C CUPRINS

Studii experimentale
Studii clinice
Meta-analize
pag.
pag.
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Utilizari speciale pag. 59
Referinte pag. 75

Material realizat cu sprijinul Dr. Dan Laptoiu

Medic Primar Ortopedie Traumatologie
Doctor in Stiinte Medicale
Competenta Artroscopie
Spitalul Clinic Colentina Bucuresti
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Studii experimentale

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Acidul Hialuronic creste viabilitatea celulelor
derivate din tendon si expresia colagenului de
tip I in vitro: Studiu comparativ intre 4 tipuri de
Acid Hialuronic cu greutati moleculare diferite
Leonardo Osti, Martina Berardoco, Viviana di Giacommo, Grazziella di Bernardo, Francesco Oliva si
Anna Berardi

REZUMAT

BACKGROUND:
Acidul Hialuronic (AH) a fost deja aprobat de catre FDA (Food and Drug Administration)
in tratamentul osteoartritei (OA), in timp ce in tratamentul tendinopatiei subiectul este
inca dezbatut. In acest studiu scopul a fost evaluarea efectelor a 4 tipuri de Acid
Hialuronic cu greutate moleculara diferita asupra celulor derivate din tendon uman
de coafa de rotatori in ceea ce priveste viabilitatea celulara, proliferarea, apoptoza si
expresia colagenului de tip I si tip III.

METODE:
S-a dezvoltat un model in vitro de celule derivate din tendon uman de coafa de rotatori
pentru a studia efectele a 4 preparate(Ps) diferite de Acid Hialuronic (hialorunat de sodiu
(GM- greutate moleculara): 500-730 KDa – Hyalgan, 1000 kDa Artrosulfur HA, 1600 kDa
Hyalubrix si 2200 kDa Synolis – VA) in concentratii variate. A fost studiata morfologia
celulelor derivate din tendon dupa 0, 7 si 14 zile de cultura. Viabilitatea, prolifereraea
si apoptoza au fost evaluate dupa 0, 24 si 48 h de cultura. Expresia si sedimentarea
colagenului de tip I si de tip III au fost evaluate dupa 1,7 si 14 zile de cultura.

REZULTATE:
Toate tipurile de AH testate au crescut viabilitatea si proliferarea, dependent de doza.
Toate AHPs au redus dupa 24 de ore apoptoza comparativ cu celulele control. Mai mult
AHPs au stimulat sinteza de colagen de tip I intr-un trend dependent de doza dupa
14 zile, fara sa creasca colagenul de tip III; in plus in prezenta Synolis-VA expresia si
sedimentarea colagenului de tip I a fost semnificativ mai mare comparativ cu alte tipuri
de AH.

CONCLUZIA:
Preparatele de AH au crescut viabilitatea, proliferarea si expresia de colagen de tip I in
celulele derivate din tendon;

CUVINTE CHEIE:
Acid Hialuronic, Tendinopatie, Celule derivate din tendon uman, tendoane de coafa de
rotatori.

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Hyaluronic Acid increases tendon derived cell
viability and collagen type I expression in vitro:
Comparative study of four different Hyaluronic
Acid preparations by molecular weight
Leonardo Osti, Martina Berardoco, Viviana di Giacommo, Grazziella di Bernardo, Francesco Oliva
and

Abstract
Background: Hyaluronic Acid (HA) has been already approved by Food and Drug Administration (FDA) for osteoarthritis (OA), while
its use in the treatment of tendinopathy is still debated. The aim of this study was to evaluate in human rotator cuff tendon derived
cells the effects of four different HA on cell viability, proliferation, apoptosis and the expression of collagen type I and collagen
type III.
Methods: An in vitro model was developed on human tendon derived cells from rotator cuff tears to study the effects of four
different HA preparations (Ps) (sodium hyaluronate MW: 500-730 KDa - Hyalgan®, 1000 kDa Artrosulfur HA®, 1600 KDa Hyalubrix®
and 2200 KDa Synolis-VA®) at various concentrations. Tendon derived cells morphology were evaluated after 0, 7 and 14 d of
culture. Viability, proliferation, apoptosis were evaluated after 0, 24 and 48 h of culture. The expression and deposition of collagen
type I and collagen type III were evaluated after 1, 7 and 14 d of culture.
Results: All HAPs tested increased viability and proliferation, in dose dependent manner. HAPs already reduce apoptosis at 24
h compared to control cells (without HAPs). Furthermore, HAPs stimulated the synthesis of collagen type I in a dose dependent
fashion over 14 d, without increase in collagen type III; moreover, in the presence of Synolis-VA® the expression and deposition of
collagen type I was significantly higher as compare with the other HAPs.
Conclusions: HAPs enhanced viability, proliferation and expression of collagen type I in tendon derived cells.

Background of the tendon derive cells, moreover, the pattern of gene

Non-traumatic rotator cuff tears are the most common shoulder
joint disease, and have age-associated incidence, since they
are favored by the co-presence of metabolic diseases such
as diabetes, thyroid disorders and hypercholesterolemia
[1–4]. Conservative treatment of tendinopathies has been
increasingly supported by scientific evidence over the last
twenty year [5]. Despite decades of study for HA in the
conservative treatment of osteoarthritis [6], poor evidence
is present in the literature about the indication of this drug
for tendinopathies [7]. During tendinopathy and tendon
acute rupture has been reported an higher incidence of
tenocyte apoptosis and decreased collagen synthesis [8].
Failure of the healing response may occur in genetically-
predisposed patients, decreasing the resistance of ten-
don structures to mechanical load, resulting eventually in
tendinopathy, or a tendon tear [4, 9, 10].
Hyaluronic acid (HA) (or “hyaluronan”, or “sodium
hyaluronate preparation”) is a high molecular weight
glycosa-miniglycan consists of the repetition of a
disaccharide unit of an N-acetyl-glucosamine and a
β-glucuronic acid [11]. Its most important physicochemical
properties are its capacity to retain water, having a very
high hydration ratio, and its visco-elasticity. These two
properties are, however, interdependent. Changes in HA
concentrations within the extracellular matrix modulate
a variety of cellular functions, such as cell migration
[12, 13], adhesion [14, 15], and proliferation [16–18].
Several important medical applications of HA have been
discovered for joints degeneration [7]. Additionally, high
local concentration of HA causes release of endogenous
growth factors and stimulates cell–cell interaction,
resulting in faster cell proliferation during early stages of in
vitro culture. Additional effects reported in clinical animal
studies are related to an accelerated healing process in
the tendons after repair, and decreased scar formation
within the tendons. There has been a lack of specific
studies on human shoulder derived cells. Much of the
study, has been limited by the lack of the exact phenotype
expression is consistent with the presence of mixed
population. [19]. Clinical studies in patients with rotator
cuff disease ranging from tendinopathy to rotator cuff
tears detected a positive influence on the reduction of
pain and improved function with no consistent side-effects
recorded. Despite the increased awareness of the effective
role of HA in regenerative medicine, the therapeutic use of
HA for tendinopathies has been poorly studied on human
tenocytes in vitro.
In this study, was evaluated the effect of four different HAPs
by molecular weight on viability, metabolic activity, apoptosis
and collagen type I and collagen type III expression on human
rotator cuff tendon tears derived cells.
Methods
All the procedures described in this investigation were approved
by the Ethical Committee of Rome Tor Vergata University. All
the patients gave written informed consent to be included in
the present study. Tendon samples were harvested from
healthy area close to degenerative supraspinatus tendons
tear area biopsy specimen in 10 patients were operated
arthroscopically for shoulder rotator cuff repair, with a
mean age of 63,6 ± 6,9 years. Trauma history, heavy smoking
habit or systemic conditions such as thyroid disorders,
diabetes, gynecological condition, neoplasia, rheumatic
diseases, and any previous or concomitant rotator cuff disease
were considered exclusion criteria.
Tendon cell cultures
Primary human tendon derived cell cultures were estab- lished
as previously described [20]. In brief, cells were iso- lated
from tissue sample by washing several times with phosphate
buffered saline Dulbecco’s W/O Ca and Mg (PBS) + 1 %
penicillin/streptomycin (Invitrogen, Life Technologies, Carlsbad,
CA, USA). Small pieces of fresh tendon isolated were carefully
dissected and mechanically disaggregated with the aid of fine
watchmaker forceps to maximize the interface between tissue
and medium. Finally, the tendons were immediately placed on

33
Petri dishes of 60 mm in diameter (Greiner CELLSTAR dish,
Sigma-Aldrich, Saint Louis, MO, USA), containing 5 mL of
α-MEM supplemented with 20% heat-inactivated foetal calf se-
rum (FCS) and 1% L-glutamine and 1% penicillin/streptomycin
(Gibco, Invitrogen, Life Technologies) at 37 °C in 5% CO2 and
air with a change medium every 2–3 d. Tenocytes were then
harvested by StemPro Accutase (Life technologies Carlsbad,
CA, USA), and centrifugated at 1,500 rpm for 5 min when the
cells migrated out of tendon pieces and reached 60–80 % of
confluence (19 day). Collected tendon derived cells were im-
mediately used for culture to avoid phenotype drift with further
in vitro passages [21]. The phenotype of the tendon derived
cells had not demonstrated significant drift as evidence by the
gene expression pattern by assessing the expression of gene
for scleraxis and genes for collagens α1(I), α2(I) and α1(III) in
real-time PCR assays with specific primers (data not shown).
Tenocyte viability and proliferation
In vitro proliferation was determined by the Alamar Blue assay.
This test was used to measure the metabolism rate of the cells.
The tendon derived cells were seeded with 5×103 vital cells
per well in a 96-well plate (Greiner CELL- STAR dish, Sigma-
In the formula ελ1 and ελ2 are constant representing the
molar extinction coefficient of alamar blue at 540 nm and 630
nm, respectively, in the oxidized (εox) and the reduced (εred)
forms. Aλ1 and Aλ2 represent absorbance of test wells at 540 nm
and 630 nm, respectively. A’λ1 and A’λ2 represent absorbance
of negative control wells at 540 and 630 nm, respectively.
The values of % alamar blue reduction were corrected for
background values of negative controls containing medium
without cells.
Finally, in parallel trypan blue exclusion assay was per-
formed. The tendon derived cells were seeded with 104 vital
cells per well in a 24-well plate (Greiner CELLSTAR dish, Sigma-
Aldrich), and in triplicates in 1 ml of α-MEM supplemented with
10 % FCS. After 0, 24 and 48 h the cultures were detached,
collected and counted (Nikon Instruments INC., Melville, NY,
USA) in the Burker chamber with vital dye Trypan Blue (Stem
Cells Technologies, Vancouver, Canada) to evaluate cell
viability.
Apoptosis induction
Hydrogen peroxide (H2O2) was used as an inducer of apoptosis
as previously described [22]. The tendon derived cells were
seeded with 105 vital cells per well in a 6-well plate in 4 ml of
α-MEM supplemented with 10 % FCS. After 24 h, the medium
was removed, and the cultured cells were treated with H2O2
(2 mM) in α-MEM and 10 % FCS with or without Hyalgan®,
Artrosulfur HA®, Hyalubrix® and Synolis-VA® (1000 μg/ml) for
44
Aldrich), and in triplicates in 100 μl of α-MEM supplemented
with 10 % FCS . Cells were cultured as previous described [20].
Briefly, after 24 h, cultured cells were exposed to 4 different
hyaluronic acid: Hyalgan MW 500–730 KDa, Artrosulfur HA®
MW 1000, Hyalubrix® MW 1600 KDa, Synolis-VA® MW 2200
KDa, their features are shown in Table 1. Three different doses
of Hyalgan or Artrosulfur HA® (250 μg/ml, 500 μg/ml and 1000
μg/ml), one doses of Hyalubrix® or Synolis-VA® (1000 μg/ml).
HAPs were dissolved in the same culture media used for the
entire experiments (α-MEM supplemented with 10 % FCS)
and the Ph was adjusted to 7. Untreated cells were used as
control. All the cells (HAPs treated and untreated) were cultured
in 1 ml of medium. Alamar blue dye test (Serotec, Oxford, UK)
was performed to assess cell viability after 0, 24, and 48 h of
culture, as previous described [16]. The absorbance was read
spectrophotometrically at 570 and 600 nm wavelengths by
MicroPlate reader (BioRad, Hercules, CA). The results, obtained
as optical density (OD) data, were processed following
manufacturer’s instructions and expressed as reduction
percentage. The calculation of the of the percentage of alamar
blue reduction is as follows according to the manufacture’s
protocol:
a further 24 h. A negative control was prepared by incubating
cells in the absence of both inducing agent and HAPs. The
PE Annexin V/Dead Cell Apoptosis Kit with SYTOX® Green
for Flow Cytometry (Invitrogen, Life Technologies) was used
to detect apoptosis by flow cytometry, cells were harvested,
and processed according to the manufacturer’s instruction.
This product detects the externalization of phosphatidylserine
in apoptotic cells using recombinant annexin V conjugated to
the orange fluorescent phycobili-protein R-PE, and dead cells
using SYTOX® Green nucleic acid stain. After treatment with
both probes, apoptotic cells show orange fluorescence, dead
cells show green fluorescence, and live cells show little or no
fluorescence. Fluorescence-activated cell sorting analysis
was carried out using a FC500 flow cytometer (FL1 and FL3
detector in a log mode) using the CXP analysis software
(Beckmann Coulter, FL, USA).
Immunofluorescence staining
The tendon derived cells were seeded with 5×103 vital cells
per well in a 2-well chamber slides (Thermo Fisher Scientific,
Inc., Rochester, NY, USA), in triplicates and cultured as previous
described [23]. After 1, 7 and 14 d of culture the tendon derived
cells were fixed with pure acetone for 10 min at −20 °C. Then,
washed a few minutes with PBS. Cells were incubated for 30
min at room temperature with PBS containing 5 % of Bovine
Serum Albumin (BSA) (Kedrion Group S.P.A., Lucca, Italy) for
protein blockage. Primary antibodies for Anti-type I (1:2000),
Anti-type III collagen molecules (1:500) (Sigma-Aldrich), and
secondary antibodies fluorochrome were diluted in PBS
containing 5 % BSA.
containing 5 % BSA. Cells were incubated overnight at 4 °C
with primary antibodies, 1 h with the appropriate secondary
antibody fluorochrome at room temperature and then washed
a few times with PBS containing 5 % BSA. Molecule’s staining
Alexa Fluor 488 (Life Tecnologies) was used for type I collagen
and Alexa Fluor 568 (Life Tecnologies) for type III collagen.
After washing with PBS plus 5 % BSA, slides were mounted
with 25 μL VECTASHIELD® Hard Set Mounting Medium
and then were examinated with ECLIPSE Ti-U inverted,
fluorescent microscope (Nikon Instruments INC., Melville, NY,
USA). For image analysis all digital images were captured
with NIS-Elements Imaging Software (Nikon Instruments
INC.). As previously described [23, 24], slides were examined
independently by two experienced operator and one researcher,
with a double-blind method. The total fluorescence intensity of
the area ≥ 10 frames from each slides was determined. The
intensity level was normalized with the control cells untreated.
Fully automated image analysis improve the accuracy of
detection and categorization of collagen staining, making this
technique more sensitive, specific and thus suitable for use in
quality assurance results.
Statistical analysis
Data are typical results from a minimum of three replicated
independent experiments and are expressed as mean ± SD.
Comparison of individual treatment was conducted using
Student’s t test. Statistical significance in comparison with the
corresponding control values was indicated by *P < 0.05 versus
control.
Results
Tendon derived cells viability
Tendon derived cells morphology was evaluated under a
light microscope at 0, 7 and 14 d. The cells maintained their
normal, bipolar, spindle shape and cell processes, during the
whole study period for each of the sets of culture conditions;
cellular morphology remained unaltered for up to 14 d in all
the experimental groups (Fig. 1a). Results from the trypan
blue exclusion assay showed that none of the HAPs reduced
cell viability (Fig. 1b). After 48 h of exposure, living cells are
in similar numbers when exposed to HAPs compared to the
control. Metabolic tests provide some information concerning
the activity of cells (Fig. 1c). Alamar blue confirmed an
increase in the metabolic activity of tendon derived cells
for all the HAPs utilized, when compared to untreated cells
(Fig. 1c). In particular, all HAPs induced cell-activity most
effectively at 1000 μg/ml (Fig. 1c, Table 2). The highest
increase was obtained at 48 h for all the HA treatments.
However, as reported in Fig. 1c, there are no significant
statistical differences between all the various HAPs.

Fig. 1 Effects of Hyalgan®, Artrosulfur HA®, Hyalubrix® and Synolis-VA® on morphologic change cell viability and cell metabolic
activity. Tendon derived cells were treated with different concentrations of Hyalgan, Artrosulfur HA®, Hyalubrix® and Synolis-VA®
for different time periods. a. after treatment for 14 d the morphology of the cells treated with all the HAPs was photographed
(1000ug/ml). Magnification, ×100. b. Absolute number of live cells was calculated using trypan blue exclusion. c. Cell metabolic
activity was evaluated with the Alamar Blue method. All tests and determinations were repeated in triplicate. The metabolic activity
rate was calculated by subtracting the background OD value (complete culture medium without cells) from the OD value from
each test well (see materials and methods section). Hyalgan®, Artrosulfur HA®, Hyalubrix®, Synolis-VA® increased cell activity
in a concentration-dependent pattern and with regard to time. No statistically significant difference were observed from control
according to Student’s t test

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Apoptosis induction
To verify whether or not they counteracted apoptosis in tendon
derived cells, the Annexin V experiment was performed. Cells
were plated and H2O2 induction was performed for 24 h to
induce apoptosis. Concurrently, tendon derived cells were
separately exposed (or not, for the untreated sample) to
Hyalgan®, Artrosulfur HA®, Hyalubrix®, and Synolis-VA®
(1000 μg/ml). Staining cells simultaneously with PE-Annexin V
(red fluorescence) and the non-vital dye, Sytox Green (green
fluorescence),
allowed, using bivariate analysis, discrimination between intact
cells (Annexix V−Sytox Green−), early apoptotic (Annexix
V+Sytox Green−) and late apoptotic (Annexix V+Sytox Green+)
and necrotic cells (Annexix V−Sytox
Green+) (Fig. 2a). The treatment of tendon derived cells with
Hyalgan®, Artrosulfur HA®, Hyalubrix®, or Synolis-VA®
(all at 1000 μg/ml) caused a sizable decrease in apoptosis,
as clearly shown in Fig. 2b. The percentage of vital cells,
at 24 h following Hyalgan®, Artrosulfur HA®, Hyalubrix®,
or Synolis-VA® exposure, increased compared to the
control (33.14, 24.01, 36.31, 33.04 and 22.25 % respectively)
(Annexix V−, Sytox green−; bottom left quadrant) (Fig. 2c,
Table 2).
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Immunofluorescence staining
Next, we determined and measured the type of collagen
deposited by tendon derived cells after stimulation with
Hyalgan®, Artrosulfur HA®, Hyalubrix®, or Synolis-VA®.
Collagen accumulation was evaluated by immunofluorescent
staining of cells cultured on chamber slides. Furthermore,
the expression of collagen type I was higher in Synolis-
VA® than in the presence of Hyalgan®, Artrosulfur HA®,
or Hyalubrix®, and was significantly higher compared
to untreated cells used as a control (Fig. 2a, b). In detail,
immunofluorescent staining at day 7 only revealed pro-
duction of collagen type I from the tendon derived cells in
intracytoplasmic staining (Fig. 3a). Moreover, at day 14 ex-
pression and production of Collagen type I had increased
in the Hyalgan®, Artrosulfur HA®, Hyalubrix® and Synolis-
VA® (Fig. 3a, b). Moreover, Synolis-VA® induced the
most significant expression of collagen type I after 14
d (Fig. 3, Table 2). Collagen type III was not found to be
present in any culture conditions (data not shown).
Fig. 2 The apoptosis rate in tendon derived cells. a. The apoptosis was induced with H2O2 (apoptotic control
cells [ACtrCs]) and treated with Hyalgan®, Artrosulfur HA®, Hyalubrix® and Synolis-VA® (1000 ug/ml).
Apoptosis rate of cells in each sample were detected in a population of 10,000 cells analyzed by flow cytometry.
b. The percentage of apoptotic cells in Hyalgan®, Artrosulfur HA®, Hyalubrix® and Synolis-VA® decreased
compared to the proliferate control cells (PCtrCs) (without HA). Flow charts: (A1), upper left quadrant annexin
V-negative and sytox green-positive cells indicate necrotic cells; (A2), upper right quadrant, annexin V and sytox
green-positive cells represent late apoptotic cells. (A3), lower left quadrant annexin V-negative and sytox green-
negative cells indicate live cells; (A4), lower right quadrant, annexin V positive and sytox green-negative cells
represent early apoptotic cells. Both early and late apoptotic cells were calculated as the incidence of apoptotic
cell. The numbers indicate percentage of total gated cells (mean ± S.D.; n = 3). c. % of cells population of live
cells, early apoptotic cells, late apoptotic cells and necrotic cells.
Graph showing the average % of results obtained in 3 independent experiment. No significant differences were
detected (mean ± S.D.; n = 3)

77
Discussion
These results suggest a binary role for HA on tendon
cells - directly, on tendon derived cells metabolic activ-
ity, and on tenocyte Collagen type I production. It was
highlighted that Hyalgan, Artrosulfur HA®, Hyalubrix®
and Synolis-VA® regulate cell activity of tendon derived
cells. All HAPs increased cell-metabolic activity and most
effectively at 1000 μg/ml and at 48 h (Fig. 1c). HA modulate
a number of biological process including cell apoptosis.
The results show a decrease rate of the apoptosis when
the tendon derived cells were exposed to the HAPs.
Collagen metabolism has been reported to be affected by
HA [25, 26]. HA stimulated the synthesis of collagen type
I, in a dose dependent manner over 14 d. This increase in
expression leads to collagen synthesis and accumulation.
It should be noted that Synolis-VA® induced the most
significant expression of collagen type I at 14d of culture.
In contrast, no HAPs induced any expression of collagen
type III, which is normally less abundant in tendons, and
only increases in concentration during the early phase of
remodeling [27] and in tendinopathy [20, 28]. The lack of
collagen type III production under HA stress should be
considered a protective factor for tendons. The results
obtained are consistent with a previous study of Yamada
and coworkers, even if a different methods focused directly
on the collagen type I and III proteins was used [29].

Fig. 3 Collagen type I, expression of tendon derived cells in vitro culture isolated from 9 healthy patients, and staining as described
in material and methods, section Immunofluorescence Staining. Representative images from 4 independent experiments. a.
Expression of collagen type I after 7 and 14 d of culture in green fluorescence and in regular light image showing the tendon derived
cells. b. Quantization of the immunohistochemistry in a. Synolis-VA® induced the expression of collagen type I significantly after 14
d of in vitro culture. The mean fluorescent intensity/pixel was measured and
expressed to the corresponding tendon derived cells. Collagen type I Intensity (Total Area was quantified by anti-collagen type I) it
was measured by Nikon software. Data are expressed as mean ± SD for 4 independent experiments for samples run in triplicate.
Scale bar (a.): 50 μm

88
Considering the results of this study, the three different molecular
weight of HAPs tested seems not exert any effects on tendon
derived cells in vitro, while is clear the essential importance of
the concentrations and of the timing of exposure. The most
significant expression of collagen type I at 14 d of culture of
Synolis-VA® can be explained to the presence of Sorbitol (4
%) that limits the HA degradation, allowing an higher local
concentration of the drug. Translating these considerations in
the clinical practice, HA are effectives on human tenocytes and
extracellular matrix of rotator cuff, with no essential differences
among HA available in the market. There are many biological
questions that remain to be answered, and translational
factors to resolve. Although, this in vitro model shows some
role played from HA on tendon derived cells, the study have
some limitations. First of all, probably these results cannot be
generalized for other tendon derived cells from other sources;
furthermore in vitro environment, rich of nutrients and oxygen
is very different from the diseased environment. The complexity
of the extracellular matrix of tendons and its relationship with
tenocytes during physiological homeostasis, disease and
healing process, attest that is reductive to investigate only the
effect of HAPs on collagen type I and III. As soon as possible
there is need to widen the knowledge of the effects of HAPs on
the main proteins of the extracellular matrix of tendons.
Despite we tested the three different molecular weight HA,
perhaps more HAPs and different concentration need to be
tested in the same way we did to confirm which should have
the best in vitro results.
Obviously, it is advocate randomized control studies on the
use of HA in the conservative treatment of tendinopathy and in
selected patients with rotator cuff tears, in order to understand
and clarify best timing, doses, intervals of injections and, finally,
full clinical confirmation of effectiveness.
Conclusion
In conclusion, HAPs in dose dependent manner but not
related to the molecular weight, induces increase of
cells activities, decrease of apoptosis of tendon derived
cells Collagen type I protein secretion. Taken together,
these results strengthen a physiological role of HA in the
homeostasis of tendons and has implications for regen-
erative medicine.

Competing interests
The authors declare that they have no competing interests.

Authors’ contributions
LO and ACB made substantial contributions to the conception and design of this manuscript, data acquisition,
analysis and interpretation and the drafting of the manuscript. MB carried out the Tendon cell cultures, Tendon
derived cells viability and metabolic activity. VdG Apoptosis analyses. GDB participated in tendon derived
cells culture. ACB conceived the study and participated in its design and coordination. FO critically revised
the manuscript for important intellectual content, and gave the final approval of the version to be published. All
authors read and approved the final manuscript.

Authors’ information
Not applicable.

Acknowledgements
The laboratory “Stem Cells” is supported by Fondazione PCFF ONLUS. The authors also wish to thank Blood
Donors Association FIDAS Pescara.

Author details
1Unit of Arthoscopy and Sports Trauma Surgery, Hesperia Hospital, Modena, Italy.
2U.O.C. of Immunohaematology and Transfusion Medicine, Laboratory of Stem Cells, Spirito Santo Hospital, via
Fonte Romana 8, 65125 Pescara, Italy.
3Department of Pharmacy, University G. d’Annunzio, Chieti, Italy. 4U.O.C. of Immunohaematology and
Transfusion Medicine, Santo Spirito Hospital, Pescara,
Italy. 5Department of Orthopedics and Traumatology, University of Rome “Tor Vergata” School of Medicine,
Rome, Italy.

