Korean J Sports Med.  2016 Dec;34(2):107-119. 10.5763/kjsm.2016.34.2.107.

Tendinopathy as Sports Injury: Characteristics and Management

• Yoo JD
• Lim HM
• Kim YK

• KMID: 2382047
• DOI: http://doi.org/10.5763/kjsm.2016.34.2.107

Abstract

With increased participation in sporting activity, overuse tendon injuries are a major problem in sports medicine. Tendinopathy is generic descriptive term for the clinical conditions in and around tendons arising from overuse. Tendinopathy is debilitating condition that results in significant deficits in performance and prolonged time away from activity. Histological studies show either absent or minimal inflammation. There are three main theories to explain the development of tendinosis, including the mechanical theory, vascular theory, and neural theory. Risk factors are divided into intrinsic factors and extrinsic factors. The management of tendinopathy revolves around modulating tendon pain, as pain is the presenting and limiting factor for activity. Despite an abundance of therapeutic options, the scientific evidence base for managing tendinopathies is limited. The aim of this review is to report the options for most widely used conservative management of tendinopathy.

Keyword

Tendon; Tendinopathy; Management

MeSH Terms

Athletic Injuries*
Inflammation
Intrinsic Factor
Risk Factors
Sports Medicine
Sports*
Tendinopathy*
Tendon Injuries
Tendons
Intrinsic Factor

Figure

• 

  Fig. 1. Eccentric loading of the gastrocnemius muscle and Achilles tendon. (A) Standing with all body weight on the forefoot and the ankle joint in plantar flexion. (B) Lower the heel with the knee straight. (C) Bending the knee.

• 

  Fig. 2. Single-leg eccentric training on a decline board for patellar tendinopathy. (A) Standing with upright position on a decline board. (B) Slowly bending the knee to 90o of flexion.

Reference

References

1. Maffulli N, Wong J, Almekinders LC. Types and epidemiology of tendinopathy. Clin Sports Med. 2003; 22:675–92.

2. Maffulli N, Khan KM, Puddu G. Overuse tendon conditions: time to change a confusing terminology. Arthroscopy. 1998; 14:840–3.

3. Maffulli N, Longo UG, Maffulli GD, Rabitti C, Khanna A, Denaro V. Marked pathological changes proximal and distal to the site of rupture in acute Achilles tendon ruptures. Knee Surg Sports Traumatol Arthrosc. 2011; 19:680–7.

4. Maffulli N, Longo UG, Franceschi F, Rabitti C, Denaro V. Movin and Bonar scores assess the same characteristics of tendon histology. Clin Orthop Relat Res. 2008; 466:1605–11.

5. Abate M, Silbernagel KG, Siljeholm C, et al. Pathogenesis of tendinopathies: inflammation or degeneration? Arthritis Res Ther. 2009; 11:235.

6. Fu SC, Rolf C, Cheuk YC, Lui PP, Chan KM. Deciphering the pathogenesis of tendinopathy: a three-stages process. Sports Med Arthrosc Rehabil Ther Technol. 2010; 2:30.

7. Herring SA, Nilson KL. Introduction to overuse injuries. Clin Sports Med. 1987; 6:225–39.

8. Rees JD, Wilson AM, Wolman RL. Current concepts in the management of tendon disorders. Rheumatology (Oxford). 2006; 45:508–21.

9. Longo UG, Rittweger J, Garau G, et al. No influence of age, gender, weight, height, and impact profile in achilles tendinopathy in masters track and field athletes. Am J Sports Med. 2009; 37:1400–5.

10. Khan KM, Scott A. Mechanotherapy: how physical therapists' prescription of exercise promotes tissue repair. Br J Sports Med. 2009; 43:247–52.

11. Lian OB, Engebretsen L, Bahr R. Prevalence of jumper's knee among elite athletes from different sports: a cross-sectional study. Am J Sports Med. 2005; 33:561–7.

12. Gardin A, Movin T, Svensson L, Shalabi A. The longterm clinical and MRI results following eccentric calf muscle training in chronic Achilles tendinosis. Skeletal Radiol. 2010; 39:435–42.

