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Letter to the Editor |
1 Department of Trauma and Orthopaedic Surgery, Keele, University School of Medicine Staffs, England2 Musculoskeletal Research Centre, La Trobe University, Bundoora, Victoria, Australia3 School of Human Kinetics and Allan McGavin Sports Medicine Center, University of British Columbia, Vancouver, Canada
Dear Editor:
We read with great interest "Recalcitrant Patellar Tendinosis in Elite Athletes: Surgical Treatment in Conjunction With Aggressive Postoperative Rehabilitation," published in the July 2006 issue (pages 1141–1146), and we congratulate Drs Shelbourne, Henne, and Gray for focusing on the challenging clinical issue of surgical management of patellar tendinopathy in elite athletes. We would appreciate the opportunity to add 4 comments to this valuable article.
First, Dr Shelbourne and colleagues write as if there were a continuum from "tendinitis" through "tendinosis" and "recalcitrant tendinosis" (paragraph 1). They suggest that tendinosis is "usually associated with more severe symptoms." We fear that this assertion has the potential to confuse a field that has only recently come to consensus that tendinopathy1,7 is the appropriate term for the clinical presentation of this condition, without histological evidence of pathology. We note that the authors did not report the histopathology in their patients. There is no evidence yet that "tendinitis" (histopathology showing prominent inflammatory cell invasion) exists in humans suffering overuse tendon pain. Thus, it is impossible to compare the clinical symptoms associated with tendinosis with a theoretical "tendinitis." Interestingly, "tendinosis" is not necessarily symptomatic. Indeed, this was recognized by Puddu et al9 and proven without doubt by Kannus and Jozsa.4 More recently, the work by Cook et al has indicated that in the patellar tendon, there is no statistically significant relationship between ultrasonographic patellar tendon abnormalities and clinical outcome in elite male athletes,2 although an ultrasonographic hypoechoic area is associated with a greater risk of developing jumper’s knee symptoms.3
Second, the caption for Figure 2 describes the "inflamed areas on both patellar tendons that are visibly evident by a lump." In the text, the authors describe this tissue as being "necrotic." We alert the AJSM reader to the widespread agreement that classic cellular inflammation is not a feature of tendinopathies.5,7 This was already appreciated by Puddu et al in 1976.9 The histopathological term tendinosis is probably more appropriate, but in reality, the lesion is a failed healing response. Modern pathological research has determined that these lesions are far from being necrotic and are instead hypercellular and hypervascular, with florid production of extracellular matrix.8 Certainly, at a time in which there is increasing interest in a possible apoptotic contribution to chronic tendinopathy,10 we believe that the authors may concur that the term necrosis as used in this article is merely a clinically descriptive term referring to a tendinopathic tendon (ie, a tendon with a failed healing response) rather than a precise pathological term that implies one pathway by which cells can die.
We appreciate the authors’ contribution to the increasing recognition that time to return to sport after major tendon surgery averages 8 months.6 These data are of great clinical significance for athletes themselves and to clinicians involved in rehabilitation.
Finally, we agree that the issues of the specific type of surgery and the specific type of rehabilitation in these difficult cases warrant investigation. Clearly, the study of Shelbourne et al is not designed to attribute causality to the type of surgery or the "aggressive postoperative rehabilitation" protocol. Nevertheless, it provides an important stimulus to the question of how rehabilitation should be prescribed in this setting. A limitation of undertaking research in clinical practice with elite athletes is that conclusions about what "contributed to success" must necessarily be limited.
REFERENCES
The Shelbourne Clinic at Methodist Hospital, Indianapolis, Indiana
Thank you for your comments about our article. The purpose of our study was to focus on the clinical presentation of recalcitrant tendinosis. Although the report did not include our histological findings, we did, indeed, have histological results of the removed tendon in 12 of the 16 patients in the study. The pathology reports consistently read the removed tissues to have "chronic inflammation with neovascularization" or "reactive and reparative changes with fibrosis and neoangiogenesis consistent with chronic tendinitis." We believe we can assign the diagnosis of "tendinosis" for the patients in our study given the consistent readings of the pathology reports.
What is important to consider from a clinical perspective is that a surgeon would not do a biopsy to confirm a histological diagnosis of "tendinosis" before performing the surgery, but that does not mean that tendinosis is not present. All patients in our study were elite athletes who had a long history of tendinopathy that could not be resolved with rehabilitation or rest, MRI confirmation of a failed healing response, and hypertrophy of the anterior portion of the tendon that was visible on examination. The clinical presentation of symptoms of tendinopathy corresponded to the MRI evaluation of abnormal tissue, and tendinosis was then confirmed in most cases by pathological analysis. We believe that when all the clinical factors outlined in our article are present, a diagnosis of tendinosis can be appropriately given because most assuredly the removed tendon would be confirmed to have histological evidence of pathology.
I do believe that there is a continuum from "tendinitis" through "tendinosis" and "recalcitrant tendinosis" for some athletes, as it is described in our study population. The patients’ histories described in our article in which athletes have undergone multiple trials of rehabilitation, rest, and other modalities to alleviate symptoms are typical. That history combined with clinical findings on physical examination and MRI confirmation of abnormal tissue must all be present before surgery is ever considered.
Tendinosis may not always be symptomatic, as you have mentioned. Our purpose, however, was to present the typical clinical presentation of tendinosis (that would undoubtedly be confirmed histologically), the criteria for when surgery would be indicated, specifics about the surgery, and a rehabilitation program to return elite athletes back to competition. Our approach to surgery and rehabilitation was successful for 14 of 16 patients.
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