Received: 10 June 2015 Accepted: 24 September 2015

99
Evaluarea conceptelor actuale
Leziuni ale tendoanelor si tendinopatia:
Vindecarea si Recuperarea
Pankaj Sharma, Mrcs, and Nicola Maffulli, Md, Ms, Phd, Frcs(Orth)

- Afectiunile tendoanelor sunt frecvente si sunt responsabile pentru morbiditate

substantiala, atat în domeniul sportului cat si la locul de munca.
- Tendinopatia, spre deosebire de tendinita sau tendinoze, este cel mai bun termen
generic descriptiv pentru conditiile clinice in si in jurul tendoanele care rezulta din
utilizarea excesiva a lor.
- Tendinopatia este o problema dificila, care necesita gestionare de lunga durata, iar
pacientii raspund adesea slab la tratament.
- Degenerarea preexistenta este considerata factor de risc pentru ruptura de tendon
acuta.
- Au fost dezvoltate mai multe modalitati fizice pentru a trata tendinopatia. Exista dovezi
limitate si mixte la nivel inalt pentru a sprijini, utilizarea clinica a acestor modalitati.
- Sunt necesare cercetarile suplimentare si evaluare stiintifica inainte ca solutiile
biologice sa devina optiuni reale.

Tendoanele conecteaza muschii la nivelul osului si permit transmiterea fortelor generate

de acestia la nivel osos, ceea ce are ca rezultat miscarea articulatiei.
Leziunile de tendon produc o morbiditate considerabila, iar handicapul pe care il
provoaca poate dura mai multe luni in ciuda a ceea ce este considerat management 1
adecvat. Problemele cronice cauzate de suprasolicitarea tendoanelor, au o probabilitate
de aparitie de 30% dintre toate leziunile legate de alergare 2 , iar prevalenta tendinopatiei
de cot la jucatorii de tenis poate atinge 40% 3. Biologia de baza a celulelor tendoanelor
nu este inca pe deplin inteleasa, iar gestionarea leziunilor de tendon reprezinta o
provocare considerabila pentru clinicieni.
Acest articol descrie functia si structura tendoanelor, revizuieste patofiziologia leziunilor
de tendon si fazele de vindecare ale tendonului precum si posibile strategii pentru
optimizarea vindecarii si repararatiei tendoanelor.

10
10
 THE JOURNAL OF BONE & JOINT SURGERY

JB&JS
Tendon Injury and tendinopathy : Healing and Repair
Pankaj Sharma and Nicola Maffulli
J. Bone Joint Surg. Am. 87:187-202, 2005. doi:10.2106/JBJS.D.01850

Letters to The Editor are available at

http://www.ejbjs.org/cgi/content/full/87/1/187#responses

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 Current Concepts Review
Tendon Injury and
Tendinopathy: Healing and
Repair
BY PANKAJ SHARMA, MRCS, AND NICOLA MAFFULLI, MD, MS, PHD, FRCS(ORTH)

- Tendon disorders are frequent and are responsible for substantial morbidity both in sports and
in the workplace.
- Tendinopathy, as opposed to tendinitis or tendinosis, is the best generic descriptive term for the
clinical conditions in and around tendons arising from overuse.
- Tendinopathy is a difficult problem requiring lengthy management, and patients often respond
poorly to treatment.
- Preexisting degeneration has been implicated as a risk factor for acute tendon rupture.
- Several physical modalities have been developed to treat tendinopathy. There is limited and
mixed high-level evidence to support the, albeit common, clinical use of these modalities.
- Further research and scientific evaluation are required before biological solutions become
realistic options.

Tendons connect muscle to bone and allow transmission of
forces generated by muscle to bone, resulting in joint move-
ment. Tendon injuries produce considerable morbidity, and
the disability that they cause may last for several months de-
spite what is considered appropriate management1. Chronic
problems caused by overuse of tendons probably account for
30% of all running-related injuries2, and the prevalence of el-
bow tendinopathy in tennis players can be as high as 40%3.
The basic cell biology of tendons is still not fully understood,
and the management of tendon injury poses a considerable
challenge for clinicians. This article describes the function and
structure of tendons, reviews the pathophysiology of tendon
injury and the phases of tendon healing, and reviews possible
strategies for optimizing tendon healing and repair.
Tendon Structure
Healthy tendons are brilliant white in color and have a fibroelas-
tic texture. Tendons demonstrate marked variation in form; they
can be rounded cords, straplike bands, or flattened ribbons4.
Within the extracellular matrix network, tenoblasts and teno-
cytes constitute about 90% to 95% of the cellular ele- ments
of tendons5. Tenoblasts are immature tendon cells. They are
spindle-shaped and have numerous cytoplasmic organelles,
reflecting their high metabolic activity5. As they mature, teno-
blasts become elongated and transform into tenocytes5. Teno-
cytes have a lower nucleus-to-cytoplasm ratio than tenoblasts,
with decreased metabolic activity5. The remaining 5% to 10%
of the cellular elements of tendons consists of chondrocytes at
the bone attachment and insertion sites, synovial cells of the
tendon sheath, and vascular cells, including capillary endotheli-
al cells and smooth muscle cells of arterioles. Tenocytes are ac-
tive in energy generation through the aerobic Krebs cycle, an-
aerobic glycolysis, and the pentose phosphate shunt, and they
synthe- size collagen and all components of the extracellular
matrix network6-8. With increasing age, metabolic pathways
shift from aerobic to more anaerobic energy production9,10.
The oxygen consumption of tendons and ligaments is
7.5 lower than that of skeletal muscles11. The low meta-
bolic 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 injury12.
The dry mass of human tendons is approximately 30% of
the total tendon mass, with water accounting for the remaining
70%. Collagen type I accounts for 65% to 80% and elastin ac-
counts for approximately 2% of the dry mass of tendons6,13-15.
Tenocytes and tenoblasts lie between the collagen fibers along
the long axis of the tendon16.
Collagen is arranged in hierarchical levels of increasing
complexity, beginning with tropocollagen, a triple-helix poly-
peptide chain, which unites into fibrils; fibers (primary bun-
dles); fascicles (secondary bundles); tertiary bundles; and the
tendon itself (Fig. 1)17-19. Soluble tropocollagen molecules
form cross-links to create insoluble collagen molecules, which
aggregate to form collagen fibrils. A collagen fiber is the small-
est tendon unit that can be tested mechanically and is visible
under light microscopy. Although collagen fibers are mainly

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oriented longitudinally, fibers also run transversely and hori-
zontally, forming spirals and plaits20-22.
The ground substance of the extracellular matrix network
surrounding the collagen and the tenocytes is composed of
proteoglycans, glycosaminoglycans, glycoproteins, and several
other small molecules5. Proteoglycans are strongly hydrophilic,
enabling rapid diffusion of water-soluble molecules and the
migration of cells. Adhesive glycoproteins, such as fibronectin
and thrombospondin, participate in repair and regeneration
processes in tendon20,23,24. Tenascin-C, another important
component of the tendon extracellular matrix network, is
abundant in the tendon body and at the osteotendinous and
myotendinous junctions25,26. Tenascin-C contains a number of
repeating fibronectin type-III domains, and, fol- lowing stress-
induced unfolding of these domains, it also functions as an
elastic protein26,27. The expression of tenascin-C is regulated
by mechanical strain and is upregulated in tendinopathy25,28,29.
Tenascin-C may play a role in collagen fiber alignment and
orientation30.
The epitenon, a fine, loose connective-tissue sheats
containing the vascular, lymphatic and nerve supply to
the tendon, covers the whole tendon and extends deep
within it between the tertiary bundles as the endotenon.
The endotenon is a thin reticular network of connective
tissue investing each tendon fiber31-32. Superficially, the
epitenon is surrounded by paratenon, a looser areolar
connective tissue consisting of type I and type III collagen
fibrils, some elastic fibrils, and an inner lining synovial
cells9. Synovial tendon sheaths are found in areas subjected to
increased mechanical stress, such as tendons of the hands and
feet, where efficient lubrication is required. Synovial sheaths
consist of an outer fibrotic sheath and an inner synovial sheath,
which consists of thin visceral and parietal sheets18. The inner
synovial sheath invests the tendon body and functions as an
Fig. 1
Anatomy of a normal tendon.
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ultrafiltration membrane to produce synovial fluid33. The fibrous
sheath forms condensations, the pulleys, which function as
fulcrums to aid tendon function34.
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
fibrils35-39. This complex architecture reduces the tensile stress
exerted on the tendon during muscle contraction35. However,
the myotendinous junction still remains the weakest point of the
muscle-tendon unit35,39-42.
The osteotendinous junction is composed of four zones: a
dense tendon zone, fibrocartilage, mineralized fibrocartilage,
and bone43. The specialized structure of the osteotendinous
junction prevents collagen or fiber bending, fraying, shearing,
and failure44,45.
Blood Supply
Tendons receive their blood supply from three main sources:
the intrinsic systems at the myotendinous junction and osteo-
tendinous junction, and the extrinsic system through the
paratenon or the synovial sheath46,47. The ratio of blood supply
from the intrinsic systems to that from the extrinsic system
varies from tendon to tendon. For example, the central third
of the rabbit Achilles tendon receives 35% of its blood supply
from the extrinsic system48,49. At the myotendinous junction,
perimysial vessels from the muscle continue between the fasci-
cles of the tendon25. However, blood vessels originating from
the muscle are unlikely to extend beyond the proximal third of
the tendon46. The blood supply from the osteotendinous junc-
tion is sparse and is limited to the insertion zone of the ten-
don, although vessels from the extrinsic system communicate
with periosteal vessels at the osteotendinous junction5,46.
In tendons enveloped by sheaths to reduce friction,
Fig. 2
Stress-strain curve demonstrating the basic physical properties of a tendon
branches from major vessels pass through the vincula (meso-
tenon) to reach the visceral sheet of the synovial sheath, where
they form a plexus18 that supplies the superficial part of the
tendon, while some vessels from the vincula penetrate the
epitenon. These penetrating vessels course in the endotenon
septa and form a connection between the peritendinous and
intratendinous vascular networks.
In the absence of a synovial sheath, the paratenon provides
the extrinsic component of the vasculature. Vessels entering
the paratenon course transversely and branch repeatedly to
form a complex vascular network50. Arterial branches from the
paratenon penetrate the epitenon to course in the endotenon
septa, where an intratendinous vascular network with abundant
anastomoses is formed5,51.
Tendon vascularity is compromised at junctional zones and
sites of torsion, friction, or compression. In the Achilles tendon,
angiographic injections techniques have demonstrated
a zone of hypovascularity 2 to 7 cm proximal to the
tendon injection46,52 . However, laser Doppler flowmetry
has demonstrated substantially reduced blood flow near the
Achilles tendon insertion, with an otherwise even blood flow
throughout the tendon53. A similar zone of hypovascularity is
present on the dorsal surface of the flexor digitorum profundus
tendon subjacent to the volar plate, within 1 cm of the tendon
insertion54.In general, tendon blood flow decreases with
increasing age and mechanical loading53.
Tendon Innervation
Tendon innervation originates from cutaneous, muscular, and
peritendinous nerve trunks. At the myotendinous junction,
nerve fibers cross and enter the endotenon septa. Nerve fibers
form rich plexuses in the paratenon, and branches penetrate
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the epitenon. Most nerve fibers do not actually enter the main
body of the tendon but terminate as nerve endings on its
surface.
Nerve endings of myelinated fibers function as specialized
mechanoreceptors to detect changes in pressure or tension.
These mechanoreceptors, the Golgi tendon organs, are most
numerous at the insertion of tendons into the muscle55,56.
Golgi tendon organs are essentially a thin delicate capsule of
connective tissue that encloses a group of branches of large
myelinated nerve fibers. These fibers terminate with a spray of
fiber endings between bundles of collagen fibers of the ten-
don57,58. Unmyelinated nerve endings act as nociceptors, and
they sense and transmit pain. Both sympathetic and parasym-
pathetic fibers are present in tendon59.
Biomechanics
Tendons transmit force from muscle to bone and act as a
buffer by absorbing external forces to limit muscle damage60.
Tendons exhibit high mechanical strength, good flexibility, and
an optimal level of elasticity to perform their unique role16,61,62.
Tendons are viscoelastic tissues that display stress re- laxation
and creep63,64.
The mechanical behavior of collagen depends on the number
and types of intramolecular and intermolecular bonds65.
A stress-strain curve helps to demonstrate the behavior of
tendon (Fig. 2). At rest, collagen fibers and fibrils display a
crimped configuration66. The initial concave portion of the
curve (toe region), where the tendon is strained up to 2%, rep-
resents flattening of the crimp pattern13,67,68. Beyond this point,
tendons deform in a linear fashion as a result of intramolecular
sliding of collagen triple helices, and the fibers become more
parallel69,70. If the strain remains <4%, the tendon behaves in an
elastic fashion and returns to its original length when unloaded71.
Microscopic failure occurs when the strain exceeds 4%.
Beyond 8% and 10% strain, microscopic failure occurs
from intrafibril damage by molecular slippage61,67,72.
X-ray diffraction studies have demonstrated that collagen fibril
elongation initially occurs as a result of molecular elongation,
but as stress increases, the gap between molecules increases,
eventually leading to slippage of lateral adjoining molecules73.
After this, complete failure occurs rapidly, and the fibers recoil
into a tangled bud at the ruptured end60.
The tensile strength of tendons is related to thickness and
collagen content, and a tendon with an area of 1 cm2 is capable
of bearing 500 to 1000 kg31,74,75. During strenuous activities
such as jumping and weight-lifting, very high loads are placed
on tendons76. Forces of 9 kN, corresponding to 12.5 times
body weight, have been recorded in the human Achilles tendon
during running77-79. Since these forces exceed the single-load
ultimate tensile strength of the tendon, the rate of loading may
also play an important role in tendon rupture67,79. Tendons are
at the highest risk for rupture if tension is applied quickly and
obliquely, and the highest forces are seen during eccentric
muscle contraction65,80-84.
Tendon Injury
Tendon injuries can be acute or chronic and are caused by
in- trinsic or extrinsic factors, either alone or in combination. In
acute trauma, extrinsic factors predominate.
Tendon Rupture
An acceleartion-decelaration mechanism has been reported
in up to 90% of sports-related Achilles tendon ruptures85.
Malfunction of the normal protective inhibitory pathway of the
musculotendinous unit may result in injury86. The etiology of
tendon rupture remains unclear12. Degenerative tendinopathy
is the most common histological finding in spontaneous ten-
don ruptures. Arner et al. reported degenerative changes in all
of their seventy-four patients with an Achilles tendon rupture,
and they hypothesized that those changes were due to intrinsic
abnormalities that had been present before the rupture87. Kan-
nus and Jozsa found degenerative changes in 865 (97%) of 891
tendons that had spontaneously ruptured, whereas degenera-
tive changes were seen in 149 (33%) of 445 control tendons10.
Tendon degeneration may lead to reduced tensile strength and
a predisposition to rupture. Indeed, histological evaluation of
ruptured Achilles tendons has demonstrated greater degenera-
tion than was found in tendons that were chronically painful as
a result of an overuse injury88.
Tendinopathy
Overuse injuries generally have a multifactorial origin. Interac-
tion between intrinsic and extrinsic factors is common in
chronic tendon disorders12. It has been claimed that intrinsic
factors such as alignment and biomechanical faults play a
causative role in two-thirds of Achilles tendon disorders
in athletes19,90. In particular, hyperpronation of the foot
has been linked with an increased prevalence of Achilles
tendinopathy91,92. Excessive loading of tendons during vigorous
physical training is regarded as the main pathological stimulus
for degeneration93, and there may be a greater risk of excessive
loading inducing tendinopathy in the presence of intrinsic risk
factors. Tendons respond to repetitive overload beyond the
physiological threshold with either inflammation of their sheath
or degeneration of their body, or both94. Different stresses
induce different responses. Unless fatigue damage is actively
repaired, tendons will weaken and eventually rupture95. The
repair mechanism is probably mediated by resident tenocytes,
which maintain a fine balance between extracellular matrix
network production and degradation. Tendon damage may
even occur from stresses within the physiological limits, as
frequent cumulative microtrauma may not allow enough time
for repair93. Microtrauma can also result from nonuniform stress
within tendons, producing abnormal load concentrations and
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frictional forces between the fibrils and causing localized fiber
damage96.
The etiology of tendinopathy remains unclear, and many
causes have been theorized17,89. Ischemia occurs when
a tendon is under maximal tensile load. On relaxation,
reperfusion occurs, generating oxygen free radicals97,98;
this may cause tendon damage, resulting in tendinopathy
Peroxiredoxin 5 is an antioxidant enzyme that protects
cells against damage from such reactive oxygen species.
Peroxiredoxin 5 is found in human tenocytes. Its expression
is increased in tendinopathy, a finding that supports the
view that oxidative stress may play a role99. Hypoxia alone
may also result in degeneration, as tendons rely on oxidative
energy metabolism to maintain cellular ATP levels100. During
vigorous exercise, localized hypoxia may occur in tendons,
with tenocyte death.
During locomotion, tendons store energy, 5% to 10% of
which is converted into heat101,102. In the equine superficial
digital flexor tendon, temperatures of up to 45°C have been
recorded during galloping103. Although short periods at 45°C
are unlikely to result in tenocyte death, repeated hyperthermic
insults and prolonged hyperthermia may compromise cell via-
bility and lead to tendon degeneration104,105.
Excessive tenocyte apoptosis, the physiological process
often referred to as “programmed cell death,” has been
implicated in rotator cuff tendinopathy106. Application of
strain to tenocytes produces stress-activated protein kinases,
which in turn trigger apoptosis107,108. Oxidative stress may play
a role in inducing apoptosis, but the precise details remain to
be elucidated109. There are more apoptotic cells in ruptured su-
praspinatus tendons than in normal subscapularis tendons110.
Tendinopathic quadriceps femoris tendons exhibited a rate of
spontaneous apoptosis that was 1.6 times greater than that of
normal tendons111.
In animal studies, local administration of cytokines and
inflammatory prostaglandins produced a histological picture
of tendinopathy112,113. Application of cyclic strain increases
production of prostaglandin E2 (PGE2) in human patellar
tenocytes , and it increases interleukin-6 (IL-6) secretion115 and
IL-1ß gene expression in human flexor tenocytes116. Human
flexor tendon cells treated with IL-1ß produced increased
mRNA for cycloox-ygenase-2, matrix metalloproteinase-1
(MMP-1), MMP-3, and PGE2 . IL-1ß released on mechanical
stretching of rabbit Achilles tendons results in increased
production of MMP-3 (stromelysin-1)118. Hence, prolonged
mechanical stimuli induce production of cytokines and
inflammatory prostaglandins, which may be mediators of
tendinopathy.
Ciprofloxacin also induces IL-1ß-mediated MMP-3 release,
and use of fluoroquinolone is associated with tendon rupture
and tendinopathy119-121. Fluoroquinolones inhibit tenocyte
metabolism, reducing cell proliferation and collagen
and matrix synthesis a mechanism that may induce
tendinopathy122,123.
MMPs, a family of proteolytic enzymes124, are classified
according to their substrate, specificity, and primary structure.
They have the combined ability to degrade the components
of the extracellular matrix network and to facilitate tissue
remodeling125-127. Downregulation of MMP-3 mRNA has
been reported in Achilles tendinopathy128,129. Alfredson et al.
found, in addition to downregulation of MMP-3, upregulation
of MMP-2 (gelatinase A) and vascular endothelial growth
factor (VEGF) in Achilles tendinopathy compared with control
samples129. Decreased MMP-3 and MMP-2 activity, but in-
creased MMP-1 (collagenase-1) activity, has been reported in
ruptured supraspinatus tendons130. However, a rabbit model of
supraspinatus tears showed increased expression of MMP-2
and TIMP-1 (tissue inhibitor of metalloproteinase-1)131.
Failure to adapt to recurrent excessive loads may result in
release of cytokines by tenocytes, leading to further modula-
tion of cell activity132. An increase in cytokine levels in response
to repeated injury or mechanical strain may induce MMP
release, with degradation of the extracellular matrix network
and eventual tendinopathy. Mechanical loading studies have
varied with regard to the strain protocol used, and direct
comparison of their results is often difficult. The amount and
frequency of application of strain may in fact determine the
type and amount of cytokines released. Although an imbalance
in MMP activity has been demonstrated in tendinopathic and
ruptured tendons, differences in expression of the various
MMPs have been reported125-131. A differential temporal
sequence of MMP expression may occur, and MMP expression
may differ between tendinopathic and ruptured tendons.
Histological Changes in Tendinopathy
The term “tendinosis” has been in use for nearly three
decades to describe the pathological features of the
extracellular matrix network in tendinopathy133. Despite
that, most clinicians still use the term “tendinitis” or
“tendonitis”, thus implying that the fundamental problem
is inflammatory. We advocate the use of the term
“tendinopathy” as a generic descriptor of the clinical
conditions in and around tendons arising from overuse, and
we suggest that the terms “tendinosis” and “tendinitis”
be used only after histopathological examination134.
Histological examination of tendinopathy shows disor-
dered, haphazard healing with an absence of inflammatory
cells, a poor healing response, noninflammatory intratendi-
nous collagen degeneration, fiber disorientation and
thinning, hypercellularity, scattered vascular ingrowth,
and increased interfibrillar glycosaminoglycans18,135-137.
Frank inflammatory lesions and granulation tissue
are infrequent and are mostly associated with tendon
ruptures138.
Various types of degeneration may be seen in tendons,
but mucoid or lipoid degeneration is usually found in the
Achilles tendon18,139. Light microscopy of a tendon with
mucoid degeneration reveals large mucoid patches and
vacuoles between fibers. In lipoid degeneration, abnormal
intratendinous accumulation of lipid occurs, with disruption
of collagen fiber structure18,140,141. In rotator cuff tendinopathy,
mucoid degeneration occurs, but fibrocartilaginous metaplasia,
often accompanied by calcium deposition, is also common147.
Amyloid deposition in supraspinatus tendons with degenerative
tears has also been reported148.
Tendinosis can be viewed as a failure of the cell matrix
to adapt to a variety of stresses as a result of an imbalance
be- tween matrix degeneration and synthesis93,132. Macroscopi-
cally, the affected portions of the tendon are seen to have lost
their normal glistening-white appearance and to have become
gray-brown and amorphous. Tendon thickening, which can
be diffuse, fusiform, or nodular, occurs149. Tendinosis is often
clinically silent, and its only manifestation may be a rupture;
however, it may also coexist with symptomatic paratendin-
opathy98,150-152. Mucoid degeneration, fibrosis, and vascular
pro- liferation with a slight inflammatory infiltrate have been
reported in paratendinopathy12,153,154. Edema and hyperemia of
the paratenon are seen clinically. A fibrinous exudate accumu-
lates within the tendon sheath, and crepitus may be felt on
clinical examination149.
In samples from 397 ruptured Achilles tendons, Kannus
and Jozsa found no evidence of inflammation under light and
electron microscopy10. Arner et al. also found no neutrophilic
infiltration in Achilles tendons on the first day after rupture, and
they concluded that any inflammation seen at a later stage
occurred subsequent to the rupture87. In a recent study, im-
munohistochemical staining of neutrophils confirmed acute
inflammation in all of sixty ruptured Achilles tendons155. Col-
lagen degeneration and tenocyte necrosis may trigger an acute
inflammatory response, which further weakens the tendon,
predisposing it to rupture.
In summary, tendinopathy shows features of disordered
healing, and inflammation is not typically seen. Although de-
generative changes do not always lead to symptoms, preexist-
ing degeneration has been implicated as a risk factor for acute
tendon rupture10,87,88.
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The role played by inflammation in tendon rupture is less
clear.
Pain in Tendinopathy
Classically, pain in tendinopathy was attributed to
inflammation. However, chronically painful Achilles and
patellar tendons show no evidence of inflammation,
and many tendons with intratendinous lesions detected
on magnetic resonance imaging or ultrasound are not
painful149. Pain may originate from a combination
of mechanical and biochemical factors149. Tendon
degeneration with mechanical breakdown of collagen
could theoretically explain the pain, but clinical and surgical
observations have challenged this view149. Chemical irritants
and neurotransmitters may generate pain in tendinopathy,
and microdialysis sampling has revealed a twofold increase
in lactate levels in tendons with tendinopathy compared
with those in controls156. Patients with chronic Achilles
tendinopathy and patellar tendinopathy showed high
concentrations of the neurotransmitter glutamate, with no
significant elevation of the proinflammatory prostaglandin
PGE2157. However, the levels of PGE2 were consistently higher
in the tendinopathic tendons than they were in controls, and it
is possible that the results lacked significance because of the
small sample size of the study.
Substance P functions as a neurotransmitter and neuro-
modulator, and it is found in small unmyelinated sensory
nerve fibers158. A network of sensory innervation is present in
tendons, and substance P has been found both in tendino-
pathic Achilles tendons and in medial and lateral epicondy-
lopathy159-162. Sensory nerves transmit nociceptive information
to the spinal cord, and increased levels of substance P correlate
with pain levels in rotator cuff disease162.
An opioid system has been demonstrated in the Achilles
tendons of rats163. Under normal conditions, there is probably
a balance between nociceptive and anti-nociceptive pep-
tides164,165, with alteration of this equilibrium in pathological
conditions164,165.
Tendon Healing
Studies of tendon healing predominantly have been per-
formed on transected animal tendons or ruptured human ten-
dons, and their relevance to healing of tendinopathic human
tendons remains unclear.
Tendon healing occurs in three overlapping phases. In the
initial, inflammatory phase, erythrocytes and inflammatory
cells, particularly neutrophils, enter the site of injury. In
the first twenty-four hours, monocytes and macrophages pre-
dominate and phagocytosis of necrotic materials occurs. Vaso-
active and chemotactic factors are released with increased
vascular permeability, initiation of angiogenesis, stimulation of
tenocyte proliferation, and recruitment of more inflammatory
cells166. Tenocytes gradually migrate to the wound, and type-III
collagen synthesis is initiated167.
After a few days, the proliferative phase begins. Synthesis
of type-III collagen peaks during this stage and lasts for a few
weeks. Water content and glycosaminoglycan concentrations
remain high during this stage167.
After approximately six weeks, the remodeling phase
commences, with decreased cellularity and decreased
collagen and glycosaminoglycan synthesis. The remodeling
phase can be divided into a consolidation stage and a
maturation stage168. The consolidation stage begins at about
six weeks and continues for up to ten weeks. In this period,
the repair tissue changes from cellular to fibrous. Tenocyte
metabolism remains high during this period, and tenocytes and
collagen fibers become aligned in the direction of stress169. A
higher proportion of type-I collagen is synthesized during this
stage170. is synthesized during this stage170. After ten weeks,
the maturation stage occurs, with gradual change of the
fibrous tissue to scar-like tendon tissue over the course
of one year169,171. During the latter half of this stage, tenocyte
metabolism and tendon vascularity decline172.
 Tendon healing can occur intrinsically, by proliferation of
epitenon and endotenon tenocytes, or extrinsically, by invasion
of cells from the surrounding sheath and synovium173-175.
Epitenon tenoblasts initiate the repair process through prolifer-
ation and migration176-179. Healing of severed tendons can be
achieved by cells from the epitenon alone, without reliance
on adhesions for vascularity or cellular support180,181. Internal
tenocytes contribute to the intrinsic repair process and secrete
larger and more mature collagen fibers than do epitenon
cells182. Despite this, fibroblasts in the epitenon and tenocytes
synthesize collagen during repair, and different cells probably
produce different collagen types at different time-points.
Initially, collagen is produced by epitenon cells, with endotenon
cells synthesizing collagen later183-187. The relative contribution
of each cell type may be influenced by the type of trauma
sustained, the anatomical location, the presence of a synovial
sheath, and the amount of stress induced by motion after repair
has taken place188.
Tenocyte function may vary depending on the region of
origin. Cells from the tendon sheath produce less collagen and
glycosaminoglycans than do epitenon and endotenon cells.
However, fibroblasts from the flexor tendon sheath proliferate
more rapidly189,190. The variation in phenotypic expression of
tenocytes has not been extensively investigated, and this infor-
mation may prove useful for optimizing repair strategies.
Intrinsic healing results in better biomechanics and fewer
complications;in particular, a normal gliding mechanism
within the tendon sheath is preserved191. In extrinsic
healing, scar tissue results in adhesion formation, which
disrupts tendon gliding192. Different healing patterns may
predominate in particular locations; for example, extrinsic
healing tends to prevail in torn rotator cuffs193.
MMPs are important regulators of extracellular matrix
network remodeling, and their levels are altered during ten-
don healing126-128. In a rat flexor tendon laceration model, the
expression of MMP-9 and MMP-13 (collagenase-3) peaked
between the seventh and fourteenth days after the surgery.
MMP-2, MMP-3, and MMP-14 (MT1-MMP) levels increased
after the surgery and remained high until the twenty-eighth
day194. These findings suggest that MMP-9 and MMP-13
participate only in collagen degradation, whereas MMP-2,
MMP- 3, and MMP-14 participate both in collagen degradation
and in collagen remodeling. Wounding and inflammation also
provoke release of growth factors and cytokines from platelets,
polymorphonuclear leukocytes, macrophages, and other in-
flammatory cells195-200. These growth factors induce neovascu-
larization and chemotaxis of fibroblasts and tenocytes and
stimulate fibroblast and tenocyte proliferation as well as syn-
thesis of collagen201,202.
Nitric oxide is a short-lived free radical with many bio-
logical functions: it is bactericidal, it can induce apoptosis
in inflammatory cells, and it causes angiogenesis and
vasodilation203-205. Nitric oxide may play a role in several
aspects of tendon healing. Nitric oxide synthase is responsible
for synthesizing nitric oxide from L-arginine. Levels of nitric
oxide synthase peaked after seven days and returned to
baseline fourteen days after tenotomies of rat Achilles
tendons206. In that study, inhibition of nitric oxide synthase
reduced healing, resulted in a decreased cross-sectional area,
and reduced failure load206. The authors did not identify the
specific isoforms of nitric oxide synthase. More recently, the
same research group demonstrated a temporal expression of
the three isoforms of nitric oxide synthase207. The inducible
isoform peaks on the fourth day, the endothelial isoform
peaks on the seventh day, and the neuronal isoform peaks on
the twenty-first day207. Interestingly, in a rat Achilles tendon
rupture model, nerve fiber formation peaked between two
and six weeks after the rupture, in concert with peak levels of
the neuronal isoform of nitric oxide synthase208. These nerve
fibers presumably deliver neuropeptides that act as chemical
messengers and regulators, and they may play an important
role in tendon healing. Substance P and calcitonin gene-related
peptide (CGRP) are proinflammatory and cause vasodilation
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and protein extravasation209-211. In addition, substance P
enhances cellular release of prostaglandins, histamines, and
cytokines212,213. Levels of substance P and CGRP peak during
the proliferative phase, suggesting a possible role during that
phase.
Limitations of Healing
Adhesion formation after intrasynovial tendon injury poses a
major clinical problem214. Disruption of the synovial sheath at
the time of the injury or surgery allows granulation tissue and
tenocytes from surrounding tissue to invade the repair site.
Exogenous cells predominate over endogenous tenocytes, al-
lowing the surrounding tissue to attach to the repair site and
resulting in adhesion formation.
Despite remodeling, the biochemical and mechanical
properties of healed tendon tissue never match those of intact
tendon. In a study of transected sheep Achilles tendons that
had spontaneously healed, the rupture force was only 56.7%
of normal at twelve months215. One possible reason for this
is the absence of mechanical loading during the period of
immobilization.
Current Strategies for Tendon Healing
Physical Modalities
Many physical modalities are used in the management of
ten- don disorders. However, although these modalities are in
rou- tine clinical use, only a few controlled clinical trials have
been performed. Most of the evidence is still pre-clinical and,
at times, controversial.
Extracorporeal shock wave therapy applied to rabbit Achilles
tendons, at a rate of 500 impulses of 14 kV in twenty
minutes, resulted in neovascularization and an increase in the
angiogenesis-related markers such as nitric oxide synthase
and VEGF216. Extracorporeal shock wave therapy promoted
healing of experimental Achilles tendinopathy in rats217. The au-
thors proposed that the healing improved because of an
increase in growth factor levels, as they had noted elevated
lev- els of transforming growth factor-ß1 (TGF-ß1) in the early
stage and persistently elevated levels of IGF-1217. In another
study, seventy-four patients with chronic noncalcific rotator
cuff tendinopathy were randomized to receive either active
ex- tracorporeal shock wave therapy (1500 pulses of 0.12 mJ/
mm2) or sham treatment monthly for three months218. The
mean duration of symptoms was 23.3 months in both groups.
All patients were assessed for pain in the shoulder, including
night pain measured with a visual analogue score, and a dis-
ability index was calculated before each treatment and at one
and three months after the completion of the treatment. There
were no significant differences between the two groups before
treatment. Both groups showed marked and sustained im-
provements from two months onward, but the moderate doses
of extracorporeal shock wave therapy provided no added
benefit compared with the sham treatment.
In a double-blind, randomized, placebo-controlled trial
of 144 patients with calcific tendinopathy of the rotator cuff,
patients received high-energy extracorporeal shock wave
therapy, low-energy extracorporeal shock wave therapy, or a
placebo (sham treatment)219. The two groups treated with ex-
tracorporeal shock wave therapy received the same cumulative
energy dose. All patients received two treatment sessions ap-
proximately two weeks apart, followed by physical therapy.
Both the high-energy and the low-energy extracorporeal shock
wave therapy resulted in an improvement in the mean Constant
and Murley score at six months compared with the score after
the sham treatment. Also, the patients who had re- ceived the
high-energy extracorporeal shock wave therapy had a higher
six-month Constant and Murley score than did the patients
who had received the low-energy extracorporeal shock wave
therapy. Compared with the placebo, both the high-energy and
the low-energy extracorporeal shock wave therapy appeared to
provide a beneficial effect in terms of bet- ter shoulder function,
less self-rated pain, and diminished size of calcifications. Also,
the high-energy extracorporeal shock wave therapy appeared
to provide a beneficial effect in terms of better shoulder function,
less self-rated pain, and diminished size of calcifications.
Also, the high-energy extracorporeal shock wave therapy
appeared to be superior to the low-energy therapy. However,
caution should be exercised when using extra-corporeal shock
wave therapy, as dose-dependent tendon damage, including
fibrinoid necrosis, fibrosis, and inflammation, has been
reported in rabbits220.
Pulsed magnetic fields with a frequency of 17 Hz im-
proved collagen fiber alignment in a rat Achilles tendinopathy
model221. In another study, tenotomized rat Achilles tendons
were sutured and then treated with low-intensity galvanic cur-
rent for fifteen minutes a day for two weeks222. Biomechanical
analysis revealed an increased force to breakage in the anode-
stimulated group compared with controls and a cathode-stim-
ulated group.
Direct current applied to rabbit tendons in vitro in-
creased type-I-collagen production and decreased adhesion
formation223. In a randomized trial, lacerated rabbit flexor ten-
dons were repaired and then received pulsed electromagnetic
field stimulation for six hours a day, starting six days after the
surgery and continuing until twenty-one days after the
surgery224. At four weeks, no difference in adhesion formation
was noted.
The effects of laser therapy on tendon healing have also
been studied. Laser phototherapy increased collagen produc-
tion in rabbits subjected to tenotomy and surgical repair225.
In a placebo-controlled, double-blind, prospective study of
twenty-five patients with a total of forty-one digital flexor
tendon repairs, laser therapy reduced postoperative edema
but provided no improvement with regard to pain relief, grip
strength, or functional results compared with controls226.
Radiofrequency coblation is a new application of bipo-
lar radiofrequency energy used for volumetric tissue removal.
Under appropriate conditions, a small vapor layer forms on
the active electrode of the device. The electrical field of the
energized electrode causes electrical breakdown of the vapor,
producing a highly reactive plasma that is able to break down
most of the bonds found in soft-tissue molecules. Radiofre-
quency coblation stimulates an angiogenic response in normal
rabbit Achilles tendons227. Rapid pain relief was reported in a
preliminary uncontrolled prospective, nonrandomized, single-
center, single-surgeon study of twenty patients with tendinop-
athy of the Achilles tendon, patellar tendon, and common
extensor origin227. Six months after the procedure, magnetic
resonance imaging showed complete or near complete resolu-
tion of the tendinopathy in ten of the twenty patients.
Cytokines and Growth Factors
Increased levels of TGF-ß2 have been reported in tendino-
pathic human Achilles tendons and in rabbit flexor tendons after
injury228,229. TGF-ß results in scar formation and fibrosis, and
TGF-ß1 expression is increased in patients with hypertrophic
scarring and keloids following a burn230,231. The response to
cytokines may be site-specific, and insulin-like growth factor-I
(IGF-I) induces a higher rate of collagen synthesis in rabbit
flexor tendons than it does in rabbit Achilles tendons232. The
use of cytokines and growth factors to enhance tendon healing
remains largely experimental and has been restricted to in vitro
studies and animal models233-249. The clinical use of growth
factors for the treatment of tendon problems has not yet been
reported, to our knowledge.
Gene Therapy
Gene therapy delivers genetic material (DNA) to cells, permit-
ting modification of cellular function, by means of viral or non-
viral vectors or direct gene transfer250,251. Gene therapy enables
the delivery of individual proteins to specific tissues and cells252.
Several animal studies have been done to investigate
the feasibility of gene transfer to tendons. For example,
hemaggluti- nating virus of Japan (HVJ)-liposome constructs
were used to deliver ß-galactosidase to rat patellar tendons253.
In vivo and ex vivo gene transfer techniques have been used as
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18
well. With these methods, sustained gene expression seems
to last for about six weeks, possibly long enough for clinical
applications254,255. Ex vivo gene transduction is possibly more
efficient, but the techniques must be optimized.
Gene therapy can also alter the healing environment
of tendons in animal models of tendon repair. Adenoviral
transduction of focal adhesion kinase (FAK) into partially
lacerated chicken flexor tendons resulted in an expected
increase in adhesion formation and a twofold increase in the
work required for flexion compared with the results in control
groups256. These differences were significant (p = 0.001). While
tendon healing was not improved in this study, the re- sults
did demonstrate that the healing environment and con- ditions
could be manipulated.
Bone morphogenetic protein-12 (BMP-12) is the human
analogue of murine GDF-7257. BMP-12 increases the expression
of procollagen type-I and III genes in human patellar tenocytes,
and it is found at sites of tendon remodeling258. BMP-12
increased synthesis of type-I collagen by 30% in chicken
flexor tenocytes, and application of tenocytes transfected with
the BMP-12 gene to a chicken flexor tendon laceration model
resulted in a twofold increase in tensile strength and load to
failure at four weeks259.
Transfer of genes to tendons is feasible, and, as the healing
environment can be manipulated for up to eight to ten weeks226,
this may be long enough to be clinically relevant. While the
above studies were conducted in tendon transection models,
delivery of substances such as platelet-derived growth factor-B
(PDGF-B), BMP-12, and decorin may improve healing of
tendinopathy257-267; additional research in this area is required.
Tissue Engineering with Mesenchymal Stem Cells
Mesenchymal stem cells are capable of undergoing differentia-
tion into a variety of specialized mesenchymal tissues,
including bone, tendon, cartilage, muscle, ligament, fat,
and marrow stroma (Fig. 3)268. In adults, mesenchymal stem
cells are preva- lent in bone marrow, but they are also found
in muscle, fat, and skin and around blood vessels269. The
differentiation of mesenchymal stem cells along a particular
phenotypic pathway may be controlled by a master regulatory
gene, a concept formulated after the discovery of MyoD, a
muscle transcription factor capable of inducing expression
of a bank of muscle-specific genes270. However, MyoD may
not be the only transcription factor responsible for myogenic
differentiation; Myf5, myogenin, and MRF4 may also play
a role271. Transcription factors that regulate adipogenic and
osteogenic differentiation have also been identified, but no
transcription factors regulating tenocyte differentiation have yet
been identified272-275.
Mesenchymal stem cells can be applied directly to the site of
injury or can be delivered on a suitable carrier matrix, which
functions as a scaffold while tissue repair takes place. In ex
vivo, de novo tissue engineering with use of mesenchymal
stem cells, whole body tissues are constructed in the labora-
tory and are subsequently implanted into patients. Tissue-
engineered tendons could be used to bridge areas of tendon
loss or to replace severely degenerated regions276-279.
At present, tissue engineering is an emerging field, and many
issues, such as ideal scaffold materials, optimal cellseeding
density, and optimal culture conditions, need to be es-
tablished before it becomes a real option in the management
of tendon disorders. Effective vascularization and innervation
of implanted tissue-engineered constructs must take place for
the constructs to be viable. Vascularization allows survival of
the construct. Innervation is required for proprioception and
to maintain reflexes, mediated by Golgi tendon organs, to pro-
tect tendons from excessive forces280,281.
Prevention of Adhesions
The most important factor implicated in adhesion formation
is trauma282. Tenocytes and tenoblasts are key cells in tendon
healing. The actin isoform α-smooth muscle actin has been
identified in tendons and ligaments283,284.Tenocytes that express
smooth muscle actin are known as myofibroblasts. There
are three essential morphological elements that define
myofibroblasts: stress fibers (actin microfilaments), well-
developed cell-stroma attachment sites (fibronexus), and
intercellular gap junctions285. The fibronexus is presumed to
transfer tensile forces to the extracellular matrix network286.
Myofibroblasts are thought to play a role in extracellular matrix
network homeostasis in tendons and ligaments, and they may
well be responsible for the formation of tendon adhesions287.
Many attempts have been made to reduce adhesion for-
mation by using materials acting as mechanical barriers such
as polyethylene or silicone or by using pharmacological agents
such as indomethacin and ibuprofen, but no simple method is
widely used288-291. Hyaluronate is found in synovial fluid around
tendon sheaths292. Its use decreased adhesion formation in
repaired rabbit flexor tendons293,294 but resulted in no signifi-
cant differences in adhesion formation in a rat Achilles tendon
model295. The absence of a synovial membrane around the
Achilles tendon may explain this difference. A single dose of
hyaluronate, at a concentration of 10 mL/mg, had no effect on
rabbit tenocyte proliferation or matrix synthesis296. Therefore, it
Fig. 3
Schematic representation of mesenchymal stem cell differentiation.
Mobilization and Mechanical Loading
In animal experiments, training has improved the tensile
strength, elastic stiffness, weight, and cross-sectional area of
tendons299,300. These effects can be explained by an increase
in collagen and extracellular matrix network synthesis by teno-
cytes300. There are little data on the effect of exercise on human
tendons, although intensively trained athletes are reported to
have thicker Achilles tendons than control subjects301. Most of
our current knowledge is therefore based on the results of ani-
mal studies. However, care must be taken when interpreting
animal studies, as the results in untrained animals cannot be
directly compared with those in trained animals. Also, con-
fined animals are likely to have reduced connective-tissue
mass and tendon tensile strength, and physical training may
merely return these parameters to normal302.
Prolonged immobilization following musculoskeletal
injury may have detrimental effects. Collagen fascicles
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19
is unclear whether hyaluronate has any effect on myofibroblast
function or just acts as a mechanical barrier. Results may vary
with different doses of hyaluronate.
5-fluorouracil, an antimetabolite with anti-inflammatory
properties, inhibits fibroblast proliferation, with a greater effect
on synovial fibroblasts than on endotenon fibroblasts296,297.
Lacerated chicken flexor tendons were repaired and were
exposed to various doses of 5-fluorouracil for five minutes298.
A dose of 25 mg/mL effectively preserved tendon gliding,
and, at three weeks after the surgery, there was no significant
difference in excursion, maximal load, or work of flexion
between the repaired tendons and normal controls. Use of 50
mg/mL of 5-fluorouracil produced inferior results, suggesting
that there is a therapeutic threshold beyond which 5-fluorouracil
may be detrimental to tendon healing.
Despite many efforts, adhesion formation after tendon trauma
remains a clinical problem, with no ideal method of prevention.
With advances in the understanding of the mechanisms
involved in adhesion formation, it may be possible to formulate
improved strategies of prevention.
from stress-shielded rabbit patellar tendons displayed lower
tensile strength and strain at failure than did control samples303.
Immobilization reduces the water and proteoglycan content
of tendons and increases the number of reducible collagen
crosslinks304,305. Immobilization results in tendon atrophy,
but, as a result of the low metabolic rate and vascularity,
these changes occur slowly301.
After the inflammatory phase of healing, controlled stretching
is likely to increase collagen synthesis and improve fiber
alignment, resulting in higher tensile strength306. Collagen that
remains unstressed during the proliferative and remodeling
phases remains haphazard in organization and is weaker than
stressed collagen307. Experimental studies have demonstrated
the beneficial effects of motion and mechanical loading
on tenocyte function. Repetitive motion increases DNA
content and protein synthesis in human tenocytes308.
Even fifteen minutes of cyclic biaxial mechanical strain applied
to human tenocytes results in cellular proliferation309.
Application of a cyclic load to wounded avian flexor tendons
results in migration of epitenon cells into the wound310. In
rabbit patellar tendons, application of a 4% strain provides
protection against degradation by bacterial collagenase311.
Clinical studies have shown the benefit of early mobili-
zation following tendon repair, and several postoperative
mo- bilization protocols have been advocated312-316. The
precise mechanism by which cells respond to load remains
to be elucidated. However, cells must respond to mechanical
and chemical signals in a coordinated fashion. For example,
intercellular communication by means of gap junctions is
necessary to mount mitogenic and matrigenic responses in ex
vivo models317.
Overview
Tendon injuries produce substantial morbidity, and at present
there are only a limited number of scientifically proven man-
agement modalities. A better understanding of tendon func-
tion and healing will allow specific treatment strategies to be
developed. Many interesting techniques are being pioneered.
20
20
The optimization strategies discussed in this article are cur-
rently at an early stage of development. While these emerging
technologies may develop into clinical treatment options, their
full impact on tendon healing needs to be critically eval- uated
in a scientific fashion.
Pankaj Sharma, MRCS
Nicola Maffulli, MD, MS, PhD, FRCS(Orth)
Department of Trauma and Orthopaedics, Keele University School
of Medicine, Thornburrow Drive, Hartshill, Stoke-on-Trent, Stafford- shire,
ST4 7QB, United Kingdom. E-mail address for N. Maffulli: n.maffulli@keele.
ac.uk
The authors did not receive grants or outside funding in support of their
research or preparation of this manuscript. They did not receive pay- ments
or other benefits or a commitment or agreement to provide such benefits
from a commercial entity. No commercial entity paid or directed, or agreed
to pay or direct, any benefits to any research fund, foundation, educational
institution, or other charitable or nonprofit organization with which the
authors are affiliated or associated.
doi:10.2106/JBJS.D.01850
 21
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S
Studii clinice

