The risks of local aprotinin injections for treating chronic tendinopathy
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Abstract:
Overuse or degenerative tendon injuries (tendinopathies) are common in sport, certain occupations and even everyday life. They are difficult to treat because of the high failure rate of treatment, tendency towards chronicity and risk of recurrence. (author abstract)Keywords:
Aprotinin
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Achilles tendon rupture
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Athletes usually complain of an ongoing or chronic pain over the Achilles tendon, but recently even non-athletes are experiencing the same kind of pain which affects their daily activities. Achilles tendinosis refers to a degenerative process of the tendon without histologic or clinical signs of intratendinous inflammation. Treatment is based on whether to stimulate or prevent neovascularization. Thus, until now, there is no consensus as to the best treatment for this condition. This paper aims to review the common ways of treating this condition from the conservative to the surgical options.
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Purpose. To report on the present option for management of tendinopathy of the main body of the Achilles tendon.Background. Tendinopathy of the main body of tendo Achillis affects athletic and sedentary patients. Mechanical loading is thought to be a major causative factor. However, the exact mechanical loading conditions which cause tendinopathy are poorly defined. Repetitive mechanical loading induces a non-inflammatory pathology, and repetitive microtrauma ultimately exceeds the healing response. The management of Achilles tendinopathy is primarily conservative. Although many non-operative options are available, few have been tested under controlled conditions. This review article specifically focuses on eccentric training, and on shock wave therapy. Surgical intervention can be successful in refractory cases. However, surgery does not usually completely eliminate symptoms and complications are not rare.Conclusions. Further studies are needed to discern the optimal non-operative and surgical management of midsubstance Achilles tendinopathy.
Microtrauma
Tendinitis
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Achilles tendinopathy affects athletes, recreational exercisers and even inactive people. The pathology is not inflammatory; it is a failed healing response. The source of pain in tendinopathy could be related to the neurovascular ingrowth seen in the tendon’s response to injury. The treatment of Achilles tendinopathy is primarily conservative with an array of effective treatment options now available to the primary care practitioner. If conservative treatment is not successful, then surgery relieves pain in the majority of cases. Directing a patient through the algorithm presented here will maximise positive treatment outcomes.
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Acute and chronic tendon injuries are very common among athletes and in sedentary population. Most physicians prescribe anti-inflammatory managements to relieve the worst symptoms of swelling and pain, including non-steroidal anti-inflammatory drugs, corticosteroids and physical therapies. However, experimental research shows that pro-inflammatory mediators such as prostaglandins may play important regulatory roles in tendon healing. Noticeably nearly all cases of chronic tendon injuries we treat as specialists have received non-steroidal anti-inflammatory drugs by their physician, suggesting that there might be a potential interaction in some of these cases turning a mild inflammatory tendon injury into chronic tendinopathy in predisposed individuals. We are aware of the fact that non-steroidal anti-inflammatory drugs and corticosteroids may well have a positive effect on the pain control in the clinical situation whilst negatively affect the structural healing. It follows that a comprehensive evaluation of anti-inflammatory management for tendon injuries is needed and any such data would have profound clinical and health economic importance.
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Forceful eccentric contraction may cause a partial or complete rupture of a vulnerable large tendon, especially in middle-aged men. When diagnosing a large-tendon rupture, it is essential to rule out a systemic illness or history of local or systemic corticosteroid or anabolic steroid use, because any of these may lead to poor tendon quality and increased risk for rupture. Ultrasound or MRI may help confirm the diagnosis. Treatment is generally surgical with anatomic repair. Return to sport depends on the patient's age, lifestyle, tendon involved, and medical comorbidities.
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Achilles tendinopathy is a common condition, which can become chronic and interfere with athletic performance. The proteinase inhibitor aprotinin (as injection) has been found to improve recovery in patellar tendinopathy (evidence level 1b) and Achilles tendinopathy. Internationally this therapy is being used based on this limited knowledge base.
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Patellar tendinopathy causes substantial morbidity in both professional and recreational athletes. The condition is most common in athletes of jumping sports such as basketball and volleyball, but it also occurs in soccer, track, and tennis athletes. The disorder arises most often from collagen breakdown rather than inflammation, a tendinosis rather than a tendinitis. Physicians must address the degenerative pathology underlying patellar tendinopathy because regimens that seek to minimize (nonexistent) inflammation would appear illogical. Suggestions for applying the 'tendinosis paradigm' to patellar tendinopathy management include conservative measures such as load reduction, strengthening exercises, and massage. Surgery should be considered only after a long-term and appropriate conservative regimen has failed.
Tendinosis
Tendinitis
Sports medicine
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Achilles tendon injury is a common cause of disability in adult sportsmen. The majority of cases are due to overuse injury often exacerbated or precipitated by specific and recognizable factors. The main reason is probably the increased popularity of recreational sports among middle-aged people. The 2 most frequently discussed pathophysiological theories involve chronic degeneration of the tendon and failure of the inhibitory mechanism of the musculotendinous unit. It has been postulated that a physically inactive lifestyle leads to a decrease in tendon vascularization, while maintenance of a continuous level of activity counteracts the structural changes within the musculotendinous unit induced by inactivity and aging. Comparable studies have been published with surgical versus nonsurgical treatment and postoperative cast immobilisation versus early functional treatment. Although conservative treatment is popular in 1970s, surgical treatment seems to have been the method of choice in the late 1980s and the 1990s in athletes and young people; and in cases of delayed ruptures. Conservative management of Achilles tendon injury may be unrewarding except in low demand and very cooperative patients. The role of surgery in management of Achilles tendon rupture is discussed in detail with particular reference to the indications and the surgical procedures available. There is also no single, uniformly accepted surgical technique. Although early ruptures have been treated successfully with simple end-to-end suture, many authors have combined simple tendon suture with augmentation and plastic procedures of various types. Comparison of open versus percutaneous surgical methods also will be discussed in details. The complications of conservative treatment include mostly reruptures and residual lengthening of the tendon, which may result in significant calf muscle weakness.The major complaint against surgical treatment has been the high rate of complications. Most are minor wound complications, which delay improvement but do not influence the final outcome. Major complications are rare, but often difficult to treat with minor procedures.
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