo hip joint replacement for a tendinopathy.

For further discussion of lateral hip pain and groin pain, consider the link here.

Please add your comments in the box below.

Our New Zealand colleagues had a great sports medicine conference in Wellington this week following their successful hosting of the World Championships in Rowing. Congratulations to Dr Chris Milne and colleagues from all disciplines who made this a success.

In a conversation with Chris I was reminded that the lateral hip pain label of  ‘trochanteric bursitis’ is often given to what is really gluteus medius tendinopathy. As with other tendon problems, the hip external rotator tendons can fail (tendinosis), causing lateral hip pain, pain with getting out of the car to that side and eventually even aching in upper thigh.

MR technology highlighted this pathology as ‘rotator cuff tear of the hip’ in the late 1990s. I always wondered why hip external rotator strengthening was effective for a condition that was meant to be a ‘bursitis’. In a nice BMJ study, cortisone injection to the ‘bursa’, even under fluroscopic control, was not effective – further suppport that the diagnosis is not ‘trochaneric bursitis’. Today’s tip – if you are thinking ‘trochanteric bursitis’, put ‘ gluteus medius tendinopathy’ down as the diagnosis and most times you’ll be glad you did.

Remember too that this is an important differential in the older person – hip OA radiates to the GROIN and patients generally DON’T point to the lateral hip region with their finger when they have OA.

The April 2011 edition of BJSM will focus on Tendinopathy.

Authors with manuscripts that clarify treatment options, improve the basic understanding of the condition or have an innovative perspective are invited to submit their papers by January 15 2011.
 
Enquiries about suitability of manuscripts for this issue can be directed to jill.cook@deakin.edu.au

Spring into action!

Dear fellow Tendinopathy Researcher,

On behalf of the Organizing Committee please click here to download a PDF of the 1st Announcement of the International Scientific Tendinopathy Symposium that will be held in Umeå, Sweden, on September 30 – October 1, 2010. We hope that you will be interested to join the Symposium and would greatly appreciate if you would also distribute the announcement to your colleagues.

Please, note on page 4 of the PDF that we are accepting preliminary registrations at this point. The Symposium will have a limited number of subsidized seats (at symposium fee: 100 Euro; regular fee: 150 Euro). The first 60 persons to send in such preliminary registration (i.e. notification of intention to participate in the symposium) before April 30, 2010, will be ensured to be admitted at the subsidized fee. (“First come, first served.”) This preliminary registration is however not binding.

Final registration dead-line is June 30, 2010, after 2nd Announcement (dead-line for submission of abstracts: June 20). Express your interest to participate in the Symposium by emailing Patrik Danielson, and in your e-mail reply please state:

• Title, name and affiliation
• Contact information (including e-mail address and phone number)
• Expected number of participants from your team/group
• Intention to make contribution to scientific program, and please specify
  • number of expected contributions
  • preferred session for contribution/-s:
  • session 1 “Basic science – pathophysiology of tendinopathy”
  • or  session 3 “Clinical tendinopathy research/management”
  • preference of oral or poster presentation

We are looking forward to an exciting Symposium!

Yours sincerely,

Patrik Danielson, M.D., Ph.D.,
Associate Professor
UMEÅ UNIVERSITY
Department of Integrative Medical Biology
Section for Anatomy

The following is a letter to BJSM from Ralph S. Bovard MD:

Dear BJSM,

I have a question regarding the use of autologous platelet rich plasma (PRP) injections for tendinopathies of various sorts.  This procedure has been gaining favor with sports medicine clinicians for use in athletes with tendon injuries that are slow to respond or resistant to conservative therapies.  Despite the fact that it would appear to be a seemingly innocent matter of re-injecting one’s own spun down blood products, the World Anti-Doping Agency (WADA) most recent 2009 Prohibited List, if taken literally, would make it an illegal procedure for international competition or national competition under any NGB’s who endorse WADA.  The culprit substances in this case would be growth hormone (GH), Insulin-like Growth Factors (IGF-1), and Mechano Growth Factors (MGF’s).

The relevant section from the code is included below:

S2. HORMONES AND RELATED SUBSTANCES

The following substances and their releasing factors, are prohibited:
1. Erythropoiesis-Stimulating Agents (e.g. erythropoietin (EPO), darbepoietin (dEPO), hematide);
2. Growth Hormone (GH), Insulin-like Growth Factors (e.g. IGF-1), Mechano Growth Factors (MGFs);
3. Chorionic Gonadotrophin (CG) and Luteinizing Hormone (LH) in males;
4. Insulins;
5. Corticotrophins;
and other substances with similar chemical structure or similar biological effect(s).

[Comment to class S2:
Unless the Athlete can demonstrate that the concentration was due to a physiological or pathological condition, a Sample will be deemed to contain a Prohibited Substance (as listed above) where the concentration of the Prohibited Substance or its metabolites and/or relevant ratios or markers in the Athlete's Sample satisfies positivity criteria established by WADA or otherwise so exceeds the range of values normally found in humans that it is unlikely to be consistent with normal endogenous production.

If a laboratory reports, using a reliable analytical method, that the Prohibited Substance is of exogenous origin, the Sample will be deemed to contain a Prohibited Substance and shall be reported as an Adverse Analytical Finding.] The Prohibited List 2009 20 September 2008

It would thus seem that PRP is banned under “Class S2: Hormones and Related Substances”, rather than under “M1: Blood Doping”.  The re-delivery of blood is prohibited under blood doping; regardless of whether it is endogenous or exogenous.  There is no mention or attempt to discriminate between blood products that are re-injected immediately into soft tissues versus those that are shelved and re-infused by IV weeks or months later in the typical manner of “blood doping”.

The argument is made that while PRP indeed delivers  the athletes own growth factors to a musculoskeletal site, the platelets are concentrated to a level not normally achieved physiologically, and they are activated either chemically (via calcium addition) or mechanically (centrifugation) and thus degranulate  rapidly and deliver a bolus of factors never “normally” or physiologically achieved.

Given this stance it would seem that the use of platelet rich plasma injections is clearly prohibited.   Tendinopathies are not life threatening or otherwise serious medical conditions and as such the rational of applying for a therapeutic use exemption (TUE) would seem a difficult argument.   Yet how would PRP injections be detected other than by admission?  What is the opinion of the BJSM readership regarding this topic?

Thank you,

Raph S. Bovard MD