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LYNEN 2012
Tratamentul tendinopatiilor cronice cu injectii cu hialuronat peritendon sub control
imagistic - studiu interventional, multicentric, prospectiv, cu un singur brat.

REZUMAT :

ABSTRACT:
Tendinopatiile cronice reprezinta o problema uzuala, pentru care metodele actuale de
tratament sunt adesea nesatisfacatoare. In studiul de fata a fost evaluata eficacitatea
clinica si siguranta a doua injectii peritendinoase cu solutie 2% de Acid Hialuronic ad-
ministrat la un interval de o saptamana (OSTENIL® tendon seringa preumpluta, TRB
CHEMEDICA AG, Germania Haar) la 35 de pacienti care sufereau de tendinopatia dure-
roasa persistenta timp de cel putin sase saptamani a tendonului Ahilean, a tendonului
extensor comun de la nivelul articulatiei mainii sau a tendoanelor peroniere. Rezultatele
au aratat ca prin tratament se obtine o reducere semnificativa a durerii si o imbunatatire
semnificativa a simptomelor legate de boala. Tolerabilitatea si siguranta produsului ex-
celente au fost in mod clar demonstrate in acest studiu.

CUVINTE CHEIE:
Tendinopatia, tendinoze, Acid Hialuronic, hialuronat, tendonul lui Ahile, tendon peronier,
epicondilita, cotul tenismenului;

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WISSENSCHAFT / RESEARCH Original Article / Originalarbeit

N. Lynen1

Treatment of chronic tendinopathies

with peritendinous hyaluronan
injections under sonographic
guidance – an interventional,
prospective,single-arm, multicenter
study
Behandlung von chronischen Tendinosen durch ultraschallgesteuerte
peritendinöse Hyaluronsäureinjektion - Eine interventionelle,
prospektive, einarmige multizentrische Studie

Abstract: Chronic tendinopathies are a common problem, for which current treatment methods are often unsatisfactory. In the
present study, the clinical efficacy and safety of two peritendinous injections of a 2% solution of hyaluronic acid administered at
an interval of one week (OSTENIL® TENDON pre-filled syringe , TRB Chemedica AG, Haar Germany) was assessed in 35 patients
who suffered from painful tendinopathy of the Achilles tendon, the common wrist extensor tendon or the peroneal tendons persis-
tent for at least six weeks. The results showed that treatment achieves a significant pain reduction and a significant improvement in
disease-related symptoms. Excellent tolerability and safety of the product were clearly demonstrated in this study.

Keywords: Tendinopathy, tendinosis, hyaluronic acid, hyaluronan, Achilles tendon, peroneal tendon, epicondylitis, tennis elbow.

Introduction
Overuse injuries of tendons are a common cause of painful symptoms in the extremities, particularly in young and active
individuals. This is often due to increased physical stress from sports activities [1]. But tendinopathy can also occur as a
result of physical work or improper loading. Pathological changes in tendons typically have a protracted course lasting
6 months or longer [2], with a smooth transition from a healthy tendon, via acute inflammatory achillodynia to chronic
tendinopathy. Tendon pain that persists for a long period is particularly difficult to treat successfully.
Although a wide variety of conservative treatment methods are available, few have lasting success, especially for patients with
a long history of symptoms [3]. The most likely reason is that there is an aseptic inflammatory response only at the onset of the
disease process. As shown in recent studies, the role of the inflammatory component becomes relatively minor already at an
earlier stage of the disease, so that the anti-inflammatory characteristics of corticosteroids or nonsteroidal anti-inflammatory drugs
(NSAIDs) do not provide effective treatment at this stage [4, 5]. In the further course of the disease, fibrosis develops with increased
formation of collagen between tissue layers, which leads in turn to adhesion of the tendons and a painful reduction in the ability
of the tendon to glide freely. The adhesions also result in reduced nutrition of the bradytrophic tendons, since synovial fluid is no
longer distributed in sufficient quantities. This leads to metabolic disorders, with changes in fibre structure and dedifferentiation of
type I collagen to type III collagen as well as sprouting of nociceptive nerve endings.
Several studies have shown that peritendinous application of hyaluronic
acid (HA) is an effective therapeutic option for the treatment of chronic tendinopathy [6, 7, 8]. HA is the main component of synovial
fluid, which is found in the normal tendon sheath and surrounding tissues; synovial fluid contributes to the nutrition of the tendon [9].
The viscoelastic properties of HA also have significant therapeutic effects, since HA can help to reduce the surface
friction of tendons whose capacity to glide freely has been reduced by microtears and adhesions. Recent studies provide an
explanation of the physical mechanism by which surface friction of tendons is reduced: the application of HA together with the
formation of a network of the cells on the tendon surface result in the “gliding effect“ [10,11,12].
At the cellular level, a further effect is produced by expansion of the extracellular space. Because of its high anionic charge,
HA is able to bind a large quantity of water molecules, and the HA-water aggregate may swell to occupy as much as 10,000
times the volume of the HA molecule alone [13]. Due to the increased osmotic pressure, spaces form in the extracellular matrix

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Figure 1
Box plot analysis, visual analogue scale

and between the cells, contributing to an increase in cell mobility and thus leading to increased cell migration [14]. Furthermore,
the tightly interlocked HA macromolecules act like a molecular sieve, which prevents free passage of inflammatory cells,
prostaglandins and cytokines, and at the same time channels the transport of nutritionally important metabolites from the
synovial cells to the tendon [9, 15].
In addition, HA provides an ideal environment for cell proliferation and differentiation due to its high affinity for the
extracellular matrix [16, 17]. The improved environmental conditions increase cellular activity, so that the cells produce increased
quantities of extracellular matrix, which in turn results in optimisation of the repair process [15]. HA also has an analgesic effect,
since it has a desensitising action on nociceptive receptors [18].
Due to the favourable characteristics of HA and the lack of satisfactory therapeutic alternatives, the present study was
designed to evaluate the efficacy and safety in patients with chronic tendinopathy of two peritendinous injections of HA (2
ml of 2% HA + 0.5% mannitol) at an interval of one week.