13. Magnussen RA, Dunn WR, Thomson AB. Nonoperative treatment of midportion Achilles tendinopathy: a systematic review. Clin J Sport Med. 2009; 19:54–64.

14. Paavola M, Kannus P, Paakkala T, Pasanen M, Jarvinen M. Long-term prognosis of patients with achilles tendinopathy: an observational 8-year follow-up study. Am J Sports Med. 2000; 28:634–42.

15. Ferretti A. Epidemiology of jumper's knee. Sports Med. 1986; 3:289–95.

16. Titchener AG, Fakis A, Tambe AA, Smith C, Hubbard RB, Clark DI. Risk factors in lateral epicondylitis (tennis elbow): a case-control study. J Hand Surg Eur Vol. 2013; 38:159–64.

17. Titchener AG, White JJ, Hinchliffe SR, Tambe AA, Hubbard RB, Clark DI. Comorbidities in rotator cuff disease: a case-control study. J Shoulder Elbow Surg. 2014; 23:1282–8.

18. Kjaer M, Hansen M. The mystery of female connective tissue. J Appl Physiol (1985). 2008; 105:1026–7.

19. Kaufman KR, Brodine SK, Shaffer RA, Johnson CW, Cullison TR. The effect of foot structure and range of motion on musculoskeletal overuse injuries. Am J Sports Med. 1999; 27:585–93.

20. Kvist M. Achilles tendon injuries in athletes. Ann Chir Gynaecol. 1991; 80:188–201.

21. Witvrouw E, Bellemans J, Lysens R, Danneels L, Cambier D. Intrinsic risk factors for the development of patellar tendinitis in an athletic population: a two-year prospective study. Am J Sports Med. 2001; 29:190–5.

22. Voorn R. Case report: can sacroiliac joint dysfunction cause chronic Achilles tendinitis? J Orthop Sports Phys Ther. 1998; 27:436–43.

23. Lewis JS, Green A, Wright C. Subacromial impingement syndrome: the role of posture and muscle imbalance. J Shoulder Elbow Surg. 2005; 14:385–92.

24. Khan KM, Cook JL, Kiss ZS, et al. Patellar tendon ultrasonography and jumper's knee in female basketball players: a longitudinal study. Clin J Sport Med. 1997; 7:199–206.

25. Cook JL, Khan KM, Kiss ZS, Purdam CR, Griffiths L. Prospective imaging study of asymptomatic patellar tendinopathy in elite junior basketball players. J Ultrasound Med. 2000; 19:473–9.

26. Werner RA, Franzblau A, Gell N, Hartigan A, Ebersole M, Armstrong TJ. Predictors of persistent elbow tendonitis among auto assembly workers. J Occup Rehabil. 2005; 15:393–400.

27. Jarvinen TA, Kannus P, Maffulli N, Khan KM. Achilles tendon disorders: etiology and epidemiology. Foot Ankle Clin. 2005; 10:255–66.

28. Soslowsky LJ, Carpenter JE, DeBano CM, Banerji I, Moalli MR. Development and use of an animal model for investigations on rotator cuff disease. J Shoulder Elbow Surg. 1996; 5:383–92.

29. Renstrom P, Johnson RJ. Overuse injuries in sports: a review. Sports Med. 1985; 2:316–33.

30. Gajhede-Knudsen M, Ekstrand J, Magnusson H, Maffulli N. Recurrence of Achilles tendon injuries in elite male football players is more common after early return to play: an 11-year follow-up of the UEFA Champions League injury study. Br J Sports Med. 2013; 47:763–8.

31. Stahlmann R, Lode H. Fluoroquinolones in the elderly: safety considerations. Drugs Aging. 2003; 20:289–302.

32. Wilton LV, Pearce GL, Mann RD. A comparison of ciprofloxacin, norfloxacin, ofloxacin, azithromycin and cefixime examined by observational cohort studies. Br J Clin Pharmacol. 1996; 41:277–84.

33. Shakibaei M, Stahlmann R. Ultrastructure of Achilles tendon from rats after treatment with fleroxacin. Arch Toxicol. 2001; 75:97–102.

34. van der Linden PD, van Puijenbroek EP, Feenstra J, et al. Tendon disorders attributed to fluoroquinolones: a study on 42 spontaneous reports in the period 1988 to 1998. Arthritis Rheum. 2001; 45:235–9.

35. Mokone GG, Schwellnus MP, Noakes TD, Collins M. The COL5A1 gene and Achilles tendon pathology. Scand J Med Sci Sports. 2006; 16:19–26.

36. Posthumus M, Collins M, Cook J, et al. Components of the transforming growth factor-beta family and the pathogenesis of human Achilles tendon pathology: a genetic association study. Rheumatology (Oxford). 2010; 49:2090–7.

37. Riley G. Tendinopathy: from basic science to treatment. Nat Clin Pract Rheumatol. 2008; 4:82–9.

38. Sharma P, Maffulli N. Biology of tendon injury: healing, modeling and remodeling. J Musculoskelet Neuronal Interact. 2006; 6:181–90.

39. Woo SL, Ritter MA, Amiel D, et al. The biomechanical and biochemical properties of swine tendons: long term effects of exercise on the digital extensors. Connect Tissue Res. 1980; 7:177–83.

40. O'Brien M. Structure and metabolism of tendons. Scand J Med Sci Sports. 1997; 7:55–61.

41. Schechtman H, Bader DL. Fatigue damage of human tendons. J Biomech. 2002; 35:347–53.

42. Yelland MJ, Sweeting KR, Lyftogt JA, Ng SK, Scuffham PA, Evans KA. Prolotherapy injections and eccentric loading exercises for painful Achilles tendinosis: a randomised trial. Br J Sports Med. 2011; 45:421–8.

43. Wilson JJ, Best TM. Common overuse tendon problems: a review and recommendations for treatment. Am Fam Physician. 2005; 72:811–8.

44. Warden SJ, Brukner P. Patellar tendinopathy. Clin Sports Med. 2003; 22:743–59.

45. Fredberg U, Bolvig L. Significance of ultrasonographically detected asymptomatic tendinosis in the patellar and achilles tendons of elite soccer players: a longitudinal study. Am J Sports Med. 2002; 30:488–91.

46. Malliaras P, Cook J. Patellar tendons with normal imaging and pain: change in imaging and pain status over a volleyball season. Clin J Sport Med. 2006; 16:388–91.

47. Ohberg L, Alfredson H. Sclerosing therapy in chronic Achilles tendon insertional pain-results of a pilot study. Knee Surg Sports Traumatol Arthrosc. 2003; 11:339–43.

48. Ohberg L, Alfredson H. Ultrasound guided sclerosis of neovessels in painful chronic Achilles tendinosis: pilot study of a new treatment. Br J Sports Med. 2002; 36:173–5.

49. Ohberg L, Lorentzon R, Alfredson H. Neovascularisation in Achilles tendons with painful tendinosis but not in normal tendons: an ultrasonographic investigation. Knee Surg Sports Traumatol Arthrosc. 2001; 9:233–8.

50. Gisslen K, Alfredson H. Neovascularisation and pain in jumper's knee: a prospective clinical and sonographic study in elite junior volleyball players. Br J Sports Med. 2005; 39:423–8.

51. Gabel GT. Acute and chronic tendinopathies at the elbow. Curr Opin Rheumatol. 1999; 11:138–43.

52. Mafi N, Lorentzon R, Alfredson H. Superior short-term results with eccentric calf muscle training compared to concentric training in a randomized prospective multicenter study on patients with chronic Achilles tendinosis. Knee Surg Sports Traumatol Arthrosc. 2001; 9:42–7.

53. Ferry ST, Dahners LE, Afshari HM, Weinhold PS. The effects of common antiinflammatory drugs on the healing rat patellar tendon. Am J Sports Med. 2007; 35:1326–33.

54. Fenwick SA, Hazleman BL, Riley GP. The vasculature and its role in the damaged and healing tendon. Arthritis Res. 2002; 4:252–60.

55. Cannell LJ, Taunton JE, Clement DB, Smith C, Khan KM. A randomised clinical trial of the efficacy of drop squats or leg extension/leg curl exercises to treat clinically diagnosed jumper's knee in athletes: pilot study. Br J Sports Med. 2001; 35:60–4.