Patients and Methods

The study was an interventional, prospective, single-arm, multicenter trial.
The trial was approved by an independent ethics committee, and each patient gave written consent to participation before inclu-
sion in the trial.
A total of 35 patients aged between 18 and 75 years who suffered for at least 6 weeks from chronic tendinopathy in
the mid-portion of the Achilles tendon, of the peroneal tendons or enthesitis of the lateral epicondyle of the humerus were
included in the study. All patients had severe pain symptoms with a score of at least 40 mm on the visual analogue scale (Pain
VAS) according to Huskisson [19].
Patients were excluded from participation if they had a concomitant disease that might interfere with the parameters to be as-
sessed, if they had a severe systemic disease or if the trial product was contraindicated.
Patients were also excluded if they had been treated with systemic or topical steroids less than 4 weeks prior to the first examina-
tion, or with NSAIDs within the week prior to the start of the trial. Patients were not permitted to use any additional medications
(NSAIDs in particular) or physotherapy for the entire duration of the trial. Extreme sports as well as heavy physical activities that
could have had a negative impact on the symptoms were also prohibited.
After checking the inclusion and and exclusion criteria, each patient received a peritendinous injection (with ultrasound guidance)

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 Figure 2
Visual analog scale by tendon
of 2 ml of the trial product (40 mg HA + 10 mg of mannitol)
around the affected tendon. A second injection was made
after an interval of one week. During the treatment phase,
trial parameters were recorded before the first injection and
then before the second injection. Further measurements
were made at 5 and 12 weeks after the start of treatment.
The time course of pain symptoms
was assessed with the Pain VAS (100 mm), in which 0
represents ‘no pain’ and 100 represents ‘extreme pain’
[19]. The clinical parameters typical for tendinopathy
(redness, warmth, swelling, tenderness, crepitus during
movement and peritendinous effusion) were recorded
at all time points. A 5-point ordinal scale was used to
assess intensity (0 = none, 1 = slight, 2 = moderate, 3 =
substantial, 4 = extreme) of each clinical parameter.
The overall impression of treatment success (clinical
global impression, CGI) was measured using a 7-point
ordinal scale (1 = very much improved, 2 = much improved,
3 = slightly improved, 4 = unchanged, 5 = slightly worse,
6 = much worse, 7 = very much worse). This assessment
was made by both the investigator and the patient at 1, 5
and 12 weeks after the start of treatment.
A patient questionnaire was used to assess the patient’s
perception of the extent to which his daily life, leisure
activities and work were restricted. This assessment was
made using a 5-point ordinal scale (0 = no restriction, 1 =
slight restriction, 2 = moderate restriction, 3 = substantial
restriction, 4 = extreme restriction) at all time points. Safety
aspects were evaluated by documenting all adverse
events.
Statistical analysis
Since this was a pilot study, there was no control group
and a statistical calculation of sample size was not
performed.
The number of participants was chosen to guarantee
a reliable analysis. For assessment and analysis of the
safety and effectiveness of the trial product, data from all
35 patients were analysed. Missing data were replaced
according to the ‘Last Observation Carried Forward’
(LOCF) principle.
The Pain VAS value at 5 weeks after the start of
treatment was used as the primary measure of efficacy.
Secondary parameters included clinical parameters, the
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CGI, patient questionnaire for all time time points, and the
VAS score at 1 and 12 weeks after the start of treatment.
An intra-group comparison for the primary endpoint
was performed with the 2-sided Wilcoxon-Pratt test. The
alpha level was defined as alpha = 0.05. All secondary
parameters were analysed with the 2-sided sign test, alpha
= 0.05, for intra-group comparisons between baseline and
follow-up parameters.
Results
In the period from 3 February to 30 May 2011, a total of 35
patients with a mean age of 45.9 ± 10.6 years (± SD) were
included in the study. Seventeen (51.4 %) of the patients
were female and 18 (48.6 %) were male.
Tendinopathy was localised in the mid-portion of the
Achilles tendon in 19 patients (54.3%), at the lateral
epicondyle of the humerus in 14 patients (40.0%) and in
the peroneal tendon in 2 patients (5.7%). Patients had
suffered from chronic tendinopathy for a median period of
12.3 ± 17.9 months.
Assessment of pain symptoms with the VAS showed a
significant improvement compared to baseline
(p <0.0001) at 5 weeks after the start of treatment. At
the time of enrolment, patients rated pain with a median
intensity of 62 ± 18.9 mm, but at 5 weeks the score was
only 21 ± 21.3 mm (Fig. 1).
The significant decrease in pain intensity was maintained
in the long term, since further significant improvement of
the VAS score was found at 12 weeks, with a median of 17
± 26.2 mm (p <0.0001).
Specific analysis by tendon showed a significant
improvement of pain in all affected tendons (Fig. 2). The
most pronounced improvement was found in patients
with Achilles tendinopathy. These patients reported pain
intensity before the first injection with a median VAS score
of 57 ± 19.1 mm, but during treatment this improved to a
median of 19 ± 19.9 mm at 5 weeks and 13 ± 20.1 mm at
12 weeks after the start of treatment.
Patients with tendinopathy localised to the lateral
epicondyle of the humerus reported a median VAS score
of 65 ± 19.9 mm at the initial assessment, which improved
to 29 ± 21.0 mm and 29 ± 31.1 mm at the first and second
follow-up assessments.
 Patients with affected peroneal tendons showed an
improvement in the median VAS score from an initial value
of 65 ± 19.8 mm to 26 ± 31.8 mm at 12 weeks after the
first treatment.
With regard to clinical parameters, complete resolution
of peritendinous fluid accumulation was found in all
patients (100%) at 12 weeks after the start of treatment.
Almost all patients showed complete improvement of
redness (96.9%), warmth (96.9%) and crepitation during
movement (93.8%). Almost 2/3 of the patients (60%)
experienced a reduction in tenderness, while 66% of
patients had less swelling at 12 weeks after the start of
treatment.
The CGI was very well correlated for both the
investigators and the patients. The investigators reported a
clinical global improvement at in 88.6% of patients at one
week, at 5 weeks in 91.4% of patients and at 12 weeks in
93.8% of patients.
The patients reported a clinical global improvement at one
week in 82.9% of cases, at 5 weeks in 88.6% of cases and
at 12 weeks in 87.5% of cases.
One week after the first injection, many patients (45.7%)
reported a significant improvement, and five weeks after
the start of treatment, a large number (40.0%) reported a
slight improvement compared to the initial findings.
At the check-up at 12 weeks after the start of treatment,
the majority of patients reported that their symptoms were
‘much improved’ or ‘very muchimproved’ (31.3% each).
This positive assessment was also reflected in the
evaluation of the patient questionnaire. At all time points,
there was a significant improvement in the restriction of
daily activities (p <0.0001), leisure activities (p <0.0001)
and at work (p <0.0018).
A total of 14 adverse events were reported by 11
(31.4%) patients. None of these events were associated
with the trial product. The peritendinous injections of HA
were well tolerated by all patients.
Discussion
Treatment of chronic tendinopathies often represents
a significant problem for the physician. Injections of
corticosteroids, which are commonly used, have a
particularly limited efficacy in chronic tendinopathies,
and may have significant side effects. For example,
symptoms often recur shortly after treatment with lipid-
soluble corticosteroids [20]. In particular, frequent use of
corticosteroids may be accompanied by peritendinous
crystalline deposits that can make the tendon brittle and
prone to rupture [21]. Regular administration of NSAIDs,
which are commonly used to treat tendinopathy, may have
gastrointestinal side effects among others.
HA is a naturally occurring biological substance, which
is a major component of ligaments, cartilage and synovial
structures [22]. Furthermore, HA is very effective in the
treatment of osteoarthritis, and has few side effects [23].
In the present study, 2 ml of a 2% HA solution were used.
Based on the therapeutic regimen for HA treatment of
osteoarthritis, two injections were performed at an interval
of one week. The injections were administered around the
tendon under ultrasound guidance.
In the evaluation of treatment outcomes, it was found
that treatment of painful chronic tendinopathy with
peritendinous injection of HA significantly reduced pain
symptoms. This is probably due in part to the tightly
interlocked HA macromolecules, which specifically
prevent free passage of inflammatory cells, prostaglandins
and cytokines [15], and partly to the effect of the mannitol,
added to the formulation which traps oxygen free radicals
29
29
[24]. It should also be noted that all patients enrolled in
the trial had suffered from painful tendinopathy for at least
12 months, and their pain improved in a short time with
HA treatment.
Similarly, there was also a significant improvement
in the clinical findings associated with tendinopathy.
In particular, there were significant improvements in
non-structural altera tions, although tissue swelling,
an indication of structural reorganisation of the
tendon, was still present in two thirds of the patients
at the final examination at 12 weeks after the start of
treatment. Despite the swelling of the tendon and/or the
peritendinous tissues, there were no lasting symptoms of
clinical inflammation or irritation. This may be explained by
reduction in friction and peritendinous adhesions due to
the HA injections [10, 11, 12].
With regard to the long-term effects of the HA
treatment, it was found that even at the time of the follow-
up at 12 weeks after the start of treatment, there was still
a lasting effect with clear improvement of the previous
symptoms. This is probably due to the high concentration
of HA that was used and stabilisation of the HA with the
excipient mannitol. The high concentration of HA probably
contributed to the excellent results achieved in the present
study. The favourable outcome of the treatment regimen
was sustained for a relatively long follow-up period,
although it consisted of only two HA injections at an
interval of one week.
Summary and Clinical
Significance
The results of this study indicate that two injections
of a 2% HA solution administered at an interval of one
week represent a very effective therapeutic option for
treatment of chronic tendinopathy. Treatment with
2% hyaluronic acid resulted in a rapid and sustained
reduction in pain as well as a significant improvement
of clinical symptoms. Excellent tolerability and safety
of the product were clearly demonstrated in this study.
None of the adverse events was associated with
the use of the trial product. Further clinical studies
with larger patient groups and a longer period of
assessment should be conducted in the near future to
confirm the present findings.
Conflict of interest. Dr. Lynen acted as a medical expert
for this clinical trial.
Correspondence:
Dr. Nils Lynen
Practice Centre
Nordrhein Orthopaedics and
Traumatology Friedrich-Wilhelm-Platz 5–6
52062 Aachen
n.lynen@exinmo.de
Injectii subacromiale cu hialuronat de sodiu pentru
gestionarea tendinopatiei bazale a coafei de
rotatori: studiu comparativ cu terapia de reabilitare

REZUMAT :

BACKGROUND:
Tendinopatia bazala de coafa de rotatori (CR) este o cauza obisnuita a durerii si a disfunctiei
umarului. Literatura sugereaza ca dovezi, ca o combinatie de utilizare excesiva si compresiune
extrinseca poate induce tendinopatia cronica de CR. Scopul studiului a fost de a compara rezul-
tatele actuale ale preparatelor injectabile subacromial pe baza de hialuronat de sodiu cu terapia
de reabilitare.

MATERIALE SI METODE:
Am inrolat 48 pacienti (M/F : 26/22 ; varsta medie: 50 ani; umarul drept / stang : 29/19), cu dureri
de umar persistente timp de cel putin 4 luni. Criteriile de excludere au fost dupa cum urmeaza:
ruptura de CR, tendinita calcifiata, instabilitate glenohumerala, osteoartrita, boli reumatice, terapie
fizica si / sau injectare in cele 4 luni anterioare, chirurgie de umar, bloc nervos anestezic, trauma-
tisme, boli severe. Subiectii inclusi au primit fie doua injectii sub ghidaj ecografic subacromial de
Acid Hialuronic (AH) (2% pacienti, grupa AH) la momentul initial si la 14 zile, sau au suferit terapie
de reabilitare (23 pacienti, grupul Physio), inclusiv mobilizarea activa a umarului, intinderea de
tesut moale, pozitionare capului humeral si consolidarea muschilor propulsori timp de 30 de zile (3
sesiuni in fiecare saptamana). Evaluarea clinica a functiei umarului a fost realizata cu scorul bazat
pe scala analogica vizuala pentru durere (VAS) (0-100), scorul Oxford pentru umar (OSS), si Scorul
Constant-Murley (CS). In general, pacientii au fost examinati la momentul initial, saptamana 2,
saptamana 4, saptamana 12 si saptamana 24. Semnificatia statistica fost stabilita la 5% (p \ 0,05).

REZULTATE:
Reducerea durerii globale in grupul AH a fost statistic semnificativa in saptamana a-2-a (p \ 0,05)
saptamana 4 (p \ 0,05), saptamana 12 fata de valoarea initiala. In mod similar, subscorurile de
durere (pe timpul noptii si cu activitate) au fost in mod semnificativ mai scazute in saptamana 2 (p
\ 0,05), saptamana 4 (p \ 0,05), si respective in saptamana 12 (p \ 0,05). In grupul Physio, durerea
a scazut in mod semnificativ in saptamana 2 (p \ 0,05), dar nu s-a mentinut la saptamana 4 (p \
0,05), saptamana 12 (p \ 0,05), si saptamana 24 (p \ 0,05). Scorul CS si OSS in grupul HA a crescut
in mod semnificativ in saptamana 2 (p \ 0,05), saptamana 4 (p \ 0,05), si saptamana 12 (p \ 0,05).
O crestere nesemnificativa statistic a scorurilor clinice a fost gasit in saptamana 24 (p \ 0,05). O
imbunatatire semnificativa a CS si OSS s-a inregistrat in grupul Physio in saptamana 2 (p \ 0,05),
dar nu si in saptamanile 4, 12 si 24 (p \ 0,05).

CONCLUZII:
Preparatele injectabile subacromial cu AH ar putea fi o alternativa de tratament eficienta si sigura
pentru pacientii care sufera de tendinopatii de CR. Noi credem ca rezultatele acestui studiu sunt
incurajatoare, dar nu pentru un tratament de durata si am putea presupune ca o serie de trei pana
la patru injectii subacromial cu hialuronat de sodiu ar putea oferi beneficii clinice pe termen la
mediu si lung.

CUVINTE CHEIE:
Umar, injectie, hialuronat de sodiu, rotatori, tendinopatia.

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Musculoskelet Surg (2013) 97 (Suppl 1):S49–S56
DOI 10.1007/s12306-013-0259-y

Ultrasound-guided subacromial injections of sodium hyaluronate

for the management of rotator cuff tendinopathy: a prospective
comparative study with rehabilitation therapy
G. Merolla • P. Bianchi • G. Porcellini

Received: 20 December 2012 / Accepted: 3 March 2013 / Published online: 21 April 2013
© Istituto Ortopedico Rizzoli 2013

Abstract
Background: Rotator cuff (RC) tendinopathy is a common cause of pain and shoulder dysfunction. The literature evidence
suggests that a combination of overuse and extrinsic compression may induce chronic RC tendinopathy. Aim of the current
study was to compare the results of subacromial sodium hyaluronate injections with rehabilitation therapy. Materials and
methods. We enrolled 48 patients (M/F: 26/22; mean age: 50 years; shoulder right/left: 29/19) with persistent shoulder pain for at
least 4 months. Exclusion criteria were as follows: RC tear, calcifying tendinitis, glenohumeral instability, osteoarthritis, rheumatic
diseases, physical therapy and/or injection in the previous 4 months, shoulder surgery, anesthetic nerve block, trauma, and severe
medical diseases. The included subjects received either two ultrasound-guided subacromial hyaluronic acid (HA) injections (25
patients, HA group) at baseline and 14 days, or underwent rehabilitation therapy (23 patients, Physio group) including active
shoulder mobilization, soft tissue stretching and humeral head positioner and propeller muscles strengthening for 30 days (3
sessions every week). Clinical assessment of shoulder function was performed with visual analog scale score for pain (0–100),
Oxford Shoulder Score (OSS), and Constant–Murley Score (CS). Overall, patients were examined at baseline, week 2, week 4, week
12, and week 24. Statistical significance was set at 5 % (p \ 0.05).

Results Reduction in overall pain in the HA group was statistically significant at week 2 (p \ 0.05) week 4 (p \ 0.05), week 12
comparing to baseline. Similarly, pain sub- scores (at night and with activity) were significantly lower at week 2 (p \ 0.05), week 4 (p
\ 0.05), and week 12 (p \ 0.05), respectively. In the Physio group, pain decreased significantly at week 2 (p \ 0.05) but not maintained
at week 4 (p [ 0.05), week 12 (p [ 0.05), and week 24 (p [ 0.05). CS and OSS in the HA group increased significantly at week 2 (p \
0.05), week 4 (p \ 0.05), and week 12 (p \ 0.05). A non-statistically significant increase in clinical scores was found at week 24 (p
[ 0.05). A significant improvement of CS and OSS we found in the Physio group at week 2 (p \ 0.05), but not at weeks 4, 12, and
24 (p [ 0.05).

Conclusions: Subacromial HA injections could be an effective and safe alternative treatment for patients suffering from
RC tendinopathy. We believe that the results of this study are encouraging but not lasting and we might suppose that a
series of three to four subacromial sodium hyaluronate injections could provide good mid and long-term clinical benefits.

Keywords: Shoulder • Injection • Sodium hyaluronate •Rotator cuff • Tendinopathy

G. Merolla (&) • G. Porcellini

Unit of Shoulder and Elbow Surgery, D. Cervesi Hospital,
Via L. V. Beethowen 46, Cattolica, Italy e-mail: giovanni.merolla@auslrn.net; giovannimerolla@hotmail.com

P. Bianchi
Department of Orthopedics, Traumatology, Rehabilitation
and Plastic Surgery, Second University of Naples, Naples, Italy

Introduction
Rotator cuff (RC) tendinopathy is a common source of pain and shoulder dysfunction that affects both the young and older
population [1] mainly in arduous overhead workers [2]. The available research findings emphasize the multi-factorial origin of
RC tendinopathy that begins as a failure in the tendon fibers due to the overuse and cyclic loading on their internal side
[1]. Under these conditions, the subunits of the RC tendons undergo internal compressive forces which induce the development

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of fibrocartilage in these regions [3]; particularly,
fibrocartilage develops on the articular side of the
supraspinatus tendon close to its insertion, where the
articular fibers are subjected to less strain than the non-
articular side [4, 5]. Fibrocartilage is less capable of
withstanding tension load, and joint-side fibers have half
the force of the bursal-side fibers [6]. Furthermore, the
supraspinatus and infraspinatus are inserted into a cable
located 1.5 cm from the humeral insertion of the fibers [7],
and the ‘‘crescent’’ region is located between the cable
and the humerus insertion where the tendon fibers are
thinner and close to the hypovascularized region and
therefore are more susceptible to degeneration [8]. This
evidence suggests that a combination of overuse
and extrinsic compression may induce chronic RC
tendinopathy. Conservative therapies, including
rehabilitation, physical therapies analgesics, and
non-steroid anti-inflammatory drugs (NSAIDs), are
commonly recommended to restore shoulder function
in chronic RC tendinopathy. Physiotherapy is based
on the correction of the flexibility, motion, and strength
that are the cause of painful shoulder [9]. Subacromial
supplementation with sodium hyaluronate or hyaluronic
acid (HA) has been proposed to treat RC dysfunction
[10] due to its action as a lubricant [11] and
suppressor of the joint inflammatory process [12]. To
our knowledge, no studies in the literature have compared
physiotherapy and subacromial HA injection; therefore, the
purpose of the current research was to assess the
efficacy and safety of sodium hyaluronate injection
versus physiotherapy in a population of patients with
painful chronic RC tendinopathy.
Materials and methods
Study population
The study was approved by the Hospital Institutional
review board (Prot. 4232/2011/I.5/186), and all patients
gave informed consent prior to enrollment. This was
a prospective non-randomized comparative study
Table 1
Demographic and anthropometric data of the population enrolled in the study
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involving a study population of 60 patients with RC
tendinopathy aged from 47 to 53 years old, seen in
the outpatient office of our Shoulder and Elbow Unit
between June 2010 and March 2011 (Table 1). Patients
were considered eligible for subacromial therapy if they
were 18 years or older, had persistent shoulder pain for
at least 4 months, clinical diagnosis of RC tendinopathy
detected with MRI, no previous treatment with articular or
subacromial steroid injections within the last 4 months,
availability for the duration of the study. Patients were
excluded if they refused to consent to such a proce-
dure, had a positive history of shoulder trauma,
partial or complete RC tears, calcifying tendinitis,
previous arthroscopic or open shoulder surgery, shoulder
instability, infections or neoplasm, symptomatic cervical
spine disease, rheumatoid arthritis or immune diseases,
gout and uric acid diseases, severe medical conditions,
or were pregnant. Patients were also assessed for
their mental status and excluded if they presented with
cognitive limitations that could prevent them expressing
a valid consent, or undergo subjective and objective
evaluations. We also excluded subjects with known
allergic or adverse reactions to previous nonsteroid or
hyaluronan injections. All evaluations were performed by
two experienced shoulder surgeons. The diagnosis of RC
tendinopathy was performed by trained musculoskeletal
radiologists who depicted a high tendon signal intensity
that was anatomically intact on the MRI in T2-weighted
images. During the screening, 10 patients were excluded
because they refused the treatment or failed to comply
with the inclusion criteria. We allowed a rescue medication
of oral paracetamol at a maximum dosage of 4 g/day,
and the amount taken by each patient was recorded
at the four follow-up visits. Withdrawal of rescue
medication (paracetamol) 24 h prior to each follow- up
visit was recommended by the assessor and confirmed
by the patients during the examination. There were no
statistically significant differences between the two groups
of treatment with respect to demographic characteristics
at baseline (Table 1).
Fig. 1 Anatomical landmark with the two sites of injections drawn
for the anterolateral approach to the subacromial space
Treatment groups
We recruited an intent-to-treat population to be assigned
to two treatment groups with the objective of gaining
an improvement in the pain score of 4 points and in the
Constant–Murley scale of 10 points. According to these
parameters and a power value of 0.8, we had enrolled 50
patients consecutively: the first half in the hyaluronic
acid group ( HA group, N= 25) and the second half in
physiotherapy group (Physio group, N = 25).
Ultrasound-guided injection
The study material was a specific preparation (SportVisTM,
MDT Int’l SA, Switzerland), whose main content is a
STABHATM (Soft Tissue Adapted Biocompatible Hyalu-
ronic Acid) of 1 million of daltons contained in a pre-filled
syringe (12 mg/1.2 ml).
The procedure was performed in a standardized way
in the outpatients’ office with the patient in the upright
position using local disinfection, sterile drape, and marking
the site of injection (Fig. 1). A shoulder surgeon (MG) with
10 years of experience injected all the shoulders using
an ultrasound-guided anterolateral approach and the
same GE Logiq 7 ultrasound machine (7.5–14 MHz).
We first checked the tendon thickness and its superior
limitant. Subsequently, a 22G needle was introduced
beneath the anterolateral acromial edge above the tendon
(Fig. 2), taking care not to overcome the superior limitant.
The preparation was injected allowing it to spread over the
superior tendon surface (Fig. 3).
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33
Fig. 2 The preparation is injected under ultrasound assistance
taking care to direct the needle medially and posteriorly, on the
insertion area of the supraspinatus tendon
Physiotherapy
We set a standard protocol of physiotherapy [9] for 30
days, following three sessions a week. The loss of flexibility
due to the glenohumeral internal rotation deficit (GIRD)
and the coracoid base muscles tightness was treated
using open stretch in the supine position and rotation
stretch exercises with the scapula stabilized. Scapula
control was obtained performing exercises for lower
trapezius and serratus anterior with the arm below
90° abduction. RC activation exercises were allowed after
a stable scapular base was established and included
horizontal and vertical closed-chain exercises,
horizontal open-chain exercises, and diagonal closed-
chain exercises. The final sequence was completed with
open-chain plyometric exercises.
Outcome measurements
Primary outcome measurements were the visual
analog scale (VAS) for pain.
Secondary outcomes measurements were the
Constant–Murley scale (CS) [13] and the Oxford
Shoulder Score OSS) [14, 15], the Patient Global
Assessment (PGA), the tolerability and any adverse
events after each injection. Pain included overall pain,
pain at night, pain with activity, and pain without activity
and was rated subjectively on a scale ranging from 1 (no
pain) to 10 (severe pain). Patients were invited to write their
average pain rate for the previous 48 h. The CS included
a subjective ques- tionnaire for pain, the ability to perform
daily living activity (DLA), an objective evaluation of active
range of motion (ROM) and strength. Pain was scored on a
15-point scale (0 severe pain, 15 no pain), while DLA was
scored on a 20-point scale, with lower scores associated
with greater impairment on DLA. ROM was measured
using a standard goniometer between the upper arm
and the upper part of the thorax. Shoulder strength was
assessed using the Lafayette handheld dynamometer
(Lafayette Instruments, Lafayette, Ind, USA) that has a
microprocessor with a resolution of 0.4 lb (0.2 kg) in the
range 0–50 pounds
(0–22.6 kg), 0.03 % accuracy with two calibration points:
0.25 and 50 lbs (0.11 and 22.6 kg). Data were recorded
and analyzed using SPSS version 10 software (SPSS Inc,
Chicago, IL, USA). We assigned 1 point for each 0.5 kg of
strength registered.
The OSS is a 12-item patient-reported outcome
measure specifically used for assessing the impact of
RC tendin- opathy on the patient’s quality of life. Each
question on the OSS is scored 0–4, with 4 representing
the best; the twelve items are summed to produce overall
scores ranging from 0 to 48. Interpreting the OSS: a score
0–19 indicates a severe shoulder condition, a score 20–29
indicates a moderate to severe shoulder condition, a score
30–39 indicates a mild to moderate shoulder condition, a
score 40–48 may indicate a satisfactory shoulder function.
Follow-up
Overall, patients were assessed immediately before
the treatment (baseline), at the time of the second
injection (week 2), and subsequently at week 4, week
12, and week 24. The value of the subjective pain score
was recorded by each patient using a printed analogic
scale. Data were then entered on an electronic worksheet
(Microsoft Excel for Mac OS 2011) which calculated the
average values for pain overall and relative subscores.
CS and OSS were obtained as the numeric sum of the
subjective and objective evaluations using a dedicated
electronic version of both scales (www.orthopaedicscores.
com) that gave the final score at the end of the
questionnaire. Overall clinical scores were collected by
two independent observers who had not per- formed the
injections.
injection treatment with hyaluronic acid (HA group)
from June to July 2010 completed the follow-up
evaluations (Table 1).
Among the 25 patients who were assigned to the
physiotherapy group (Physio group) from August to
October 2010, two cases were excluded: one case
because he refused to consent to the use of his data
for research pur- poses at the time of the enrollment
and one case due to incomplete evaluation (lost at last
follow-up examination) (Table 1).
Pain score and subscores
In the HA group, we registered a remarkable decrease
in overall pain score from baseline to the week 2 (p \
0.05), week 4 (p \ 005), and week 12 (p \ 0.05), and it
was always statistically significant. The pain reduction
was recorded at week 24, but no statistically significant
dif- ference was found (p [ 0.05) (Table 2). Similarly, pain
subscores (at night and with activity) were significantly
lower compared with baseline values, respectively, at
week 2 (p \ 0.05), week 4 (p \ 0.05), and week 12 (p \ 0.05),
while at week 24, such reduction was maintained but not
statistically significant (p [ 0.05) (Table 3).
In the Physio group at follow-up evaluation, we found
that pain decreased significantly at week 2 (p \ 0.05) while

Statistical analysis
Statistical analysis was performed using the Kruskal–
Wallis test for the equality of populations and the ANOVA
test for the variables, setting the significance at 5 %.
Bravais–Pearson correlation coefficient was calculated to
analyze the variability of the two independent observations.