56. Bahr R, Fossan B, Loken S, Engebretsen L. Surgical treatment compared with eccentric training for patellar tendinopathy (Jumper's Knee): a randomized, controlled trial. J Bone Joint Surg Am. 2006; 88:1689–98.

57. Visnes H, Bahr R. The evolution of eccentric training as treatment for patellar tendinopathy (jumper's knee): a critical review of exercise programmes. Br J Sports Med. 2007; 41:217–23.

58. Svernlov B, Adolfsson L. Nonoperative treatment regime including eccentric training for lateral humeral epicondylalgia. Scand J Med Sci Sports. 2001; 11:328–34.

59. Martinez-Silvestrini JA, Newcomer KL, Gay RE, Schaefer MP, Kortebein P, Arendt KW. Chronic lateral epicondylitis: comparative effectiveness of a home exercise program including stretching alone versus stretching supplemented with eccentric or concentric strengthening. J Hand Ther. 2005; 18:411–9.

60. Jonsson P, Alfredson H. Superior results with eccentric compared to concentric quadriceps training in patients with jumper's knee: a prospective randomised study. Br J Sports Med. 2005; 39:847–50.

61. Roos EM, Engstrom M, Lagerquist A, Soderberg B. Clinical improvement after 6 weeks of eccentric exercise in patients with midportion Achilles tendinopathy: a randomized trial with 1-year follow-up. Scand J Med Sci Sports. 2004; 14:286–95.

62. Bisset L, Paungmali A, Vicenzino B, Beller E. A systematic review and metaanalysis of clinical trials on physical interventions for lateral epicondylalgia. Br J Sports Med. 2005; 39:411–22.

63. Huisstede BM, Gebremariam L, van der Sande R, Hay EM, Koes BW. Evidence for effectiveness of Extracorporal Shock-Wave Therapy (ESWT) to treat calcific and non-calcific rotator cuff tendinosis: a systematic review. Man Ther. 2011; 16:419–33.

64. Schmitz C, Csaszar NB, Milz S, et al. Efficacy and safety of extracorporeal shock wave therapy for orthopedic conditions: a systematic review on studies listed in the PEDro database. Br Med Bull. 2015; 116:115–38.

65. Scott A, Huisman E, Khan K. Conservative treatment of chronic Achilles tendinopathy. CMAJ. 2011; 183:1159–65.

66. Mani-Babu S, Morrissey D, Waugh C, Screen H, Barton C. The effectiveness of extracorporeal shock wave therapy in lower limb tendinopathy: a systematic review. Am J Sports Med. 2015; 43:752–61.

67. Struijs PA, Kerkhoffs GM, Assendelft WJ, Van Dijk CN. Conservative treatment of lateral epicondylitis: brace versus physical therapy or a combination of botha randomized clinical trial. Am J Sports Med. 2004; 32:462–9.

68. Faes M, van den Akker B, de Lint JA, Kooloos JG, Hopman MT. Dynamic extensor brace for lateral epicondylitis. Clin Orthop Relat Res. 2006; 442:149–57.

69. Miller MD, Hinkin DT, Wisnowski JW. The efficacy of orthotics for anterior knee pain in military trainees: a preliminary report. Am J Knee Surg. 1997; 10:10–3.

70. Nirschl RP, Ashman ES. Elbow tendinopathy: tennis elbow. Clin Sports Med. 2003; 22:813–36.

71. Magra M, Maffulli N. Nonsteroidal antiinflammatory drugs in tendinopathy: friend or foe. Clin J Sport Med. 2006; 16:1–3.

72. Magra M, Maffulli N. Genetic aspects of tendinopathy. J Sci Med Sport. 2008; 11:243–7.

73. Spacca G, Cacchio A, Forgacs A, Monteforte P, Rovetta G. Analgesic efficacy of a lecithin-vehiculated diclofenac epolamine gel in shoulder periarthritis and lateral epicondylitis: a placebocontrolled, multicenter, randomized, double-blind clinical trial. Drugs Exp Clin Res. 2005; 31:147–54.

74. Petri M, Hufman SL, Waser G, Cui H, Snabes MC, Verburg KM. Celecoxib effectively treats patients with acute shoulder tendinitis/bursitis. J Rheumatol. 2004; 31:1614–20.