Results
All the 25 patients with persistent shoulder pain due
to RC tendinopathy considered for subacromial
Fig. 3 Ultrasound image showing the needle (red arow) placed in the
subacromial bursa, on the superior limitant of the supraspinatus ten-
don. The blue arrows emphasize the preparation that expanded above
the tendon surface (color figure online)

34
34
 higher values were registered at week 4 (p [ 0.05), week
12 (p [ 0.05), and week 24 (p [ 0.05) (Table 2). Pain at
night and pain with activity had similar trend with a sig-
nificant decreasing at week 2 (p \ 0.05) and persistent
higher values at week 4 (p [ 0.05), week 12 (p [ 0.05), and
week 24 (p [ 0.05) (Table 3). Constant–Murley Score and
Oxford Shoulder Score The average values of CS and OSS
in the HA group increased significantly comparing to
baseline at week 2 non-statistically significant increase
in clinical scores was found at week 24 (p [ 0.05). In the
Physio group, we significant difference compared with
baseline values (p [ 0.05) (Tables 4, 5).
Comparison between HA and Physio groups
Overall pain and subscores
Overall pain and subscores were stratified to evaluate the
difference in pain scores between the two groups of treat-
ment. There was no statistically significant difference
in overall pain scores between the groups at baseline
and at week 2 (p \ 0.05). We found an average difference
of 2.22 points at week 4 (p = 0.0149) and 2.16 points at
week 12 (p = 0.0168), while the difference at week 24 was
not statistically significant (p \ 0.05) (Table 2). Subscores
for pain at night were significantly different at week 4
(p = 0.0487), and remained at week 12, while the average
difference found at week 24 was not significant (p \ 0.05).
A similar trend was found for pain with activity which
registered a significant difference at week 4(p = 0.0318)
and maintained at week 12 and but not at week
24(p \ 0.05). Rescue medication consumption was found
to be similar at week 2 and 4 in both groups, and higher
from the week 12 to the week 24 in the Physio group.
Clinical scores
(p \ 0.05), and maintained at week 24 follow-up but
without statistical significance (p \ 0.05). The OSS in
the two groups had the same values at baseline, but
significantly higher scorers registered in the HA group
at weeks 4 and 12 (p \ 0.05) and such improvement
difference maintained at week 24 but with no
significant difference (p \ 0.05). Interobserver agreement
resulted in k values ranging from 0.81 to 1.85 for CS and
from 0.80 to 0.88 for OSS; good intraobserver agreement
was registered with k = 0.85–0.90.
Patient global assessment and adverse events
The PGA showed good patient compliance with
no serious adverse events registered during the
experimentation. The anterolateral approach injections,
with US assistance, proved to be safe and well tolerated
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by all the patients enrolled for the study.
Discussion
Sodium hyaluronate is effective in managing acute
or chronic ligaments and tendon injuries, like ankle
sprains and epicondylalgia [16, 17]. HA is believed
to integrate into the extracellular fibrin matrix to
help realignment of fibrils thanks to electrostatic
interactions. Thus, stability of form and function is
then restored allowing healing to occur in structures
(ligaments and tendons) and shortening the rehabilitation
process. Recent research findings demonstrated that
repeated periarticular injections of the study materials
were more effective in pain relief and joint function
improvement, compared to placebo or standard
conservative treatment for ankle sprains and
lateral epicondylalgia. Long-term follow-up by
investigators confirmed the therapeutic effects
persist after 12 and 24 months [16, 17].
Several trials using sodium hyaluronate in the treatment
for chronic shoulder pain have been documented, on
shoulder osteoarthritis [18], RC tears [19], peri-arthritis
[20, 21] adhesive capsulitis [22], and chronic shoulder
pain of different etiologies [23]. The effectiveness of
subacromial injections of HA alone in patients with
chronic RC tendinopathy is also reported in the literature.
In an open label multicenter study, Itokazu et al. [21]
observed a significant pain and range of motion they
conclude that this treatment was effective in patients
with periarthritis of the shoulder. Kim et al. [24],
in a prospective randomized single-blind comparative
study on reduction and similar functional improvement
comparing to corticosteroid at 12 weeks. On the
contrary, respect to our results, Penning et al. [25]
reported a significant reduction in pain at short- and
long-term follow-up with corticosteroid injections
compared with hyaluronic acid and in the long-
term placebo injections showed the best results.
In the current study, physiotherapy was selected for
the comparator because it is proven to be effective in
shoulder tendinopathy management [26] and is recom-
mended by the recent European guidelines (2008).
A standard program of physiotherapy is recommended to
correct inflexibility, loss of strength and mobility in RC,
and associated structures, but it is common that these
conditions persist despite a proper rehabilitation program
which is phased into a maintenance program to reduce
the risk of reinjury [9]. The current study compared directly
the effects of HA injections and physiotherapy, and we
found that both treatments produced good results in pain
and clinical scores in the short term, with a significant pain
decrease at week 2 of 3.3 points in the HA group and 2.8
and clinical scores in the short term, with a significant pain decrease at week 2 of 3.3 points in the HA group and 2.8 points in the
Physio group. In midterm, the pain score maintained a significant improvement at week 4 and week 12 only in the HA group, while
the improvement found in the Physio group was not significant at week 4 and week 12 compared to the baseline. Pain subscores
at night and during activity in the HA group showed a significant reduction from the start of the study throughout follow-up, except
for week 24, while in the Physio group, the reduction in pain subscores was not significant from week 2 to week 24. CS and OSS
showed a course similar to overall pain, with a significant improvement in both treatment groups at week 2, persistent pain relief in
the HA group only at week 4 and week 12, and a return to lower but non-statistically significant scores with respect to baseline, at
week 24 in both groups. The consumption of rescue medication was higher in the Physio group from week 12 to week 24, but at the
end of the study, such difference became not significant. These results suggest that subacromial HA injections are effective in in-
ducing better clinical outcomes and pain relief compared to physiotherapy from the start of the study up to week 12, the therapeutic
effects became less important at 6 months when symptoms gradually returned. Stratifying the results, we found that five patients in
the Physio group had worsening VAS scores at the end of study, whereas this was seen in only two patients in the HA group. The
two patients in the HA group were young in age and have relative high daily activities on the shoulder in life, that is, regular fitness
training and therefore higher risk to develop overuse tendinopathy and subacromial bursitis. The procedure for shoulder injection
was safe without any adverse events registered in all the enrolled subjects.
We used the same anterolateral approach with ultra-sound assistance, to allow the injection on the superior limitant of the
supraspinatus tendon as accurate as possible [27]. Using this approach, we ensured that the HA preparation was injected on the
thinner crescent supraspinatus fibers, [7] located within the hypovascular region (critical zone) [8] and more at risk of degeneration
and tearing.
Our research findings confirmed the good early and midterm results of HA in RC tendinopathy and are consistent with the
outcomes of Itokazu et al. [23] and with those reported by Kim et al. [24] who described a good VAS and ASES scores in patients
treated with HA injections by using corticosteroids as a comparator.
The choice of two injections 2 week apart could explain the lower clinical scores observed at 6 months, and it might be reason-
able to expect that the long-term results may be more favorable if the number of injections was increased using protocols similar
to those already tested by other authors [24, 27]. The lack of randomization and placebo control, the limited sample size represent
the limitations of this research. Taking into account these limitations, we still have to note that the combination of physiotherapy
with subacromial injections showed the better results as suggested by the available literature evidence [28]. Physiotherapy can be
regarded as part of the conservative treatment to be undertaken in subjects with chronic RC tendinopathy, but this treatment alone
is not able to reduce pain and restore shoulder function in long term. A recent Cochrane review [29] concluded that subacromial
corticosteroid injection has insufficient overall evidence to support its usage. It might be beneficial for RC disease and intra-articular
injection for adhesive capsulitis, but their effect is small and not well maintained. We believe that a series of three to four subac-
romial sodium hyaluronate injections could provide good mid and long-term clinical benefits.

Conclusions

Despite the limitations of the current research, such as no randomization and relatively small sample size, we may conclude
that subacromial HA injections could be an effective and safe alternative treatment for patients suffering from RC
tendinopathy. Our results are encouraging but not lasting, and we might suppose that further investigation with a larger sample
size into the optimal injection regime and possible combination with current standard therapies, so as to provide long-term benefits,
are warranted.

Conflict of interest None.

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Efectul injectarii subacromiale de Acid
Hialuronic in boala coafei de rotatori.
Studiu clinic dublu-orb controlat placebo
Alireza Moghtaderi, Sepideh Sajadiyeh, Saeid Khosrawi, Farnaz dehghan, Vahid Bateni

Departamentul de reabilitare si medicina fizica,Universitatea de medicina si radiologie

REZUMAT

BACKGROUND:
Afectiunile coafei de rotatori sunt o cauza obisnuita a durerii de umar. Exista deja studii
despre eficacitatea hialuronatului de sodiu injectabil in durerile de umar si de genunchi,
dar putine studii care sa demonstreze eficacitatea hialuronatului de sodiu injectat sub
ghidaj ecografic in afectiunile coafei de rotatori. Acest studiu evalueaza eficacitatea
ultrasonografiei ghidate a injectarii subacromiale cu hialuronat de sodiu, la pacientii cu
sindrom de impingment fara ruptura completa de coafa de rotatori.

MATERIALE SI METODE:
Acest studiu clinica prospectiv, dublu-orb, controlat placebo a fost efectuat pe 40 de
pacienti cu sindrom subacromial de impingement fara rupere completa a coafei de
rotatori. Pacientii au fost injectati aleator sub ghidaj ecografic in 2 grupuri: grupul studiu
de caz cu hialuronat de sodiu 20 mg (Fermathron™) si grupul control cu solutie salina
0,9%. Ambele grupuri au primit 3 injectii saptamanale. Scorul de durere (scorul visual
analog de durere - VAS) 100 mm a fost evaluat inainte de prima injectie si dupa o
saptamana dupa fiecare injectie. Scorul Constant a fost evaluat dupa prima si a 12-a
saptamana dupa ultima injectie. Datele au fost analizate statistic de testul t-independent.

REZULTATE:
In ambele grupuri scorul mediu VAS a scazut, dar mai semnificativ in grupul de studiu
(p<0.001). Scorul mediu Constant a fost semnificativ mai mare in grupul de studio la 12
saptamani dupa ultima injectie (p<0.001). Scorul Constant s-a imbunatatit 12 saptamani
dupa ultima injectie in ambele grupuri, cu un rezultat semnificativ mai bun in grupul de
studiu (p<0.001).

CONCLUZIA:
Injectiile subacromiale cu hialuronat de sodiu sunt eficiente in tratamentul afectiunii
coafei de rotatori fara ruptura completa.

CUVINTE CHEIE:
Scorul constant, afectiunea coafei rotatorilor, hialuronat de sodiu, injectii subacromiale,
ghidaj ultrasonografic.

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37
Effect of subacromial sodium hyaluronate injection
on rotator cuff disease : A double-blind placebo-
controlled clinical trial
Alireza Moghtaderi, Sepideh Sajadiyeh, Saeid Khosrawi, Farnaz Dehghan, Vahid
Bateni1

Departments of Physical Medicine and Rehabilitation,1Radiology, Medical University of Isfahan, Isfahan, Iran

Abstract

Background
Rotator cuff disease is a common cause of shoulder pain. There are studies about the effectiveness of sodium hyaluronate injection
on shoulder and knee pain, but few studies demonstrating the efficacy of sodium hyaluronate ultrasonography guided injection
for rotator cuff disease. This study evaluates effectiveness of ultrasonography guided subacromial sodium hyaluronate injection in
patients with impingment syndrome without rotator cuff complete tear.

Materials and Methods

This prospective, double-blind, placebo controlled clinical trial study was performed among 40 patients with subacromial
impingement syndrome without complete tear of rotator cuff. Patients randomly injected ultrasonography guided in 2 groups: Case
group by 20 mg of sodium hyaluronate (Fermathron™) and control group by 0.9% normal saline. Both groups received 3 weekly
injections. The pain score (100 mm visual analogue score [VAS]) was evaluated before first injection and one week after each
injection. The constant score was evaluated before first and 12 week after last injection.
Data was analyzed statistically by Independent t-test.

Results
In both groups mean VAS has decreased, but more significantly in case group (P < 0.001). Mean constant score was significantly
higher in case group 12 weeks after last injection (P < 0.001). The constant score improved 12 weeks after the last injection in both
groups with a significantly better result in case group (P < 0.001).

Conclusion
Subacromial injections of sodium hyaluronate are effective in treating rotator cuff disease without complete tears.

Key Words
Constant score, rotator cuff disease, sodium hyaluronate, subacromial injections, ultrasonography guided

Address for correspondence:

Prof. Saeid Khoshrawi, Departments of Physical Medicine and Rehabilitation,1Radiology, Medical University of Isfahan, Shohadaye
Sofe, Isfahan, Iran
E-mail: khosrawi@med.mui.ac.ir
Received: 05.08.2012, Accepted: 09.02.2013

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Introduction
Shoulder pain accounts for approximately 3 million visits
to physicians each year in the United States, and of these,
rotator cuff disease is the most common cause of shoulder
pain necessitating a visit to a primary care physician.[1]
Rotator cuff disease in particular is a common cause of
shoulder pain and weakness and comprises a significant
proportion of the musculoskeletal complaints presenting
to primary care doctors.[2] Treatments for rotator
cuff lesions without complete tears are mainly
conservative[3] and surgery should be considered
if the patient fails to improve with a progressive
non-operative therapy program of 3-6 months.[4]
Subacromial injection of anesthetics or corticosteroids is
often used to treat patients with persistent symptoms after
rehabilitation and use of non-steroidal anti-inflammatory
drugs.[5] In patients who have failed conservative
treatment, there is evidence that viscosupplementation
is beneficial for the treatment of knee pain caused by
osteoarthritis.[6] In a study, evaluating rehabilitative and
infiltrative treatment with hyaluronic acid in elderly patients
with rotator cuff tears found statistically significant results,
both for the reduction of pain and for the improvement of
range of motion and autonomy in daily life activities.[7]
In one large placebo-controlled, randomized trial of 660
patients with moderate to severe shoulder pain caused
by osteoarthritis, rotator cuff tear, or adhesive capsulitis,
a significant improvement in pain relief was found in all
groups up to 13 weeks after viscosupplementation.[6]
Another study demonstrated that sodium hyaluronate
injection is effective for the treatment of osteoarthritis
and persistent shoulder pain that is refractory to other
conservative measurements.[8] Thirty patients with
symptomatic osteoarthritis of the shoulder who failed
conservative treatment and were treated with intraarticular
viscosupplementation demonstrated improvement in
function and pain levels.[9] Treatment with sodium
hyaluronate is emerging as an alternative intraarticular
regimen for osteoarthritic knee joints.[10,11] Clinical
studies have reported the efficacy of hyaluronate injection
in treating shoulder pain.[12-14] In a randomized study,
sodium hyaluronate was found to be effective for patients
with rotator cuff tears.[15]
Ultrasound is a readily available and cheap modality
for looking more specifically at the rotator cuff and
surrounding structures.[1] More recently, ultrasound
guidance has become a commonly employed method to
perform diagnostic or therapeutic interventions.[16]
Despite the long history and the fact that this is a
common diagnosis made in clinical practice, the exact
cause and best treatment for rotator cuff disease still are
being explored. Although, there are very few high-quality
studies demonstrating the efficacy of sodium hyaluronate
injection for rotator cuff disease, this study was performed
to examine the effect of ultrasound-guided subacromial
sodium hyaluronate injection in patients with impingement
syndrome without rotator cuff complete tear.
MATERIALS AND METHODS
This was a prospective, randomized, double-blind,
placebo controlled clinical trial involved 48 patients
with subacromial impingement syndrome without
a complete tear of rotator cuff. Eight patients were
excluded because of protocol violation. The reasons were
violation of the selection criteria and refused injection.
39
39
We included patients between 30 and 80 years old who
had shoulder pain, a positive Neer and Hawkins sign,
and a positive ultrasonographic diagnosis of rotator
cuff pathology without a complete tear, who did not
respond to conservative treatments or rehabilitation
for at least 6 months and signed the informed consent
form. We excluded patients who (1) had any rheumatic
disease, glenohumeral osteoarthritis, full-thickness
rotator cuff tears, fractures, diabetes mellitus, infections,
or tumors, (2) had hypersensitivity to hyaluronate, (3)
had participated in any other study within 6 months, (4)
had received a subacromial injection within 8 weeks, (5)
were pregnant or planned to become pregnant, (6) were
at risk of complications of intra-articular injections such
as patients who received anti-coagulant drugs. Forty
patients randomly allocated in 2 groups: Hyaluronate
injection (case group) and normal saline injection (placebo
group). According to demographic data gender and
age, there were no significant differences between two
groups. The test drug was Fermathron™, 20 mg/2 ml of
sodium hyaluronate. The placebo was 0.9% normal saline
solution, at 2 mL/syringe. Both groups received 3 weekly
injections in a same protocol.
All patients screened for complete tear of rotator cuff
with ultrasonography and all injections were performed
under ultrasonography guidance. Ultrasonography
with a high-frequency (7-15 MHz) linear-array probe
was performed by one radiologist with a SIEMENS G60
(SIEMENS G 60s, MODEL: 7474922 made in Japan march
2006) device.
Sonographer stood behind the patient, scanning over
its shoulder. The long head of biceps tendon was
examined within the intertubercular groove, in both the
transverse and longitudinal planes, with the patient’s
arm in a neutral position and the elbow flexed to 90°.
The presence of fluid around the tendon was noted, and a
search for fluid in the subdeltoid bursa was made. With the
shoulder externally rotated, the subscapularis tendon was
brought into view and examined in both planes. Then, the
patient was asked to rotate the shoulder internally. This
movement was achieved either by placing the forearm
behind the back with the palm facing posteriorly or by
placing the palm on the upper buttock. The supraspinatus
and infraspinatus tendons were evaluated in this position
in both the transverse and longitudinal planes.
The examination was completed by requesting the patient
to place a hand on the contralateral shoulder. This position
allowed further assessment of the infraspinatus tendon
if required. With ultrasound, the normal tendon was an
echoic structure, whereas the cartilage and fluids were
hypoechoic. Tendinitis was diagnosed when the tendon
lost its echogenicity and became diffusely hypoechoic.
[17-19] Dynamic evaluation of abduction was performed
by observing the supraspinatus tendon and bursa
longitudinally as they retract deep to the coracoacromial
ligament. Bunching of tissue or buckling of the ligament
correlated with impingement.
If ultrasonographic evidence of full-thickness
supraspinatus tendon tear was seen, patient excluded
fromourstudy. These features included non-visualization
of the distal supraspinatus tendon and dipping of the
deltoid muscle or abnormal anechoic disruption of the
supraspinatus tendon, which extended from the articular
to the bursa surface. The diagnosis of a partial rotator cuff
tear was made when the hypoechoic or bursal herniation
did not cross the full width of the tendon.[17-19]
Ultrasound guided injection was done from a lateral
approach. We used 21 gage needle for injection of 2cc
FermathronTM.
As long as the needle was kept in the same axial plane
as the probe, it followed accurately until reached the
superficial surface of the supraspinatus tendon. A
preliminary injection in this location confirmed the correct
positioning in the bursa as evident by rapid flow of injected
material away from the needle tip. After insurance firm
placement within the bursa, injection was completed.
The pain score (100 mm visual analog score [VAS]) was
evaluated blindly by the different physiatrists before
the first injection and 1 week after each injection. The
constant score[20] of shoulder also was evaluated blindly
before the first injection and 12 week after last injection. A
constant score of 80 points or more or an improvement in
the constant score by 10 points or more was considered
satisfactory.
Statistical analyses were performed using the SPSS
statistical package version 13.0 (SPSS Inc., Chicago, IL,
USA). Independent sample t-test or Mann-Whitney U-test,
paired t-test or Repeated Measure ANOVA test, and Chi-
square test were used to assess the differences between
stages, as appropriate. A P < 0.05 was considered
significant.
Results
In this study, there were 20 patients in each group, in
case group there were 8 male (40%) and 12 females (60%)
and the placebo group contained 6 males (30%) and 14
females (70%). Chi-square test showed that they did not
differ significantly in gender.
Using Independent t-test, revealed that mean VAS
scores did not differ significantly before treatment (P
= 0.617) but 1 week after the first, second and third
injection (W1, W2 and W3) mean VAS was significantly
40
40
lower in case group (P < 0.05). In both groups mean
VAS has decreased every week during the treatment
but this decrement significantly was more in case
group (P < 0.001) [Table 1].
Although, it showed that there were no significant
differences between 2 groups in mean constant score
before treatment (P = 0.4) but mean constant score was
significantly higher in case group 12 weeks after the
last injection (P < 0.001). The constant score improved
at the 12 weeks after the last injection in both groups,
although the independent t-test revealed significantly
better results in case group (P < 0.001) [Table 2].
No complications such as flare reaction, infection,
hemarthrosis and synovitis were reported by the
patients in either group. Of the patients in the placebo
group 15 had additional sodium hyaluronate injections and
6 were unavailable for follow-up. The remaining patients
were satisfied with their results so hadn’t any additional
procedures.
Of the patients in the case group, 2 had additional
injections 6 months after the last injection, 8 were lost to
follow-up and the remaining satisfied with their results.
Discussions
The literature on the efficacy of intraarticular
viscosupplementation is primarily focused on the knee,
with limited studies of other joints. Although, the literature
covering visco supplementation for knee osteoarthritis has
been conflicting and has a known publication bias,[21,22]
meta-analyses suggest an improvement in pain compared
with placebo.[22] In patients who have failed conservative
treatment, there is evidence that visco supplementation
is beneficial for the treatment of knee pain caused by
osteoarthritis.[21,22]
The clinical effects of sodium hyaluronate on pain associated with osteoarthritis of the knee are probably mediated by several
factors. In vitro and in vivo studies indicate that sodium hyaluronate can enhance prostaglandin synthesis and prevent
its release from the cell matrix. Regarding inflammation, sodium hyaluronate suppresses the production and activity of
pro-inflammatory mediators and proteases as well as altering the function of certain immune cells. Histological evidence
shows that sodium hyaluronate prevents the degradation of cartilage and may promote its regeneration.[23]

Chou et al. performed a randomized, double-blind, placebo-controlled study of sodium hyaluronate (ARTZ Dispo) treatment in
51 patients with rotator cuff lesions without complete tears. They had injections of 25 mg/wk. of sodium hyaluronate into the
subacromial bursa for 5 consecutive weeks in case group and 2.5 ml of normal saline with the same injection protocol for control
group.[24] We performed the study with patients and all the injections were performed ultrasound guided. Additionally, instead of
5 injections, we treated our patients with 3 injections of sodium hyaluronate. The results were the same.

A recent study assessed the hypothesis that injection of high-molecular weight hyaluronate in the treatment of subacromial
impingement syndrome is effective and sodium hyaluronate, compared with corticosteroid injection in the shoulder joint.
They found that subacromial hyaluronate injection to treat impingement syndrome produces similar pain and functional
improvement to corticosteroid at a short-term follow-up.[25]

The probable mechanism of action of sodium hyaluronate is an autocrine stimulation of its own synthesis in a positive
feedback manner in synoviocytes that has been shown in vitro.[26,27]

In our study, the case group had significantly better constant scores than the placebo group at the 12th week after the last
injection and improvement of VAS scores each week after the injections. It shows that although the injection of normal saline
solution into the subacromial bursa may relieve the symptoms of impingement syndrome but the results are not constant.
Furthermore, we know that signs and symptoms of rotator cuff disease may relieve gradually if extrinsic and intrinsic factors are
stabilized by resting or modification of activity.[28] It may be the cause of some degree of improvement after placebo injection.
Another theory is removing inflammatory mediators by normal saline. Sodium hyaluronate may have inhibitory effect on
the function of inflammatory cells and it may account for the deactivation of pain receptors.

In summary, Sodium hyaluronate may contribute to healing and pain reduction in rotator cuff disease. Further studies are
required to find the exact mechanisms of action of this drug.

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44
M
Meta-analize

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45
Acidul Hialuronic si leziunile de tendon

Jean-François Kaux1,2,3
Antoine Samson1, 2
Jean-Michel Crielaard1,2,3
1 Department of Physical Medicine and Sports Traumatology,
CHU Liege, Belgium
2 Multidisciplinary Department for Medicine and Sports
Traumatology (SPORTS), CHU Liege, Belgium
3 Department of Sports and Rehabilitation Sciences,
University of Liege, Belgium

Autor correspondent:
Jean-Francois Kaux
Department of Physical Medicine and Sports Traumatology,
CHU and University of Liege
Avenue de l’Hopital, B35
4000 Liege, Belgium
E-mail: jfkaux@chu.ulg.ac.be

REZUMAT

BACKGROUND:
Introducere: recent, proprietatile vascoelastice ale acidului hialuronic pe tesutul
conjunctiv lichid au fost propuse ca tratament in tendinopatii. Cateva studii fundamentale
arata rezultate incurajatoare in ceea ce priveste abilitatea acidului hialuronic de a
contribui la alunecarea tendonului si de a reduce aderentele, ca si la imbunatatirea
organizarii arhitecturale a tendonului. Unele observatii sustin deasemenea folosirea lui
clinic pentru a imbunatati durerea si functia. Aceasta revizuire a literaturii analizeaza
studii legate de folosirea Acidului Hialuronic in tratamentul tendinopatiilor.

METODE:
Aceasta revizuire a fost construita folosind baza de date Medline prin Pubmed, Scopus
si Google Scholar. Cuvintele cheie folosite in cercetare au fost: Acid Hialuronic, tendon
si tendinopatie.

REZULTATE:
In total au fost selectate pentru relevanta si calitate stiintifica 28 de articole (in engleza
si Franceza) legate de aplicarea Acidului Hialuronic pe tendoane, incluzand 13 pentru
partea de in vitro, 7 pentru in vivo pe animale si 8 pentru sectiunea umana.

CONCLUZIA:
Studiile preclinice demonstreaza rezultate incurajatoare: Acidul Hialuronic permite
alunecarea tendoanelor, reduce aderentele, creaza o mai buna oraganizarea arhitecturala
a tendonului si limiteaza inflamatia. Aceste observatii de laborator par sa fie sustinute
de rezultatele clinice limitate, dar incurajatoare pe termen scurt asupra durerii si
functionalitatii. Cu toate acestea, sunt inca necesare studii randomizate controlate.
46
46
Hyaluronic acid and tendon lesions
Jean-François Kaux1,2,3
Antoine Samson1, 2
Jean-Michel Crielaard1,2,3
1 Department of Physical Medicine and Sports Traumatology,
CHU Liege, Belgium
2 Multidisciplinary Department for Medicine and Sports
Traumatology (SPORTS), CHU Liege, Belgium
3 Department of Sports and Rehabilitation Sciences,
University of Liege, Belgium

Autor correspondent:
Jean-Francois Kaux
Department of Physical Medicine and Sports Traumatology,
CHU and University of Liege
Avenue de l’Hopital, B35
4000 Liege, Belgium
E-mail: jfkaux@chu.ulg.ac.be

Summary
Introduction: recently, the viscoelastic properties of hyaluronic acid (HA) on liquid connective tissue have been proposed for the
treatment of tendinopathies. Some fundamental studies show encouraging results on hyaluronic acid’s ability to promote tendon
gliding and reduce adhesion as well as to improve tendon architectural organ- isation. Some observations also support its use in
a clinical setting to improve pain and function. This literature review analyses studies relating to the use of hyaluronic acid in the
treatment of tendinopathies.
Methods: this review was constructed using the Medline database via Pubmed, Scopus and Google Scholar. The key words
hyaluronic acid, tendon and tendinopathy were used for the research.
Results: in total, 28 articles (in English and French) on the application of hyaluronic acid to tendons were selected for their relevance
and scientific quality, including 13 for the in vitro part, 7 for the in vivo animal part and 8 for the human section.
Conclusions: preclinical studies demonstrate encouraging results: HA permits tendon gliding, reduces adhesions, creates better
tendon architectural organisation and limits inflammation. These laboratory observations appear to be supported by limited but
encouraging short-term clinical results on pain and function. However, controlled randomised studies are still needed.

KEY WORDS: hyaluronic acid, tendinopathy, tendon, healing, cicatrization.

Introduction
Tendon lesions are very common in sportsmen and physical workers1. Their physiopathology is multifactorial, including
intrinsic and extrinsic factors, which can be modified or not2. Even if detrained tendons present the same histological structure
as chronic tendinopathies, however, this condition remains an overuse pathology which is often difficult to treat2. For this reason,
various new treatment have been developed1 such as platelet-rich plasma (PRP)3 or growth factors4 infiltrations.
Recently, the anti-inflammatory and lubrication properties of HA have also been suggested for the treatment of these
pathologies5.
Hyaluronic acid (HA) is a polysaccharide with a high molecular weight (between 100 kDa and 10 MDa), mainly found in the
extracellular matrix where it plays different roles at various places in the organism5. Its half-life is only three to five minutes in
the circulation, less than a day in tissue, and between one and three weeks in cartilage. This speed of renewal means that this
polymer is constantly synthesised and degrad- ed5. HA can be categorised into three groups based on molecular weight:
- low molecular weight: MW < 1MDa;
- medium molecular weight: 1MDa < MW < 2MDa;
- high molecular weight: MW > 2MDa.
HA ensures the viscoelasticity of liquid connective tissues such as the synovial joint and the corpus vitreum of the
eye5. As a result of this ability, its role in the body is, among other things, to bind to water and to lubricate mobile parts of
the body such as the joints and muscles5. Intra-articular injections of synthetic HA are widely used in the medical treatment of
osteoarthritis6-8.
Industrially, HA is obtained through two different procedures:
- extraction from rooster combs, after grinding and chemical treatment5;
- purification and bacterial fermentation5.
The viscosity of the gel which is obtained is proportional to the length (molecular weight, expressed in Daltons) of the polymer fibres.
This viscosity will determine how quickly the product degrades after implantation.
One major absolute contraindication is hypersensitivity to one of the ingredients. Potential undesirable side-effects are pain, a
feeling of heat, haematoma, redness and swelling.

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47
Material and methods

This literature review was constructed using the Med-line database via Pubmed, Scopus and Google Scholar, according to the
recommendations of the Journal9. Articles published in English and French, up to the 30th of September 2015, were found
using the following key words alone or in combination: hyaluronic acid, hyaluronan, tendon, tendinopathy, treatment (in English)
and acide hyaluronique, tendon, tendinopathie, traitement (in French). In total, only 28 articles on HA as applied to tendons were
selected for their relevance and scientific quality: 13 for the in vitro part, 7 for the animal in vivo part and 8 for the human section.

Results

In vitro experiments

Even if the first published paper studying the effect of HA on tendons of rabbits has not shown any effect on the functional strength
of tendons after healing in vitro10, several Authors have sought to identify the ability of HA to improve tendon gliding. Sun et al.
used 30 canine peroneus longus, randomised into five groups, and immersed for 30 seconds in one of the following five
solutions: saline solution, gelatin, carbodiimide and HA (cd-HA) and gelatin (cd-gelatin) and cd-gelatin HA11. The tendons
were first placed in an incubator at 100% humidity at 37°C, before being wrapped in damp cloths for one hour. Gliding resistance
for each tendon was measured before the surfaces of the tendons were coated in the various solutions. After 500 cycles, gliding
resistance for the tendons coated in saline solution increased significantly, by a factor of 10, while the cd-gelatin and cd-
gelatin-HA did not significantly change. In addition, under microscopy, the surface of the tendons in the saline, gelatin and
cd-HA solutions were rough, presenting a network of disorganised fibres. In contrast, the surface of the tendons immersed
in the gelatin-cd-HA solution appeared smoother than in the other groups. These observations were confirmed by the study
of Nishida et al., which suggest that HA may improve the gliding function of canine flexor tendons12.
Taguchi et al. wanted to identify whether these results could be transposed to human tendons13. They used 16 human
extrasynovial palmaris longus tendons which were divided into two and then immersed randomly in one of the following four
solutions: saline solution, carbodiimide-gelatin-HA (cg-gelatin-HA), carbodiimide-gelatin-lubrucin and cd-gelatin-HA-lubrucin. The
results, after 1,000 flexion/extension cycles, show that the tendons treated with saline solution presented significantly higher
gliding resistance than other groups. These findings, suggesting that HA may limit tendon adhesions, has already been
observed in a previous study of Akasaka et al14.
In addition to its effects on tendon biomechanics, the researchers looked at the influence of HA on tendon
regeneration.
Yamada et al. sought to determine the influence of HA on cell proliferation and mRNA expression of type I and type III
procollagens15. They used tendons from 10 subjects suffering from rotator cuff disease who had undergone surgical repair to the
cuff. For each fragment, the tendon tissue was separated from the synovial tissue, cut into small pieces and cultured in solutions
containing various concentrations of HA (1.0 to 5.0 mg/mL). The results showed HA binding to its receptors and a reduction
in cell proliferation in a dose-dependent manner in comparison with untreated cells. In addition, the expression level of
procollagen α1 (I) mRNA did not significantly reduce in contrast to the expression of procollagen α1 (III) mRNA in a dose-dependent
manner.
Another study by Shimpuku et al. analysed the suture site of the supracoracoid tendon in chickens after injection of HA16.
As well as confirming that HA treatment does not increase the production of α1 (I) procollagen, the team was able to
show early restoration of tendon continuity at the laceration site in comparison with the control group treated with saline
solution. Wiig et al. had compared the effect of HA on cell proliferation and synthesis of matrix component in intrasynovial deep
extensor tendons and extrasynovial peroneus tendons of rabbits17. They observed that HA modulates cell proliferation unequally
in intra and extrasynovial tendons, but without affecting the matrix component synthesis. This can be partly explained by
a difference in biochemical composition and cellular capacities of tendons and by a possible difference in HA sensitivity
and in its mechanism of action.
Osti et al. had compared 4 different HA preparation by their molecular weight on human tendon derived cells from rotator cuff
tears18. They observed that all the HA increased the cell viability and the proliferation at 24 hours compared to control
cells (without HA). Furthermore, the synthesis of collagen type I was stimulated over 14 days, without increase in collagen type III.
However, these observations were significantly higher in the high molecular weight HA groups.
Neumann et al. looked at the effects of HA on proinflammatory action caused by advanced glycation endproducts (AGEs)19. The
team compared the efficacy of a preparation of HA with a ‘high’ molecular weight (HMW-HA - >1.2MDa) to a preparation of HA with
a low molecular weight (LLW-HA - 0.2-0.5MDa) on the production of AGEs and activation of proinflammatory cytokines on murine
macrophages. Their results show that HMW-HA, with a molecular weight greater than 1.2 MDa, inhibits the inflammation
sig- nalling pathway (NF-kB) caused by AGEs and that this effect reduces with the molecular weight of HA. Moreover, the
results show that low molecular weight HA (<0.5MDa) is proinflammatory.
Tanimoto et al. studied the effect of proinflammatory cytokines on HA-synthetase (HAS) mRNA expression using rabbit synovial
membrane cells, cultured in inflammatory conditions IL1-β and TNF-α were used20. Their results showed that proinflammatory
cytokines increase HAS mRNA expression and, consequently, may contribute to the accumulation and fragmentation of
HA. Low molecular weight HA molecules no longer played their lubricating role in an optimal way. A study by Smith et al. highlighted
the effect of adding exongenous HA to endogenous HA synthesis in synovial fibroblasts21. Human synovial fibroblasts obtained
dur- ing biopsies or arthroplasties were cultured. Different molecular weights of HA were then added.
The results clearly showed that in vitro HA synthesis by these cells increased when the concentration and molecular weight
of the added HA was increased. The recent study of Nakamura et al., comparing the effects of corticosteroids or HA used in
subacromial injection on cell proliferation, in human tendon fibroblasts from rotator cuff tears and in rats after surgical lesion,
demonstrated that HA possesses anti-inflammatory and anti-adhesive activities in tendon and synovial fibroblasts. In
contrast to CS, HA caused no adverse effects and appears to be relatively safe22.

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Animal experiments

Zhao et al. wanted to identify the effect of HA on the reduction of adhesions and on functional improvement after failed tendon
reconstruction23. To simulate this situation, 28 flexor tendons from the 2nd and 5th digits of dogs were lacerated and repaired. One
graft tendon in each dog was treated with an injection of saline solution, and the other with an injection of HA (1%) combined with
lubricin (cd-HA-lubricin). Six weeks after the surgical operation, the allografts treated with cd-HA-lubricin showed decreased
adhesions at the proximal extremity, improved digit function and increased graft gliding ability. However, rupture resistance
at the proximal and distal repair sites was lower in the treated group than in the control group. Moreover, histological analysis
showed delayed healing in the treated group. A study by Oryan et al. aimed to assess the effects of high molecular weight (1.6MDa)
HA (0.9%) on the healing of flexor tendons in the digits of rabbits after lesion and repair through surgical suture24. Injections
were administered to 40 rabbits, randomly divided into two equal groups of injured treated with HA and injured untreated. The
results showed a significant reduction in the diameter of the treated tendons and an increase in echogenicity. In addition,
the dry weight of the injured tendons had significantly increased in comparison with the non-treated tendons. The treatment also
significantly improved tenoblast numbers and the diameter and density of collagen fibrils. Yoshida et al. also demonstrated
that high molecular weight HA (2700 kDa) was effective for pain relief and for partial restoration of the patellar tendinopathy
in a rat model, compared to saline or nothing (control group)25.
The Liang et al. team wanted to show the effect of the presence of tenocytes when injecting HA into the Achilles tendons of rats
at an early healing stage26. After transection and suture of the Achilles tendon, 96 rats were randomised into three groups: one
group (THA) received an injection of 1.0 kDa HA (1.5%) with tenocytes (5x105), one HA group received the same injection without
tenocytes, and a control group received a saline solution injection.
A significant difference in recovery, tendon stiffness and locomotive ability was observed in the THA group. The THA group
also had a shorter healing time, ending the inflammatory phase and starting the proliferation phase from day 7, while
the non-treated and HA groups were still in the inflammatory phase of the healing process on day 7. Acceleration of the
inflammatory process through injection of THA may be the main reason for this functional improvement. In addition, the few
differences measured between the tendons treated with HA and the tendons injected with saline solution may be explained
by the low molecular weight (1.0 kDa) of HA used. This study shows that adding tenocytes to HA injections may positively
influence tendon repair by reducing inflammatory response time. However, the use of low molecular weight HA in this study
makes comparisons with THA difficult. Moreover, the use of THA appears to be more appropriate for surgical interventions
on tendons than in tendinopathies, given the constraints of removing tenocytes.
The recent series of Salamanna et al. comparing the mechanobiology of patellar tendons of rats randomized into 3 groups
(untrained, trained and detrained), demonstrate that discontinuing training activity in the short term alters tenocyte synthetic
and metabolic activity and that repeated peri-patellar infiltrations of HA during detraining allow the maintenance of
tenocyte anabolic activity27: higher proliferation rate and viability, and increased synthesis of C-terminal-propeptide of type I
collagen, fibronectin, aggrecan, tenascin-c and matrix-metalloproteinase-3. These results are reinforced by those of Frizziero et al.,
comparing the same groups, who demonstrated that HA is effective in the maintenance of the structural properties of patellar
tendon and enthesis in detrained rats28.
Contrary of the in vitro observation, Yamaguchi et al. suggested that both hyaluronic acid and steroid injections suppressed of
inflammation (evaluated by the expression of calcitonin generelated peptide - CGRP) in a rotator cuff of rats, which thought to
be provided pain relief (analyzed by the gait analysis)29. While there were no significant differences, the suppression of CGRP
expression and the improved gait after hyaluronic acid and steroid injections suggested that both methods were effective for rat
rotator cuff tear model.

Human experiments
Meloni et al. examined the effect of periarticular injection of HA in patients suffering from a supraspinatus tendinopathy30.
A total of 56 patients participated in the study and were randomised into two equal groups: one group treated with an injection
containing 20 mg of HA (concentration: 20mg/2ml, molecular weight: 0.5-0.7 mDa) in 2 ml of lidocaine (1%) and 2 ml of physiological
liquid (0.9%) and a control group receiving an injection of 4 ml of physiological solution (0.9%). Lidocaine is used to reduce pain
due to the injection. After the first injection, the injection was repeated once a week for four weeks. During this period, analgesics
were prescribed for three days after each injection. After one year, 19 of the 28 patients who had received HA were satisfied
with their treatment, while all patients in the control group said they were dissatisfied after their injections. Joint extension
remained identical throughout the follow-up. At months 1 and 3 following the injection, a significant improvement in pain in
the treated group in comparison with the control group was noted. However, after one year, this pain had increased in the
treated group. Moreover, no significant difference in tendon structure was observed during the ultrasound scan between
the two groups either at the start or at the end of the follow-up.
Petrella et al. treated 330 competitive racquet sports athletes presenting with chronic lateral epicondylosis for more than three
months31. Two injections were administered one week apart, into the subcutaneous tissue and muscle one centimeter from the
lateral epi- condyle toward the primary point of pain using a two-dimensional fanning technique: the treated group received an
injection of 1.2 ml of HA (high but unspecified molecular weight) at 1% and the control group received a saline solution of 1.2 ml.
Follow-up examinations were conducted after 7, 14, 30, 90 and 356 days and consisted of a VAS at rest and during measurement
of grip strength using a Jamar dynamometer, an elbow disability scale, a functional scale, a satisfaction scale and a measure of time
to return to pain-free sport. After one year, there was a significant improvement in pain at rest and grip. Moreover, the scores on all
scales had significantly improved in the treated group in comparison with the control group. The time to return to pain-free
sport was assessed at 18 days (+/-11 days) in the treated group.
The efficiency of an HA injection for treating patellar tendinopathies was determined in fifty patients32 with stage 2 or 3 using
Blazina’s classification33. The injected solution contained 2.5 mg of HA with a molecular weight of 900 kDa in 2.5 ml of physiological
liquid and 1 ml of lidocaine. The effectiveness was assessed on the basis of pain during sport, using the modified Roles and
Maudsley scores34. After treatment, 54% of cases were ‘excellent’, and 40% of cases were ‘good’. The results of this study
are based on the subjective views of the athletes and their trainers. With a view to reducing post-surgical adhesions of digital
flexor tendons, Riccio et al. studied 45 patients randomly assigned to two groups: a control receiving a placebo (n=10), and a
treated group receiving an injection of HA (high but unspecified molecular weight) (n=26).

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All patients were assessed at 30, 60, 90 and 180 days after surgery by testing active motion, with functional capacity being assessed
using the quick-DASH questionnaire and the number of working days lost after surgery. Patients in the treated group showed
better recovery of digital motion at all time intervals (improvement of 27% in the HA group compared to 10% in the control
group, and 43 to 28% respectively at day 180), and returned to work earlier. However, no significant difference could be
shown in terms of functional score between the two groups.
More recently, HA injections has been used to treat the flexor muscle in the index finger after surgical suture36. 11 were treated
with three HA injections (0.4 ml of high molecular weight: 1.0-2.9 MDa and high concentration: 15 mg/ml) and 11 received a placebo
saline solution of identical volume. Three injections were administered: one at the time of the surgical intervention and two others
one week apart. The two groups followed the same rehabilitation protocol after the operation. The results showed no differences
between the two groups in terms of extension after three weeks. However, at three months and over the long term, significant
functional improvement of total active range of joint motions (p=0.002 and p=0.001 respectively) was noted in the treated group in
com- parison with the placebo.
The short and long-term effect of intra-articular injection of HA in patients suffering from supraspinatus tendinopathy37
was assessed in 24 patients randomised into two groups, each received three injections of 2 ml of HA (16 mg/2 ml
with a molecular weight of 6.0 MDa), following traditional physical therapy treatment. TENS current, ultrasound therapy,
thermotherapy (hotpack) and exercises at home (movements, stretches and eccentric exercises). Follow-up consisted of algo-
functional score, measurement of active and passive joint extension conducted at three weeks, three months and four years post-
injection. A significant improvement in most of the parameters measured was seen within both groups, but no significant
difference was observed for the pre-injection VAS in comparison with the VAS conducted at three weeks and three months
post-injection.
The series of Merolla et al. enrolled 48 patients with rotator cuff tendinopathy for more than 4 months randomized into 2 groups: one
group with 2 ultrasound-guided subacromial injection of HA (N=25) 14 days apart and one group with only a rehabilitation
pro-gram (N=23)38. The follow-up went up to 6 months. They observed that subacromial HA injections was more effective
on pain and algofunctional scores than rehabilitation alone, and this injection was a safe treatment for patients suffering
from rotator cuff tendinopathy.
A recent study of Kumai et al. evaluated the effects of a 2,5 mL HA (high-molecular-weight: 2700 kDa) injections, over a period of
1 week, in a total of 61 patients with enthesopathies: 16 with lateral epicondylitis,14 with patellar tendinopathy, 15 with insertional
Achilles tendinopathy, and 16 with plantar fasciitis39. They observed a significant decrease of pain (VAS) for the 4 sites (-2.20 ± 2.26
for the 4 sites overall), suggesting the efficacy of injections of HA for enthesopathies in the short-term.

Discussion
Tendinopathies are very common condition in sports and working population1. Tendinopathy and tenosynovitis disturbs tendon
gliding. The application of HA can reduce tendon glide resistance10-14. Several earlier studies have shown the link between
the inhibition of fibroblast proliferation and a reduction in type III collagen concentration in the tendon, with a reduction
in the formation of adhesions at the tendon healing site 40-42. By limiting the proliferation of fibroblasts and by stabilizing
the concentration of type III collagen, HA may reduce the risk of adhesions10-12. It is still discuss if HA can stimulate or not
the synthesis of type I collagen to improve the tendon structure and resistance5,18, but it is demonstrated that HA improve cell
viability and proliferation17,18. HA appears to inhibit the expression of key intermediaries for the inflammatory signaling pathways
(NF-kB), in a dose-dependent manner19,43. By reducing the expression of proinflammatory factors, adding exogenous HA
reduces the fragmentation of endogenous HA and stimulates synovial synthesis of endogenous HA16,26,36.
Concerning the therapeutic protocol for HA injections for tendinopathies, comparatively to other recent treatments for these
conditions, where post-injection rehabilitation could be crucial44, such as PRP for example45, only 1 or 2 injections alone are
described for HA treatments30-32,35-39. However, comparatively to PRP treatments, where it exist a wide variability in the
administered product46,47, the molecular weight and the concentration of HA are known18; high molecular weight HA seems to
have a better effect on tendons18 in the short-term.

Conclusion
Some in vitro and animal in vivo studies demonstrate encouraging results in terms of the ability of HA to encourage tendon
gliding and to reduce adhesions as well as creating better tendon architectural organisation. Moreover, the injection of
HA may limit the proinflammatory effect by restoring viscoelasticity and by stimulating the endogenous synthesis of HA. These
laboratory observations appear to be supported by limited but encouraging short-term clinical results on pain and function as well
as on the return to sport. However, controlled randomised studies are still needed.

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Utilizarea Acidului Hialuronic dupa interventia
chirugicala la nivelul tendonului si in tendinopatii
Michele Abate, Cosima Schiavone, si Vincenzo Salini

Departamentul de Medicina si Stiintele Imbatranirii, Universitatea G. d’Annunzio,

Chieti-Pescara
Via dei Vestini 31, 66013 Chieti, Italia
Corespondenta tebuie adresata catre Michele Abate; m.abate@unich.it
Primit in 11 February 2014; Acceptat in 17 April 2014; Publicat 8 May 2014
Editor Academic: Lorenzo Cavagna
Copyright c 2014 Michele Abate et al.

Vascosuplimetarea cu Acid Hialuronic este sigur si eficace in managementul osteoar-

tritei, dar utilizarea lui in tratamentul afectiunilor tendoanelor a primit mai putina atentie.
Scopul acestei analize este sa sumarizeze cunostintele actuale despre acest subiect
evaluand studii experimentale si clinice. A fost realizata o cautare a articolelor in limba
engleza folosind termenii cheie: ”Acid Hialuronic” sau “vascosuplimentare”, combinat
cu “tendon”, “tendinopatie”, “aderente” sau “alunecare” luate separate. In aproape
toate studiile experimentale efectuate dupa procedurile chirugicale pentru leziunile
de tendon sau folosite in tratamentul tendinopatiilor cronice, folosind diversi compusi
cu Acid Hialuronic, au fost observate rezultate positive (formarea redusa de tesut de
granulatie si cicatricial dupa reparatia tendonului, mai putine aderente si rezistenta la
alunecare, si o imbunatatire a vindecarii tisulare). Dupa interventia chirurgicala asupra
tendonului flexor, s-a inregistrat o functie totala de miscare mai mare, precum si a de-
getelor cu o reintoarcere mai rapida la activitatile zilnice si la munca. Similar la pacientii
care sufereau de afectiuni ale tendoanelor umarului, cotului si patelei, durerea a fost
redusa si functia imbunatatita. Efectul pozitiv al Acidului Hialuronic poate fi atribuit ac-
tivitatii anti-inflamatorii, imbunatatirii proliferarii celulare si a depunerii de colagen, pe
langa actiunea lubrifianta pe suprafata de alunecare a tendonului.

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Hindawi Publishing Corporation
BioMed Research International
Volume 2014, Article ID 783632, 6 pages
http://dx.doi.org/10.1155/2014/783632

Review Article
The Use of Hyaluronic Acid after
Tendon Surgery and in Tendinopathies

Michele Abate, Cosima Schiavone, and Vincenzo Salini

Department of Medicine and Science of Aging, University G. d’Annunzio, Chieti-Pescara,
Via dei Vestini 31, 66013 Chieti, Italy
Correspondence should be addressed to Michele Abate; m.abate@unich.it
Received 11 February 2014; Accepted 17 April 2014; Published 8 May 2014
Academic Editor: Lorenzo Cavagna
Copyright © 2014 Michele Abate et al.This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Viscosupplementation with hyaluronic acid is safe and effective in the management of osteoarthritis, but its use in the treatment of
tendon disorders has received less attention.The aim of this review is to summarize the current knowledge on this topic, evaluating
experimental and clinical trials. A search of English-language articles was performed using the key search terms “hyaluronic
acid” or “viscosupplementation” combined with “tendon,” “tendinopathy,“ “adhesions,“ or “gliding,“ independently. In quite all
the experimental studies, performed after surgical procedures for tendon injuries or in the treatment of chronic tendinopathies,
using different hyaluronic acid compounds, positive results (reduced formation of scars and granulation tissue after tendon repair,
less adhesions and gliding resistance, and improved tissue healing)were observed. In a limited number of cases, hyaluronic acid
has been employed in clinical practice. After flexor tendon surgery, a greater total active motion and fingers function, with an
earlier return to work and daily activities, were observed. Similarly, in patients suffering from elbow, patellar, and shoulder tendons
disorders, pain was reduced, and function improved.The positive effect of hyaluronic acid can be attributed to the anti-inflammatory
activity, enhanced cell proliferation, and collagen deposition, besides the lubricating action on the sliding surface of the tendon.

Introduction actively secreted by the tendon sheath and, as for joints, it is

Hyaluronic acid (HA) is an important component of articular
cartilage; it is present as a coat around chondrocytes, where
it bounds to aggrecan monomers, which imbibe water and
are responsible for the resilience of cartilage (i.e., resistance
to compression) [1]. Moreover, HA is a major component
of the synovial fluid, and, along with lubricin, it is one of
the fluid’s main lubricating components. The biological
activities of HA are very complex: (a) it inhibits matrix
metalloproteinases (MMPs) and the phagocytic activity
of macrophages and leukocytes; (b) it promotes the
release of prostaglandins and the production of tissue
inhibitor of MMP-1 and favours the normalization of
native hyaluronan synthesis; (c) it acts as free radicals
scavenger and stimulates proteoglycans synthesis by
chondrocytes; (d) finally, it is provided of protective
effects on chondrocytes or cartilage explants from
degradation by enzymes [1].
Several clinical trials have shown that viscosupplementation
therapy with HA is safe and effective in themanagement
of osteoarthritis (OA) resistant to conventional therapies
[2]. This treatment has been approved by Food and Drug
Administration for knee osteoarthritis, whereas for the
other joints there are very promising results but not
conclusive evidence.
Despite the positive results inOA, its use in the treatment of
tendon disorders has received less attention. Actually, HA is
an important component of the synovial fluid, which allows
a smooth tendon gliding, and provides nutrition to tendon
itself [3]. Moreover, it is an important component of tendon
structure, being largely present in extracellular space.
The aim of this narrative review is to summarize the current
knowledge on this topic, evaluating experimental data
and clinical trials. A search of English-language articles
was performed in Pubmed, Web of Knowledge (WOK),
and EMBASE using the key search terms “hyaluronic
acid” or “viscosupplementation” combined with “tendon,”
“tendinopathy,” “adhesions,” or “gliding,” independently.
Bibliographies were hand-searched to include any applicable
studies that were not captured by our search.
Articles were eligible if they provided specific information
related to the correlation between hyaluronic acid and
tendon disorders.
Rationale
HA has been mostly used after a surgical procedure
for tendon injuries or in the treatment of chronic
tendinopathies.
Flexor tendon injuries of the hand are common, especially
in the young and working-age population [4]. After surgical
repair, the finger motion can be dramatically impaired by
oedema, and later by excessive scar formation, and/or by
adhesions between the tendon and sheat or other tissues [5].