75. Lopez JM. Treatment of acute tendinitis and bursitis with fentiazac: a double-blind comparison with placebo. Clin Ther. 1982; 5:79–84.

76. Labelle H, Guibert R. Efficacy of diclofenac in lateral epicondylitis of the elbow also treated with immobilization: The University of Montreal Orthopaedic Research Group. Arch Fam Med. 1997; 6:257–62.

77. Hay EM, Paterson SM, Lewis M, Hosie G, Croft P. Pragmatic randomised controlled trial of local corticosteroid injection and naproxen for treatment of lateral epicondylitis of elbow in primary care. BMJ. 1999; 319:964–8.

78. Murrell GA. Oxygen free radicals and tendon healing. J Shoulder Elbow Surg. 2007; 16:S208–14.

79. Murrell GA, Szabo C, Hannafin JA, et al. Modulation of tendon healing by nitric oxide. Inflamm Res. 1997; 46:19–27.

80. Paoloni JA, Murrell GA, Burch RM, Ang RY. Randomised, double-blind, placebocontrolled clinical trial of a new topical glyceryl trinitrate patch for chronic lateral epicondylosis. Br J Sports Med. 2009; 43:299–302.

81. Pons S, Gallardo C, Caballero J, Martinez T. Transdermal nitroglycerin versus corticosteroid infiltration for rotator cuff tendinitis. Aten Primaria. 2001; 28:452–5.

82. Berrazueta JR, Losada A, Poveda J, et al. Successful treatment of shoulder pain syndrome due to supraspinatus tendinitis with transdermal nitroglycerin: a double blind study. Pain. 1996; 66:63–7.

83. Gambito ED, Gonzalez-Suarez CB, Oquinena TI, Agbayani RB. Evidence on the effectiveness of topical nitroglycerin in the treatment of tendinopathies: a systematic review and metaanalysis. Arch Phys Med Rehabil. 2010; 91:1291–305.

84. Paoloni JA, Appleyard RC, Nelson J, Murrell GA. Topical glyceryl trinitrate treatment of chronic noninsertional achilles tendinopathy: a randomized, double-blind, placebocontrolled trial. J Bone Joint Surg Am. 2004; 86:916–22.

85. McCallum SD, Paoloni JA, Murrell GA. Five-year prospective comparison study of topical glyceryl trinitrate treatment of chronic lateral epicondylosis at the elbow. Br J Sports Med. 2011; 45:416–20.

86. Fredberg U, Stengaard-Pedersen K. Chronic tendinopathy tissue pathology, pain mechanisms, and etiology with a special focus on inflammation. Scand J Med Sci Sports. 2008; 18:3–15.

87. Fredberg U, Bolvig L, Pfeiffer-Jensen M, Clemmensen D, Jakobsen BW, Stengaard-Pedersen K. Ultrasonography as a tool for diagnosis, guidance of local steroid injection and, together with pressure algometry, monitoring of the treatment of athletes with chronic jumper's knee and Achilles tendinitis: a randomized, double-blind, placebocontrolled study. Scand J Rheumatol. 2004; 33:94–101.

88. Andres BM, Murrell GA. Treatment of tendinopathy: what works, what does not, and what is on the horizon. Clin Orthop Relat Res. 2008; 466:1539–54.

89. Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet. 2010; 376:1751–67.

90. Ismail AM, Balakrishnan R, Rajakumar MK, Lumpur K. Rupture of patellar ligament after steroid infiltration: report of a case. J Bone Joint Surg Br. 1969; 51:503–5.

91. Shrier I, Matheson GO, Kohl HW 3rd. Achilles tendonitis: are corticosteroid injections useful or harmful? Clin J Sport Med. 1996; 6:245–50.

92. Arroll B, Goodyear-Smith F. Corticosteroid injections for painful shoulder: a metaanalysis. Br J Gen Pract. 2005; 55:224–8.

93. Smidt N, van der Windt DA, Assendelft WJ, Deville WL, Korthals-de Bos IB, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet. 2002; 359:657–62.

94. Kon E, Filardo G, Delcogliano M, et al. Platelet-rich plasma: new clinical application. A pilot study for treatment of jumper's knee. Injury. 2009; 40:598–603.