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To limit these negative outcomes, a proper balance
between protection and mobilization is required. Indeed,
especially in Zone II, a region where the flexor digitorum
profundus and superficialis tendons reside within a
fibroosseous pulley system, immobilization is useful to
allow tendon union but often results in adhesions that
impair the physiologic gliding [4]. Postoperative protected
mobilization, either active or passive, is usually performed,
but early motion may have detrimental effects, contributing
to gap formation or tendon rupture, while late mobilization
may favour adhesions [6].
In complicated injuries, primary repair of a flexor tendon is
often impossible. In these situations, tendon grafts, using
extrasynovial tendons (e.g., palmaris longus or plantaris),
are often used to reconstruct severely scarred or missing
tendons [7]. The extrasynovial grafts have the advantage
of being easily harvested, but the higher gliding resistance
compared with intrasynovial tendons, due to adhesion
formation, represents a main disadvantage on their use
[8]. For this reason, physical barriers and biological
techniques have been employed to reduce tendon
adhesionswithout adversely affecting the healing
process [9, 10]. In this context, HA has been considered
as a useful therapeutic tool.
However, in a limited number of cases, HA has been
also employed in the treatment of tendinopathies [11–
13].HAis an essential component of the tendon itself. It
iswell known that, after experimental damage, tendon
healing process proceeds along a complex pathway
beginning with inflammation and cellular proliferation
and followed by tissue formation and maturation,
with each phase lasting for days, weeks, and months,
respectively [14].
Briefly, in the damaged area, the injury molecular products
stimulate an acute inflammatory reaction with the secretion
of cytokines, reactive oxygen species, cationic peptides,
or proteases. This phase is followed by cell proliferation,
collagen and matrix deposition, and tissue remodeling and
the final outcome is scar tissue formation, which can
partially restore tendon function. Indeed, the mechanical
properties are compromised for years, due to composition
of the extracellular matrix and its organization.
Basic research has shown that the activity of
hyaluronidase 2 is increased in granulation tissue
during the healing of equine superficial digital flexor
tendon injuries, suggesting that HA plays a relevant
role in controlling the healing process in equine
tendonitis [15].
Experimental Studies
Several studies have been performed to evaluate
the efficacy of HA on adhesions, gliding resistance,
and tendon healing [7–10, 16–21]. Different
experimentalmodels have been used: animal species
(dog, chicken, rabbit, rat, and horse), tendons (intra- or
extrasynovial; auto- or allograft), and procedures of
induced tendon damage (surgical, collagenase, or steroid
lesion). Moreover, a lot of HA compounds (low and high
molecular weight HA, cross-linked HA) have been studied
in the form of gel, membrane, or scaffold, administered
intraand peritendinously, both in vitro and in vivo.
Quite all the authors have shown that HA reduces
the formation of scars and granulation tissue and
prevents adhesions after tendon repair. The efficacy
seems in some way dependent on the HA used. Indeed,
the native HA has a limited action because of a very short
half-life and a too rapid elimination to serve as a physical
barrier between the tendon and the sheath [3]. A slight
superiority was found when using the high molecular
weight HA (Hylan G-F 20) which has a longer half-life
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53
compared to low molecular weight HA [7]. Indeed, in the
experiments carried out by Kolodzinskyi et al. [7] on the
isolated canine peroneus longus (PL) the gliding resistance
of the tendon, treated with Hylan G-F 20, decreased
significantly compared to untreated controls.
Other authors have supposed that adhesions could be
reduced with more stable HA derivatives and HA could
be fixed to the tendon surface, and its removal could be
minimized [8–10, 19, 20]. Several HA derivatives have been
evaluated.
The carbodiimide-derivatized HA (cd-HA) is less
soluble in water than normal HA and therefore has an
increased tissue residence time [19, 20]. Preliminary
experiments, erformed on intact tendon grafts in vitro,
showed that the preparation improved gliding and
that the effect was increased when gelatin was added
[8]. Experiments were therefore performed on isolated
flexor digitorum profundus tendons in dogs, submitted
to dissection, followed by surgical repair.These studies
showed that, from the 50th mechanical stress cycle
onwards, the gliding resistance was significantly lower in
the cd-HA gel group than in the control group, without any
difference in the breaking strength nor in tendon stiffness.
These results were reported to an increased residence
time of HA on the tendon surface, favouring the cross-
linking of the HA mixture to tendon proteins [20].
Further studies were carried out by Zhao et al. [18], who
studied a compound, characterized by a cd-HA and
gelatin, added to lubricin, amucinous glycoprotein
present in the peritendinous fluid. Flexor digitorum
profundus tendons from the 2nd and 5th digits of one
forepaw of six dogs were transected and repaired. One
tendon in each paw was then treated with HA; the other
repaired tendon was not treated.
Following tendon repair, a forearm cast was applied to fully
immobilize the operated forelimb. After 3 and 7 weeks, the
dogs were euthanized and the tendons were evaluated.
The adhesion formation was assessed in two regions,
between the tendon and the sheath and between the
tendon and the bone, using a semiquantitative scoring
system (none, mild,moderate, and severe).The normalized
work of flexion, the gliding resistance, and the maximum
breaking force of treated tendons were also recorded. In
theHA-lubricin group, the normalized work of flexion was
significantly lower, as well as the prevalence of severe
adhesions. However, also the maximum breaking force
was reduced, suggesting that the positive effects of the
compound on adhesions were counteracted by some
impairment of tendon healing. The hypothesis was that
lubricin could enter the repair site, blocking the adhesion
of the healing tendon ends to each other. The authors
suggest that a gelatin patch, sealing the tendon
and carrying growth factors, could provide a better
protection of the lacerated tendon ends from lubricin
leakage and enhance teh flexor tendon intrinsic
healing[21].
Another HA-derived biomaterial is Seprafilm, a biore-
sorbable membrane composed of chemically modified
HA and carboxymethylcellulose [9]. This device,
however, suffers from several drawbacks, such as the
short in vivo residence time and the difficulty to handle
when wrapping the tendon, because the material loses
its integrity. In contrast, the Carbylan TM-SX (a new
carboxylated and thiol-modified HA-derivative) films
are elastic, robust, and easy to handle and can maintain
their integrity during manipulation. This preparation
has been shown to be more effective in reducing the
peritendinous adhesions, following partial thickness
injury in rabbits, compared to Seprafilm and Carbylan
TM-SX sprayable gel [10]. The favourable activity was
attributed to the inhibitory activity of thiol-modified HA
on cell attachement, spreading and proliferation with the
compound being negatively charged, hydrophilic, and
lacking peptidic epitopes that activate integrins.
The few studies, at present performed in humans in human
isolated tendons, confirming experimental research, suggest
that tendon surface treatment using HA (cd-HA or added
with lubricin) can reduce the excursion resistance in
the tendon-pulley unit in the intra- and extrasynovial
tendons, facilitating postoperative rehabilitation and
improving the clinical outcome [22, 23].
These studies, taken together, suggest that HA
diminishes the excursion resistance after tendon repair
and can be useful to prevent adhesion until the synovial
surface is fully developed.
Less experimental work has been performed to assess
whether HA can be effective in tendon healing [15, 17].
In Achilles tendonitis, induced by repeated injections of
corticosteroids in rats, the effects of Hylan G-F 20 were
investigated by means of histopathology [17]. For the tendon,
thickness, staining affinity, nuclear appearance, and fibrillar
appearance were taken into account, whereas, for paraten-
on fibrosis and oedema, capillary changes and inflamma-
tion were assessed, according to a semiquantitative scor-
ing system. Compared to controls, injected with saline,
Hylan-injected tendons and paratenons showed significantly
lower scores, especially after 75 days. These positive
effects were attributed mainly to the anti-inflammatory
activity of the agent, which inhibits, both in vitro and in
vivo, the leukocyte function (phagocytosis, adherence, and
mitogen-induced stimulation). Moreover, it was supposed
that HA, according to studies in chicken embryos and in
endothelial cell cultures, could inhibit vasculogenesis,
explaining the reduced vascular score at the calcaneal
insertion [17].
The positive role of HA in tendon healing has been confirmed
by the effects of the Seprafilm antiadhesion mem- brane,
composed of sodium-hyaluronate plus glucosamine
HCl-chondroitin sulfate [30]. In rabbits, submitted to ten-
don rupture and ensuing surgical repair, after 84 days, the
treatment significantly enhanced the maturation rate of the
tenoblasts, fibrillogenesis, the diameters of the collagen
fibrils, and fibrillar density. These findings suggest that
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54
Seprafilm antiadhesion membrane could be effective
in restoring the morphological properties of injured
superficial digital flexor tendon of rabbits and might be
helpful for future clinical trial studies in tendon ruptures.
Clinical Trials
Experimental evidence suggests that, in the clinical setting,
it may be possible to inject HA within the flexor sheath
during the postoperative period in patients at risk for
adhesions or with noteworthy oedema.
In a multicenter randomized controlled trial, Hyaloglide,
a thick and sticky gel which adheres to the surface of the
tendon, was applied after flexor tenolysis in Zone II following
failed flexor tendon repair [4]. 30, 60, 90, and 180 days after
surgery, patients in the study group, compared with not
treated controls, showed a greater total active motion and
finger function, with an earlier return to work and daily
activities. Noteworthy, Hyaloglide did not affect tendon and
wound healing and did not increase the complications rate.
Similarly, O¨ zgenel and Eto¨z [5] investigated the efficacy of
high molecular HA injections versus placebo (saline) on
functional outcomes after Zone II flexor tendon repair.
Three doses were given (one at the time of tenorrhaphy
and two at one-week intervals) around the tenorrhaphy
site, and a rehabilitation program was started on the 3rd
postoperative day. Range of motion (active and passive)
and functional outcome (Strickland classification) were
assessed. In the short term (3 weeks), no difference
between the two groups was observed; however, at 3
months and in the long term, a HA. Noteworthy, no
adverse events (signs of inflammation or tendon rupture)
were seen in any cases.
Besides the prevention of adhesions after flexor tendons
repair, the therapeutic efficacy of HA has been evaluated in
other tendon diseases.
In an open-label randomized study, patients with trigger
finger were randomly divided into two groups: (1) HA plus
corticosteroid and (2) open surgical release [11].
At 6 and 12 months, 93% of patients of the first group had
complete symptom resolution, compared to 73% submitted
to surgery.
In 50 athletic patients with patellar tendinopathy (stage 2 or
3 according to Blazina’s classification), a mixture of 25
mg HA and 1 mL of 1% lidocaine was injected blindly at
the proximal interface between the posterior surface of
the patellar tendon and the infrapatellar fat pad or into the
region of maximum tenderness [12]. A week after the first
injection, other injections were done on the patient’s request;
conservative treatments (exercises and instrumental thera-
pies) were also prescribed. An average of 2 injections/case
(range 1–11; total 135) was performed with 12-month (range
3–49 months) interval between injections. After treatment,
54% of patients were rated in excellent conditions
(return to previous athletic activities), while 40% in good
conditions complained of some degree of limitation. The
open design and the subjective evaluation methods used (no
imaging) are important limitations of this study.
Petrella et al. [13] determined the efficacy of periarticular
HA injections in patients suffering from tennis elbow.
In this prospective randomized clinical trial, 165
subjects with chronic lateral epicondylosis received 2
blind injections of 1.2 cc of HA (once a week) into the
subcutaneous tissue and muscle, from the lateral epicondyle
toward the primary point of pain. Saline solution was injected
in the control group (166 patients). Pain, both at rest and
after grip testing, was significantly reduced in the study
group compared to controls after 30, 90, and 365 days. The
treatment was highly satisfactory and resulted in earlier
return to pain-free sport.
The experience of HA use in rotator cuf f tendinopathies
is more consistent [24–29]. Patients with different rotator
cuff diseases (full or partial thickness tear, tendinosis) were
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55
treated with HA injections and compared to placebo or
active treatments (steroids or physical therapies). The main
results of these trials are summarized in Table 1. A superior
therapeutic effect was observed in comparison to placebo,
but no significant difference was shown when steroids or
physical therapy was used as controls.
Conclusions
Experimental research and pivotal clinical trials suggest
that HA is effective in preventing adhesions after flexor
tendons surgery. Different preparations and procedures
are at present under study to define the best option.
Promising results have been also observed in the treat-
ment of tendinopathies. In general terms, the positive effect
relies on the anti-inflammatory activity of HA, enhanced cell
proliferation, and collagen deposition, besides the lubricating
action on the sliding surface of the tendon. However, it must
be underlined that in the majority of studies the drug was
not injected inside the degenerated tendon, but nearby and/
or into the articular space. It can be speculated that the
modifications of the synovial fluid can exert a positive effect
on the tendon itself, but it cannot be excluded that the
clinical improvement may secondary to the positive action
on osteoarthritis frequently associated.
Conflict of Interests
The authors declare no conflict of interests.
Authors’ Contribution
All of the authors participated in the work and agree to the
submission of the paper to the journal.
5
6
77
U
Utilizari speciale

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Injectia unica cu Hialuronat in Managementul
Tendinopatiei insertionale Ahiliene in comparatie
cu injectiile cu corticosteroid si tratamentele
conservative non-invazive

Lauren Gorelick1, Ayala Rozano-Gorelick2, Anwar Saab2, Edward Ram3

1Orthopaedic and Hand Surgeon, Assuta Medical Center, Haifa, Israel.
2Clalit Health Services- Bar Ilan Medical Faculty, Zefat.
3Division of General Surgery, Rabin Medical Center- Golda Campus, Sackler School of Medicine,
Tel Aviv University,
Israel.
*Autor corespondent:
Lauren Gorelick, MD
Email: gorelick@netvision.net.il

REZUMAT

Tendonul lui Ahile este cel mai puternic si mai gros tendon din organism si joaca un rol
important în biomecanica extremitatii inferioare. El poate rezista la forte mari in timpul
exercitiilor fizice precum si la torsiunea excesiva si intindere.Tendinopatia Ahiliana
(TA) nu are un mecanism patofiziologic cunoscut si nici o intelegere clara a procesului
patologic. In acest moment se folosesc pentru tratamentul tendinoptiei Ahiliene ,repausul
si exercitii specifice, antiinflamatoarele nesteroidiene, injectiile cu corticosteroizi si
tratamentele chirugicale. Niciuna dintre ele nu au o eficacitate dominanta pentru nicio
perioda de timp. In ultimul timp, injectiile cu hialuronat au fost din ce in ce mai utilizate
pentru tratamentul diferitelor procese degenerative ale articulatiilor si tesuturilor moi.
Autorii au evaluat 56 de pacienti cu TA insertionala tratati intre 2007 si 2012. Toti
pacientii au fost umariti timp de un an. Pacientii au fost divizati in 3 grupuri: primul grup
tratat prin injectarea de corticosteroizi, al doilea grup tratat prin injectie cu hialuroniat
in doza unica si al treilea grup tratat prin repaus, atela, AINS si fizioterapie. Cei mai
multi pacienti care au fost tratati cu o singura injectie cu hialuronat au aratat rezultate
de la bine la excelent pentru o lunga perioada de timp, in comparatie cu injectiile cu
corticosteroizi si pacientii tratati in mod conservator, in functie de scorurile Fadi si VAS.
In concluzie, se pare ca terapia de injectare a hialuronatului este superior fata de terapia
cu corticosteroizi si un tratament conservator non-invaziv pentru TA insertionala.

CUVINTE CHEIE:
tendonul lui Ahile, tendinopatia insertionala Ahiliana, injectare de corticosteroizi, injectia
hialuronatului

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See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/280556510

Single Hyaluronate Injection in the

Management of Insertional Achilles
Tendinopathy in Comparison to Corticosteroid
Injections and Non-invasive Conservative
Treatments

Article · July 2015

Viscosupplementation with hyaluronic acid is safe and effective in the management of osteoarthritis, but its use in the treatment of
tendon disorders has received less attention.The aim of this review is to summarize the current knowledge on this topic, evaluating
experimental and clinical trials. A search of English-language articles was performed using the key search terms “hyaluronic
acid” or “viscosupplementation” combined with “tendon,” “tendinopathy,“ “adhesions,“ or “gliding,“ independently. In quite all
the experimental studies, performed after surgical procedures for tendon injuries or in the treatment of chronic tendinopathies,
using different hyaluronic acid compounds, positive results (reduced formation of scars and granulation tissue after tendon repair,
less adhesions and gliding resistance, and improved tissue healing)were observed. In a limited number of cases, hyaluronic acid
has been employed in clinical practice. After flexor tendon surgery, a greater total active motion and fingers function, with an
earlier return to work and daily activities, were observed. Similarly, in patients suffering from elbow, patellar, and shoulder tendons
disorders, pain was reduced, and function improved.The positive effect of hyaluronic acid can be attributed to the anti-inflammatory
activity, enhanced cell proliferation, and collagen deposition, besides the lubricating action on the sliding surface of the tendon.

Available from: Lauren Gorelick

Retrieved on: 19 April 2016

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Scholars Bulletin
(A Multidisciplinary Bi-weekly Journal)
An Official Publication of “Scholars Middle East Publishers”,
Dubai, United Arab Emirates
Website: http://scholarsbulletin.com/

Single Hyaluronate Injection in the Management of

Insertional Achilles
Tendinopathy in Comparison to Corticosteroid
Injections and Non-invasive
Conservative Treatments
Lauren Gorelick1, Ayala Rozano-Gorelick2, Anwar Saab2, Edward Ram3
1Orthopaedic and Hand Surgeon, Assuta Medical Center, Haifa, Israel.
2Clalit Health Services- Bar Ilan Medical Faculty, Zefat.
3Division of General Surgery, Rabin Medical Center- Golda Campus, Sackler School of Medicine, Tel Aviv University, Israel.

*Corresponding Author:
Lauren Gorelick, MD
Email: gorelick@netvision.net.il

Abstract:
The Achilles tendon is the strongest and thickest tendon in the body and plays an important role in the biomechanics of the lower
extremity. It can withstand high forces during sporting exercises and excessive torsion and
stretching. Achilles Tendinopathy (AT) has no pathophysiological theory and no clear understanding of the pathological process.
Rest and specific exercises, NSAIDs, steroid injections and surgical treatments are currently used to treat AT. Not one of them
has a dominant efficacy for any length of time. Lately, hyaluronate injections have increasingly been used for the treatment of
different degenerative processes of joints and soft tissues. The authors reviewed 56 patients with insertional AT treated between
2007 and 2012. All patients were followed up for one year. Patients were divided into three groups: the first group treated by
the corticosteroid injection, the second group treated by single hyaluronate injection and the third group treated by rest, splint,
NSAIDs, and physiotherapy. Most patients that treated by a single hyaluronate injection showed good to excellent results for a long
time in comparison with corticosteroids injections and the conservatively treated patients, according to FADI and VAS scores. In
conclusion, it seems that hyaluronate injection therapy is superior to steroid therapy and non-invasive conservative treatment for
insertional AT.

Keywords:
Achilles tendon, Achilles insertional tendinopathy, corticosteroid injection, hyaluronate injection

Introduction insertional tendinitis, paratenonitis, retrocalcaneal

Achilles tendinopathy (AT) is becoming a more common
complaint due to increased medical awareness and
greater physical activities of the general population. It
can be the reason for substantial pain and loss of function
of the affected limb for a long time. AT is considered an
overload injury at the point of attachment at the calcaneus
and two to six cm. proximally of that point at the region of
maximum torsion. Chronic stress can lead to a defective
arrangement of collagen fibers in the AT and result in
pain and limited function. At this time, there is no
pathophysiologic theory with a clear understanding of
the pathological process of this entity. There first appears
the evidence of the existence of the TNF-α system in the
human AT. Findings are confirmed by mRNA and protein
levels as well as biochemically. The TNF-α system was
in principle confined to the tenocytes. The connection
between tenocyte morphology and the expression
pattern of TNF-α, TNFR1, and TNFR2 suggests that the
TNF-α system may be involved in tenocyte activation in
Achilles tendinosis[1]. AT disorders are multifactorial
and include tendinosis, tendinosis with partial rupture,
bursitis, and subcutaneous Achilles tendon bursitis. It
occurs in combinations of the above in most cases. The wide
spectrum of nonsurgical treatment modalities (the rest,
activity modification, specific exercises, use of a brace,
NSAIDs, steroid injections, shockwave therapy) indicate
that not one of them is strongly effective. AT, therefore,
is difficult to manage and up to 29% of AT patients may
require surgery[2]. Specific exercises show the most
evidence of effectiveness in the treatment of AT[3].
Injection of corticosteroids have strong potential for
pain relief for a short period but is problematic because
of potentially severe adverse effects[4]. Rupture of the
Achilles’ tendon following intratendinous injections has
been reported. There is evidence supporting the use
of hyaluronate injections in patients with ankle sprain,
adhesive capsulitis of the shoulder, patients after flexor
tendon injury, trochanteric bursitis, and rotator cuff
disorder, although the mechanism of the effect has
not yet been clarified[5-10]. There is some evidence
in experimental laboratory studies that hyaluronate
increases proliferation of vascular endothelial growth
factor (VEGF) and collagen type 4 during the six weeks

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after injection, and decrease the amount of adhesion
tissue[11]. Hyaluronic acid dose-dependently inhibited
cell proliferation and decreased the expression level of
mRNA for adhesion-related procollagens and cytokines
[6, 9]. In another study, Hylan G-F 20 has shown a
promising curative effect on the tendon and paratenon
in an experimental study in rats, and Hylan-injected
tendons and paratenons demonstrated significant
improvement in comparison to saline injection especially
after 75 days[12]. A single hyaluronate injection
resulted in similar improvements in pain in each of
the four enthesopathies-lateral epicondylitis, patellar
tendinopathy, insertional AT, and plantar fasciitis[13].
No published studies have been found that have followed
patients who were administered hyaluronate in AT in
comparison to other kinds of conservative treatments.
Corticosteroid injection beneficial in the short term for
the treatment of tendinopathy but may be worse than
other treatments in the intermediate and long term[14].
The use of hyaluronate injections for different kinds of
tendinopathy has been routine in this author’s practice for
the last seven years. This study evaluates of three groups
of patients treated with Hyaluronate and compared with
corticosteroid injection and non-invasive therapy.
METHODS
Patients
This study evaluates of a consecutive series of 56 patients
treated for Achilles insertional tendinopathy. M/W
ratio was 21/35. The average age was 54 (range 20-85
years). 17 patients treated by rest, splint, NSAIDs, and
physiotherapy. 19 patients treated with corticosteroid
injection(betamethasone dipropionate five mg. and
betamethasone sodium phosphate two mg.). 20 patients
of the third group treated with a standard single
sodium hyaluronate 2% (40 mg/2.0 ml) injection (Ostenil
Tendon, TRB Chemedica International S.A., 1211 Geneva,
Switzerland).
Achilles tendinopathy diagnosis.
Insertional AT is characterized by “deep pain at the tendon-
bone junction of the posterior calcaneus point over a bony
prominence or spurs located at the posterior superior aspect
of the calcaneus”[15]. High-resolution sonography made
of all patients for diagnosis of AT as a relatively reliable
diagnostic method in Achillodynia [16].
Inclusion Criteria.
All patients were newly diagnosed with insertional AT without
any previous treatment before being included in the study.
Exclusion Criteria.
•All patients treated in the past and having received any
intervention due to insertional AT.
•Patients who operated on in the same area.
•Patients that had a systemic or rheumatological disease,
tarsal tunnel syndrome, moderate to severe osteoarthritis
of the ankle and foot, lumbar stenosis or disc disease, and
instability of the ankle.
•Patients who were unable to understand the questionnaires.
Treatment Effect Assessment
Patients were assessed using a back-translated FADI (Foot
and Ankle Disability Index) version (Hebrew, Russian and
Arabic). The questionnaire was self-filled by the patients,
and a research assistant verified questionnaire filling. Also,
a standardized VAS (Visual Analogue Scale) score was filled
out in answer to the question:”What number would you give
your pain right now?”
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12
Statistical Analysis
Statistical analysis was performed using the SPSS statistical
program. ANOVA with post-hoc analysis was used.
Between-group differences in the primary outcome analyzed
based on the intention-to-treat principle. Between-group
differences in continuous outcome measure analyzed with
repeated measures for general linear models. A difference at
the 0.05 level is termed significant.
RESULTS
FADI Score
The FADI score evaluated for the entire cohort. The FADI
score increased from 26.3 to 67. 91 after six months and
75.179 after a year. The pre-treatment average score was
similar in the three groups. A significant difference was found
between the groups (ANOVA, p < 0.05). The average score
of patients treated by corticosteroid injection was 55.39
as compared with 64.77 for the hyaluronate injected
group and 48.96 for the conservative treatment group.
There was a time interaction with inter-group difference
in time. In the corticosteroid group, the average score
significantly improved from 26.95 to 73.95 at six months but
decreased at 12 months (65.26). The time-related behavior
was different in the hyaluronate group with a pre-injection
average of 24.90 increasing to 72.85 at six months, and to
96.55 at 12 months. The conservative treatment group had
a time-related behavior similar to the corticosteroid group at
the one-year follow-up (Figure 1).
VAS Scale
VAS scale declined over time for the entire cohort from
10 to 2.68 after a year. There was a significant inter-
group difference of the VAS scores with average VAS of
the conservative treatment group higher (5.46) than the
corticosteroids treated group (4.74) and the hyaluronate
group (3.88). There is a time-dependent intergroup
difference with a steep decline from pre-treatment to the six
weeks mark, and an insignificant decrease in conservatively
treated group at later time points of three months, six
months and one year. There is an insignificant increase of
the VAS scale in the corticosteroids treated group at three
months and a significant increase at six and twelve months
(Figure 2). The time dependence of the hyaluronate groups
is different with a continuing significant drop during the one
year of follow-up.
DISCUSSION
The mechanism of action of hyaluronate in Achilles
tendinopathy appears to be complicated. The basic pathology
underlying the symptoms is not yet fully understood. The
disorder is apparently complex as a spectrum of diseases
ranging from inflammation of the paratendinous tissue to
structural degeneration of the tendon. Hyaluronate plays
a significant role during wound healing and regeneration.
It has anti-inflammatory effects as well as the possibility
that its presence will restore normal tissue function. It
enhances muscle progenitor cell recruitment and inhibits
premature myotube fusion, implicating a role for these
glycosaminoglycans in functional repair[17].
The current study appears to demonstrate that there is
an ameliorative effect of hyaluronate injections in AT. The
pain relief appears to be significant with a large effect
size for the hyaluronate group. The effect of steroids
appears to be short lived, and this concurs with the
findings comparing effects of steroids and hyaluronic
acid in knee osteoarthritis[18]. Corticosteroid injection
may be worse than other treatments in the intermediate
and long term. There is no consensus as to whether
local steroid injections have a therapeutic role in the
treatment of AT. However, they may incur a risk of tendon
damage[19].
 Figure 1: The FADI score is similarly affected by injection therapy in the hyaluronate and steroid at six months, while the amelio-
rative effect of steroids appears to be short-lived. No difference between steroid and non-invasive treated groups at long time
follow-up.

Figure- 2: The VAS score response to injection therapy is similar to that of the FADI score but in decreased direction. Note the
similar effects of steroids and non-invasive therapy at twelve months of the follow-up.

Corticosteroid injection may be worse than other CONCLUSION

treatments in the intermediate and long term. There is
no consensus as to whether local steroid injections have
a therapeutic role in the treatment of AT. However, they
may incur a risk of tendon damage [19].
The current study appears to indicate that hyaluronate
injection is an acceptable alternative to steroid injections
for the treatment of AT. This alternative treatment
may be more useful in a diabetic patient without any
complications and side effects of steroids[20]
The current study appears to indicate that single
hyaluronate injection is efficacious for the treatment of
insertional AT. The effect size is larger with hyaluronate
injections and lasts longer. Limitations of the current study
were the small size of the groups and the fact that the patient
were not randomized. A further prospective randomized
clinical trial should be done prior to making a clear-cut
recommendation that hyaluronate injections are superior to
other conservative modalities and may provide an alternative
for clinicians.