95. Foster TE, Puskas BL, Mandelbaum BR, Gerhardt MB, Rodeo SA. Platelet-rich plasma: from basic science to clinical applications. Am J Sports Med. 2009; 37:2259–72.

96. Sanchez M, Anitua E, Orive G, Mujika I, Andia I. Platelet-rich therapies in the treatment of orthopaedic sport injuries. Sports Med. 2009; 39:345–54.

97. Sampson S, Gerhardt M, Mandelbaum B. Platelet rich plasma injection grafts for musculoskeletal injuries: a review. Curr Rev Musculoskelet Med. 2008; 1:165–74.

98. Hall MP, Band PA, Meislin RJ, Jazrawi LM, Cardone DA. Platelet-rich plasma: current concepts and application in sports medicine. J Am Acad Orthop Surg. 2009; 17:602–8.

99. Mishra A, Pavelko T. Treatment of chronic elbow tendinosis with buffered platelet-rich plasma. Am J Sports Med. 2006; 34:1774–8.

100. Mishra A, Woodall J Jr, Vieira A. Treatment of tendon and muscle using platelet-rich plasma. Clin Sports Med. 2009; 28:113–25.

101. Sanchez M, Anitua E, Azofra J, Andia I, Padilla S, Mujika I. Comparison of surgically repaired Achilles tendon tears using platelet-rich fibrin matrices. Am J Sports Med. 2007; 35:245–51.

102. Mei-Dan O, Mann G, Maffulli N. Platelet-rich plasma: any substance into it? Br J Sports Med. 2010; 44:618–9.

103. de Vos RJ, van Veldhoven PL, Moen MH, Weir A, Tol JL, Maffulli N. Autologous growth factor injections in chronic tendinopathy: a systematic review. Br Med Bull. 2010; 95:63–77.

104. Peerbooms JC, Sluimer J, Bruijn DJ, Gosens T. Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: platelet-rich plasma versus corticosteroid injection with a 1-year follow-up. Am J Sports Med. 2010; 38:255–62.

105. de Vos RJ, Weir A, van Schie HT, et al. Platelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial. Jama. 2010; 303:144–9.

106. Filardo G, Kon E, Della Villa S, Vincentelli F, Fornasari PM, Marcacci M. Use of platelet-rich plasma for the treatment of refractory jumper's knee. Int Orthop. 2010; 34:909–15.

107. Iwasaki M, Nakahara H, Nakata K, Nakase T, Kimura T, Ono K. Regulation of proliferation and osteochondrogenic differentiation of periosteum-derived cells by transforming growth factor-beta and basic fibroblast growth factor. J Bone Joint Surg Am. 1995; 77:543–54.

108. Edwards SG, Calandruccio JH. Autologous blood injections for refractory lateral epicondylitis. J Hand Surg Am. 2003; 28:272–8.

109. Taylor MA, Norman TL, Clovis NB, Blaha JD. The response of rabbit patellar tendons after autologous blood injection. Med Sci Sports Exerc. 2002; 34:70–3.

110. Kazemi M, Azma K, Tavana B, Rezaiee Moghaddam F, Panahi A. Autologous blood versus corticosteroid local injection in the short-term treatment of lateral elbow tendinopathy: a randomized clinical trial of efficacy. Am J Phys Med Rehabil. 2010; 89:660–7.

111. James SL, Ali K, Pocock C, et al. Ultrasound guided dry needling and autologous blood injection for patellar tendinosis. Br J Sports Med. 2007; 41:518–21.

112. Clementson M, Loren I, Dahlberg L, Astrom M. Sclerosing injections in midportion Achilles tendinopathy: a retrospective study of 25 patients. Knee Surg Sports Traumatol Arthrosc. 2008; 16:887–90.

113. Hoksrud A, Ohberg L, Alfredson H, Bahr R. Color Doppler ultrasound findings in patellar tendinopathy (jumper's knee). Am J Sports Med. 2008; 36:1813–20.

114. Willberg L, Sunding K, Ohberg L, Forssblad M, Fahlstrom M, Alfredson H. Sclerosing injections to treat midportion Achilles tendinosis: a randomised controlled study evaluating two different concentrations of polidocanol. Knee Surg Sports Traumatol Arthrosc. 2008; 16:859–64.

115. Alfredson H, Ohberg L, Zeisig E, Lorentzon R. Treatment of midportion Achilles tendinosis: similar clinical results with US and CD-guided surgery outside the tendon and sclerosing polidocanol injections. Knee Surg Sports Traumatol Arthrosc. 2007; 15:1504–9.

116. Alfredson H, Ohberg L. Neovascularisation in chronic painful patellar tendinosis: promising results after sclerosing neovessels outside the tendon challenge the need for surgery. Knee Surg Sports Traumatol Arthrosc. 2005; 13:74–80.

117. Alfredson H. Conservative management of Achilles tendinopathy: new ideas. Foot Ankle Clin. 2005; 10:321–9.

118. Orchard J, Massey A, Brown R, Cardon-Dunbar A, Hofmann J. Successful management of tendinopathy with injections of the MMP-inhibitor aprotinin. Clin Orthop Relat Res. 2008; 466:1625–32.

119. Coleman CI, Rigali VT, Hammond J, Kluger J, Jeleniowski KW, White CM. Evaluating the safety implications of aprotinin use: the Retrospective Evaluation of Aprotinin in Cardio Thoracic Surgery (REACTS). J Thorac Cardiovasc Surg. 2007; 133:1547–52.

120. Dayer JM. Chronic inflammatory joint diseases: natural inhibitors of interleukin 1 and tumor necrosis factor alpha. J Rheumatol Suppl. 1991; 27:71–5.

121. Ehrlich MG, Armstrong AL, Treadwell BV, Mankin HJ. Degradative enzyme systems in cartilage. Clin Orthop Relat Res. 1986; 213:62–8.

122. Dietrich W, Spath P, Zuhlsdorf M, et al. Anaphylactic reactions to aprotinin reexposure in cardiac surgery: relation to antiaprotinin immunoglobulin G and E antibodies. Anesthesiology. 2001; 95:64–71.

123. Orchard J, Massey A, Rimmer J, Hofman J, Brown R. Delay of 6 weeks between aprotinin injections for tendinopathy reduces risk of allergic reaction. J Sci Med Sport. 2008; 11:473–80.

124. Brown R, Orchard J, Kinchington M, Hooper A, Nalder G. Aprotinin in the management of Achilles tendinopathy: a randomised controlled trial. Br J Sports Med. 2006; 40:275–9.

125. Capasso G, Maffulli N, Testa V, Sgambato A. Preliminary results with peritendinous protease inhibitor injections in the management of Achilles tendinitis. J Sports Traumatol Rel Res. 1993; 15:37–43.

126. Capasso G, Testa V, Maffulli N, Bifulco G. Aprotinin, corticosteroids and normosaline in the management of patellar tendinopathy in athletes: a prospective randomized study. Sports Exerc Inj. 1997; 3:111–5.

127. Longo UG, Ronga M, Maffulli N. Achilles tendinopathy. Sports Med Arthrosc. 2009; 17:112–26.

128. Kannus P, Jozsa L. Histopathological changes preceding spontaneous rupture of a tendon: a controlled study of 891 patients. J Bone Joint Surg Am. 1991; 73:1507–25.

129. Paavola M, Kannus P, Jarvinen TA, Jarvinen TL, Jozsa L, Jarvinen M. Treatment of tendon disorders. Is there a role for corticosteroid injection? Foot Ankle Clin. 2002; 7:501–13.

130. Santander J, Zarba E, Iraporda H, Puleo S. Can arthroscopically assisted treatment of chronic patellar tendinopathy reduce pain and restore function? Clin Orthop Relat Res. 2012; 470:993–7.

131. Baker CL Jr, Baker CL 3rd. Long-term follow-up of arthroscopic treatment of lateral epicondylitis. Am J Sports Med. 2008; 36:254–60.

132. Maffulli N, Testa V, Capasso G, Bifulco G, Binfield PM. Results of percutaneous longitudinal tenotomy for Achilles tendinopathy in middle- and long-distance runners. Am J Sports Med. 1997; 25:835–40.

133. Maffulli N, Longo UG, Denaro V. Novel approaches for the management of tendinopathy. J Bone Joint Surg Am. 2010; 92:2604–13.