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Managementul Cotului Tenismenului cu
injectiile periarticulare cu hialuronat
Robert J Petrella1*, Anthony Cogliano2, Joseph Decaria3, Naem Mohamed4, Robert Lee5

REZUMAT

OBIECTIV:
Sa determine eficacitatea si siguranta injectiilor periarticulare cu Acid Hialuronic in epicondilita
laterala (cotul tenismenului).
Design: studiu clinic prospectiv randomizat, in ingrijirea primara din medicina sportiva.
Pacienti: trei sute treizeci si unu atleti consecutivi si competitivi ai sportului cu racheta cu
epicondilita laterala cronica (>3 luni) li s-au administrat 2 injectii (prima injectie la baseline)
in tesutul subcutanat si muschi la 1 cm distanta de epicondilul lateral spre punctul de
durere primar, folosind tehnica bidimensionala de tatonare. Cea de-a doua injectie a fost
administrata o saptamana mai tarziu.

MASURAREA OBIECTIVELOR:
Evaluarile au fost facute la baseline, zilele 7, 14, 30, 90 si 356. Masuratorile de eficacitate
au inclus scara vizuala analogica (VAS) de durere in repaus (0-100 mm) si apoi o evaluare
a rezistentei de prindere (0-100 mm). Puterea de prindere a fost determinata folosind un
dinamometru Jamar cu brat hidraulic. Alte evaluari au inclus evaluare globala a leziunii
cotului (scala categorica de puncte; 1= fara dizabilitati, 5 = dizabilitatea maxima), evaluarea
functiei/activitatii normale a pacientilor (scala categorica de 5 puncte), evaluarea satisfactiei
pacientilor/medicilor (scala categorica de 10 puncte), timpul pana la reintoarcere la sport fara
durere si fara dizabilitati si efecte adverse conform definitiei WHO. Diferenta dintre grupuri a
fost determinata folosind ANOVA – intentie de tratament.

REZULTATE:
Varsta medie a populatiei de studiu a fost 49 de ani (+/- 12 ani). 165 de pacienti au fost
randomizati pe Acid Hialuronic si 166 au fost randomizati pe grupul de control. Schimbarea
in scala VAS pentru durere a fost -6.7 (=/- 2.0) pentru AH vs -1.3 (+/- 1.5) pentru grupul
control (p<0.001). Scorul VAS post handgrip a fost de 7.8 (+/-1.3) vs +0.3 (± 2.0) (p < 0.001)
care corespunde unei imbunatatiri semnificative a fortei de strangere de 2.6 kg in grupul
cu Acid Hialuronic vs grupul control (p < 0.01). De asemenea au fost inregistrate imbunatiri
semnificative ale evaluarii globale a leziunii cotului (p < 0.02),a functionalitatii si activitatii
normale (p < 0.05) si a evaluarii satisfactiei pacientilor/medicilor (p<0.05) favorizand grupul
cu AH. Timpul de reintoarecere la sport fara durere si fara dizabilitate a fost de 18 (+/- 11) zile
in grupul cu AH si nu a fost atins in grupul control. Modificarile de VAS au fost mentinute in
grupul cu AH la fiecare vizita de urmarire in timp ce celor din grupul control indicele a scazut
semnificativ de la baseline. Evaluarile satisfactiei pacientului si medicului au continuat sa fie
in favoarea grupului cu AH, la vizitele de urmarire ulterioare.

CONCLUZIE:
Tratamentul periarticular cu AH pentru cotul tenismenului a fost semnificativ mai bun decat
in grupul control in ameliorarea durerii in repaus si dupa testarea aderentei maxime. In plus,
tratamentul cu AH a fost considerat foarte satisfacator de catre pacienti si medici si a dus la
o reintoarcere mai buna la sportul fara durere, comparativ cu grupul control.

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Petrella et al. Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology
2010, 2:4 http://www.smarttjournal.com/content/2/1/4

RESEARC H Open
Access
Management of Tennis Elbow with sodium
hyaluronate periarticular injections
Robert J Petrella1*, Anthony Cogliano2, Joseph Decaria3, Naem Mohamed4, Robert Lee5

Abstract
Objectives: To determine the efficacy and safety of peri-articular hyaluronic acid injections in chronic lateral epicondylosis
(tennis elbow).
Design: Prospective randomized clinical trial in primary care sport medicine.
Patients: Three hundred and thirty one consecutive competitive racquette sport athletes with chronic (>3 months) lateral
epicondylosis were administered 2 injections (first injection at baseline) into the subcutaneous tissue and muscle 1 cm. from
the lateral epicondyle toward the primary point of pain using a two-dimensional fanning technique. A second injection was
administered 1 week later.
Outcomes measures: Assessments were done at baseline, days 7, 14, 30, 90 and 356. Efficacy measures included
patient’s visual analogue scale (VAS) of pain at rest (0-100 mm) and following assessment of grip strength (0-100 mm). Grip strength
was determined using a jamar hydraulic hand dynamometer. Other assessments included patients’ global assessment of elbow
injury (5 point categorical scale; 1 = no disability, 5 = maximal disability), patients’ assessment of normal function/activity (5 point
categorical scale), patients/physician satisfaction assessment (10 point categorical scale), time to return to pain-free and disability-
free sport and adverse events as per WHO definition. Differences between groups were determined using an intent-to-treat ANOVA.
Results: Average age of the study population was 49 years (± 12 years). One hundred and sixty-five patients were randomized to
the HA and 166 were randomized to the control groups. The change in VAS pain was -6.7 (± 2.0) for HA vs -1.3 (± 1.5) for control
(p < 0.001). The VAS post handgrip was -7.8 (± 1.3) vs +0.3 (± 2.0) (p < 0.001) which corresponded to a significant improvement in
grip of 2.6 kg in the HA vs control groups (p < 0.01).
Statistically significant improvement in patients’ global assessment of elbow injury (p < 0.02), patients’ assessment of normal
function/activity (p < 0.05) and patients/physician satisfaction assessment (p < 0.05) were also observed favoring the HA group.
Time to return to pain-free and disability-free sport was 18 (± 11) days in the HA group but was not achieved in the control group.
VAS changes were maintained in the HA group at each followup while those in the control significantly declined from baseline.
Assessment of patient and physician satisfaction continued to favor the HA group at subsequent followup.
Conclusion: Peri-articular HA treatment for tennis elbow was significantly better than control in improving pain at rest and after
maximal grip testing. Further, HA treatment was highly satisfactory by patients and physicians and resulted in better return to pain
free sport compared to control.

CONCLUSION efficacy in terms of pain and function with low incidence

Chronic tennis elbow or lateral epicondylosis produces
symptoms of pain and functional disability. Typical
treatments include RICE for acute exacerbations as well
as oral or topical NSAIDs, bracing and physical therapy.
However, there is no consensus on treatment while
efficacy of existing treatments is poor. Intra-articular
hyaluronic acid (HA) has shown efficacy equivalent
to NSAID in the treatment of osteoarthritis while
it’s periarticular efficacy and safety have recently been
reported for soft tissue use in acute ankle sprain. Hence,
many patients, particularly those who require more rapid
improvement to return to sport or work activity, or those
in whom previous therapies have not achieved expected
results, would benefit from a more rapid alleviation of
symptoms, while still achieving the longer term benefits of
hyaluronic acid that have been reported in other soft tissue
indications.
Previous studies regarding treatment of chronic tennis
elbow have shown lack of consensus as well as variable
efficacy and high incidence of adverse effects[1].
Hyaluronic acid has been used in soft tissue application
for acute ankle sprain with high degree of efficacy and
very limited side effect. Hence, given the biocompatibility
of HA in treatment of acute ankle sprain we may show
of side effect and treatment of chronic tennis elbow.
Tennis elbow (lateral epicondylosis), a common cause of
chronic elbow pain and wrist extensor dysfunction in adults,
affects 1-3% of the general population each year[2]. Tennis
players have been reported to account for 5- 8% of all cases,
although between 40-50% of all tennis players will be afflicted
with the condition at some time[3]. Lateral epicondylosis
is most prevalent in the fourth decade of life and the
syndrome is rarely seen in individuals under the age of 30.
Localized tenderness around the lateral epicondyle generally
characterizes the condition, and pain can be reproduced by
resisted extension of the wrist or the middle finger with the
elbow in a straight position. The injury results in elbow pain
that usually heals spontaneously, although it can become
a source of chronic pain and morbidity if left untreated. On
average, a typical episode of lateral epicondylosis lasts 6-24
months[4]. The primary lesion and epicondylosis consists
of micro ruptures and result in inflammatory granulation
tissue in the tendinous portion of the origins of the forearm
musculature just distal to the epicondyle of the humerus. The
lesion is found primarily in the extensor carpi radialis brevis
(ECRB) origin, with less frequent involvement of the extensor
carpi radialis longus (ECRL) and the anterior portion of the
extensor digitorum communis[5]. Nirschl [6] maintains that

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angiofibroblastic hyperplasia, resulting from avascular
compromise and subsequent micro tears in the origin of
the ECRB, is the basic cause of chronic lateral epicondy-
losis. While the muscle fibres have adequate blood sup-
ply and good healing potential, the tendon fibres attached
to the periosteum are relatively avascular and are prone to
ischemic stress and thus slow to heal [7]. Recent studies of
chronic tennis elbow have not found any significant evidence
of inflammatory processes and the term epicondylosis
has been suggested as a more appropriate term than
epicondylitis [8].
There is currently no consensus on the optimum
treatment, but numerous options are available. The
best available scientific evidence suggests that topical
and possibly oral non-steroidal anti-inflammatory
drugs may be the most useful for short-term pain
relief. Corticosteroid injections may be beneficial as a
temporary measure but carry the risk of possible
adverse affects [9,10]. Symptoms usually start with an ache
in the extensor aspect of the forearm with certain movements
that become localized in the lateral epicondyle. Visible
swelling is not a common feature in lateral epicondylosis
and, if present, should suggest some other pathology.
Elbow radiographs are usually normal and seldom helpful.
Ectopic calcification of the lateral epicondyle appears in
approximately 25% of the cases but its presence does
not appear to alter prognosis. Differential diagnosis should
include referred pain from the cervical spine, rheumatoid
arthritis, radial tunnel syndrome and compression of the
posterior interosseous nerve [11].
Hyaluronic acid is a natural occurring biological
substance, which has been shown to have a positive
effect in inter-articular administration for osteoarthritis
[12] as well as more recently periarticular use in acute
ankle sprain[13]. These studies have shown improved pain
and functional range of the arthritic as well as the soft tissue
injury with high degree of patient satisfaction and few adverse
events. Previous studies of topical NSAID and botulinum
toxin for the treatment of epilateral epicondylitis [14,15] have
shown improved pain at 1-3 months post injection. However,
this was associated with rash, mild gastric upset [14] and
digit paresis and weakness of finger extension [15]. Further,
efficacy was not assessed long term. Hence, given the lack
of consensus, the high rate of adverse effects and lack of
long term followup with current options, use of HA, which is
relatively free of these adverse effects and has been used in
ankle sprain with long term efficacy[16], could prove to be an
option for patients with chronic tennis elbow.
Hyaluronic acid is an unbranched, high molecular weight
polysaccharide distributed throughout the body, especially
as a major component of synovial fluid cartilage and
surrounding structures of arthroidial joints.
The primary role of the HA in these tissues is to
maintain their viscoelastic structural and functional
characteristics. Given the long term efficacy and safety
of periarticular HA in acute ankle sprain, it would suggest
similar protective effects of HA in chronic lateral
epicondylosis.
We are unaware of any other published studies that have
prospectively followed patients who were adminis- tered
HA in lateral epicondylosis for treatment of tennis elbow in
clinical practice.
Hence, we hypothesized that HA administered in the soft
tissue of lateral epicondylosis for chronic tennis elbow
will be well-tolerated with few adverse events and result
in improved clinical pain and function outcomes from
baseline to long term followup compared to patients
administered placebo.
Methodology
We collected data on 331 consecutive patients administered
HA (a clear solution of sterile 1% sodium hyaluronate in a
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16
phosphate buffered saline contained in a prefilled syringe;
1.2 cc) [165 patients] versus 166 patients administered 1.2
cc saline placebo. Treatment course was randomized and
consisted of 2 injections (1 at baseline and a second at 7
days). Injections were administered using blinded syringes
affixed to a 27- gauge, 1-inch needle. Skin was prepped
using betadine 1%. Injections were delivered by the study
physician using a standard approach along the lateral
epicondyle with the affected arm flexed and resting on a firm
surface. Injections were be administered into the soft tissue
1 cm from the lateral epicondyle at the point of greatest
pain in two planes using a fanning technique [13] (Fig. 1)
whereby contents were injected on withdrawl of the needle
from the point of maximal tenderness in a single puncture.
All patients had radiograph to exclude other pathologies
at the discretion of the study physician (ie to exclude
fracture). None took any other treatment modalities during
the observation period or 48 hours prior to assessments.
Assessments included general demographics, comorbidities
and previous treatments.
Patients rated pain on a 10 cm VAS, with 0 representing
no pain and 10 representing maximal pain. Patients’
glo-bal assessment of elbow injury (5 point categorical
scale; 1 = no disability, 5 = maximal disability),
patients’ assessment of normal function/activity (5 point
categori-cal scale; 1 = no change in function/activity,
5 = maxi-mal change in normal function/activity) and
physician’s global assessment of elbow injury (5 point
categorical scale; 1 = no impact of injury on function,
5 = maximal impact of injury on function) were also
collected. Global assessments have not been validated
but have been used previously by our and other groups to
link the findings to implementation into routine practice.
Time to return to pain and disability-free sport and adverse
events were determined from review of a patient diary. After
enroll- ment, patients were randomized (1:1) to one of two
treatments using a computer-generated randomization
schedule: HA or placebo.
Follow-up examinations were completed at Day 14 (± 2
days), Day 30 (± 2 days), Day 90 (± 2 days) and at Day 356
(± 7 days). Patients will assess pain on a VAS at rest and
after assessment of grip strength. Grip strength will be
determined using a jamar hydraulic hand dynamometer
(Sammons Preston, Bolingbrook, Illinois). Assessment
will be conducted with the patient’s elbow fully extended,
shoulder in neutral position and the dynamometer’s handle
in the middle position.
Patients will perform three grip tests on the affected arm with
a mean score calculated and used for analysis.
During the study, including the follow-up period, the
patients received usual care including RICE (rest, ice,
compression and elevation). Use of any analgesics was
prohibited and all concomitant medication use was recorded
in the patient’s diary. Specifically, no NSAID, corticosteroid
or topical analgesics were allowed during the study. ASA at
the dose of 325 mg and less for cardiovascular prophylaxis
was allowed.
Patients were assessed for pain on a VAS at rest and after
assessment of grip strength. Patients’ global assessment of
elbow injury (5 point categorical scale), patients’ assessment
of normal function/activity (5 point categorical scale), and
physician’s global assessment of elbow injury (5 point
categorical scale) was performed. Also, patients/physician
satisfaction assessment (10 point categorical scale; 1 = no
satisfaction with the procedure, 10 = very high satisfaction
with the procedure) and review of a patient diary for adverse
events and return to pain and disability-free sport was
performed.
The primary outcome measures were an improvement
on the VAS-pain at rest in the affected elbow and
VAS-pain immediately following grip strength testing.
Secondary outcome measures included patients’ global
assessment of elbow injury (5 point categorical scale),
patients’ assessment of normal function/activity (5
point categorical scale), physician’s global assessment
of elbow injury (5 point categorical scale), patients/
physician satisfaction assessment (10 point categorical
scale), time to return to pain and disability-free sport,
concomitant medication use and adverse events.
The patients were recruited and screened in 4 sites
(Canadian Center for Activity and Aging; University
of Western Ontario-Fowler-Kennedy Sport Medicine
Center; U Waterloo Sport Medicine Center; U Guelph
Sport Medicine Center). Patients eligible for the study were
18 or older, with clinically or radiographic diagnosis of
tennis elbow, and who were newly referred to the medical
outpatient clinics at the author’s institution which are primary
sport medicine referral centers serving a population of 1.5
million patients. Inclusion criteria were pain at the lateral side
of the elbow that had persisted more than 3 months and
pain at the lateral epicondyle during resisted dorsiflexion of
the wrist with the elbow in full extension. Exclusion criteria
were previous local injection treatments (ie. corticosteroid
injections or acupuncture), nerve entrapment or systemic
neuromuscular disorders.
The diagram below provides a description of the over-all
study design (Table 1).
The analyses of the efficacy endpoints used an intent-to-
Figure 1 Localization and administration of HA.
6817
treat (ITT) population. The ITT population was patients who
received at least 1 injection of double-blind study therapy.
For the efficacy analysis, all patients were counted in the
group they were randomized to irrespective of their actual
treatment assignment.
Statistical Power and Sample Size
For the primary analysis of the change from baseline in elbow
pain we estimated a sample size of 160 per group using a
40% difference in resting VAS scores at Day 30 between
treatment and control, a potential dropout rate of 25% and
95% confidence assuming a standard deviation of <10 mm
of the mean deviation, an a of 5%, and a b level of 10%.
Results
Both groups (HA = 165 vs placebo = 166) were similar for age
(49 ± 15 vs 47 ± 11) and gender (55 vs 53% male) distribution
(Table 2). There was also no difference among groups in the
duration of their symptoms (26 vs 33 months). There were no
serious adverse events reported throughout the study. Three
patients (1.8%) in the HA and 5 patients (4%) in the control
reported pain during injection. No other adverse events were
reported. No subjects withdrew from the study during the
treatment phase.
Mean baseline rest VAS was similar (8.5 ± 1.1 cm and 8.4
± 1.6 cm) for HA and control respectively. VAS pain at
rest and after grip testing was significantly better in the
HA vs control (Table 2) at D 30. This was associated with
significantly greater grip strength, patient global satisfaction
and assessment of normal elbow function in the HA group
vs control (Table 2). Physician global assessment of elbow
injury was significantly better for the HA vs the control (Table
2). These differences persisted at each follow up assessment
(90 and 356 days). Time to return to pain-free and disability-
free sport was 18 (± 11) days in the HA group (in 147
patients; 89% response rate) but was not achieved in any of
the control group patients.
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Discussion
There is currently no consensus in the management of
chronic tennis elbow. Several, reviews have included var-
ious therapies targeting local or systemic interventions.
Further, these therapies have not shown ability to shorten
the disability period nor have they shown long term benefit.
In our study, patients who received HA for lateral
epicondylosis (tennis elbow) had significantly greater
improvement in VAS pain at rest and after grip testing
than control that persisted to 356 days followup. The
treatment was highly satisfactory to patients and
physicians and was associated with very few minor
and transient adverse effects. Given the less than
optimal treatment options for tennis elbow and given
the associated chronic morbidity associated with this
condition, periarticular injection with HA may provide
an alternative for clinicians and their patients.
Eficacitatea si siguranta pe termen lung ale
Acidului Hialuronic periarticular in entorsa acuta
de glezna
Michael J. Petrella, PhD; Anthony Cogliano, MD; Robert J. Petrella, MD, PhD

REZUMAT

Obiectivele acestui studiu au fost sa determine eficacitatea si siguranta pe termen lung

a injectiilor cu Acid Hialuronic periarticular in entorsa laterala acuta de glezna. Studiu
prospectiv randomizat controlat placebo in medicina primara sportiva si practica de
urgenta au inclus 158 de atleti competitivi care sufereau de o entorsa laterala acuta
de glezna de Grad 1 sau grad 2 si care au fost randomizati in primele 48 de ore de la
accidentare. Pacientii au fost randomizati la baseline pe injectie periarticulara cu Acid
Hialuronic + terapia standard de ingrijire (odihna,gheata,ridicare si compresie) (RICE) sau
injectie placebo (PL) + terapie standard de ingrijire (RICE) la evaluarea baseline si in ziua
a 4 dupa accidentare. Urmarirea a fost efectuata la 30, 90, si 712 de zile dupa tratament.
Evaluarile la baseline si zilele 4,8, 30 , 90 si 712 au inclus scala vizuala analoga de durere
(VAS)(0-10 cm) a greutatii si a mersului 20 m, evaluarea globala a accidentarii gleznei
(scala categorica de 5 puncte), satisfactia pacientului cu tratament (scala categorica de
5 puncte) timpul de reintoarcere la sportul fara durere si dizabilitate, entorsa recurenta
de glezna, numarul total de zile de absenta din activitatea sportiva primara, si efecte
adverse (EA). Timpul pana la interventie a fost de 39 +/- 4 ore fara diferente intre grupuri.
O reducere semnificativa a VAS pe greutate si mers a fost observata la toate vizitele
de urmarire la grupul cu AH comparat cu placebo (p<0.001). Timpul de reintoarcere
la sport fara durere si fara dizabilitate a fost de 11 (+/-8) versus 17 (+/-) zile pentru
AH si placebo, respective (p<0.05). La 24 de luni, in grupul placebo vs AH au fost 2
versus 0 fracturi de membru inferior, 16 versus 7 a-2-a entorsa de glezna,(p<0.05), 3
versus 1 a 3-a entorsa de glezna, I un numar semnificativ mai mare zile de lipsa din
activitatea sportiva (41 versus 21; p <0.002). Satisfactia pacientilor a fost semnificativ
mai mare la pacientii din grupul cu AH versus placebo la toate evaluarile de urmarire.
Niciun eveniment advers grav nu a fost inregistrat in decursul urmaririi. Tratamentul
periarticular cu Acid Hialuronic in entorsa acuta de glezna a fost inalt satisfacatoare pe
termen scurt si lung versus placebo. Aceasta asociata cu trecerea durerii, intoarecerea
mai rapida la sport, mai putine entorse recurente de glezna, mai putine zile de lipsa de
la sport cu putine efecte advserse in 24 de luni.

CUVINTE CHEIE
entorsa de glezna, Acid Hialuronic, eficacitatea si siguranta pe termen lung

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70
Long-Term Efficacy and Safety of Periarticular
Hyaluronic Acid in Acute Ankle Sprain
Michael J. Petrella, PhD; Anthony Cogliano, MD; Robert J. Petrella, MD, PhD

Abstract
The objectives of this study were to determine the long-term efficacy and safety of periarticular hyaluronic acid injections in acute
lateral ankle sprain. A randomized controlled prospective trial in a primary sport medicine and emergency practice involved 158
competitive athletes who suffered an acute Grade 1 or 2 lateral ankle sprain, and who were randomized within 48 hours of injury.
Patients were randomized at baseline to periarticular injection with hyaluronic acid (HA) + standard of care (rest, ice, elevation,
and compression [RICE]) or placebo injection (PL) + standard of care (RICE) treatment at baseline assessment and Day 4 post
injury. Follow-up was at 30, 90, and 712 days post treatment. Assessments at baseline and Days 4, 8, 30, 90, and 712 included
visual analog scale (VAS) (0-10 cm) pain on weight bearing and walking 20 m, patient global assessment of ankle injury (5-point
categorical scale), patient satisfaction with treatment (5-point categorical scale), time to return to pain-free and disability-free sport,
recurrent ankle sprain, total number of days missing from primary sport activity, and adverse events (AEs). Time to intervention
was 39 ± 4 hours with no difference between groups. A significant reduction in VAS pain on both weight bearing and walking was
observed at all follow-up assessments for HA compared with PL (P < 0.001). Time to pain-free and disability-free return to sport was
11 (± 8) versus 17 (± 8) days for HA and PL, respectively (P < 0.05). At 24 months, in the PL versus HA group, there were 2 versus 0
lower limb fractures, 16 versus 7 second ankle sprains (P < 0.05), 3 versus 1 third ankle sprains, and a significantly greater number
of days missing primary sport activity (41 versus 21; P < 0.002). Significantly greater patient satisfaction was also observed for HA
versus PL at all follow-up assessments. No serious AEs were recorded throughout follow-up. Periarticular HA treatment for acute
ankle sprain was highly satisfactory in the short and long term versus PL. This was associated with reduced pain, more rapid return
to sport, fewer recurrent ankle sprains, fewer missed days from sport, with few associated AEs to 24 months.
Keywords: ankle sprain; hyaluronic acid; long-term efficacy and safety

Michael J. Petrella, PhD1 Anthony Introduction

Cogliano, MD1 Ankle sprains are among the most common of all sports injuries, with approximately
Robert J. Petrella, MD, PhD1 2 million people per year seeking medical treatment.1–3 An epidemiological study of
professional, competitive, and recreational athletes found a prevalence of ankle sprain
1Faculties of Medicine and Health as high as 73%4 or a crude incidence rate of at least 52.7 per 10 000.5 Ankle sprains
Sciences, University of Western are also the cause of significant morbidity in the longer term. A recent review by van Rijn
Ontario, London, Canada et al6 found up to 33% of patients still experienced pain after 1 year, while only 36% to
85% reported full recovery up to 3 years later. There is also a wide variation in subjective
instability, of up to 33% to 53%. Hence, the impact of ankle sprain is of considerable
Correspondence: concern to long-term function and performance of athletes beyond the acute event.
Robert J. Petrella, MD, PhD, Dept. Compounding the impact of ankle sprain is the absence of a standard treatment
of Family and Physical approach that directly targets the injury. The American Academy of Orthopaedic
Medicine & Rehabilitation, Surgeons (AAOS) does recommend an initial rehabilitation program (up to 3 weeks)
Schulich School of Medicine, with nonsteroidal anti-inflammatory drugs (NSAIDs), rest, ice, compression, and
Lawson Health Research Institute, elevation (RICE), as well as protected weight bearing, early mobilization, and
University of Western Ontario, 801 isometric exercise.7 Further, while NSAIDs may effectively reduce the pain and swelling
Commissioner’s Road East, associated with acute ankle sprain,8–12 this may not alter the clinical course of ankle
London, Ontario, Canada N6C 5J1 sprain regarding return to sport and may also cause significant adverse events (AEs)
Tel: 519-685-4292 (ext 42633) including gastrointestinal intolerance and serious events such as ulcers and bleeding.
Fax: 519-685-4071 The conservative treatment approach recommended by the AAOS may limit disability to
E-mail: petrella@uwo.ca an average of 8 days for a Grade 1 and 15 days for a Grade 2.3–4 However, the longer-
term efficacy in terms of recurrent sprains and return to sport is limited. In one study of
ankle sprain, pain and dysfunction was found to persist 6 to 18 months (average, 12.8 months) after initial ankle sprain in 73% of
patients, with 40% reporting inability to walk 1 mile and 11% continuing to use medications for ankle symptoms,14 while in a long-
term follow-up study, nearly 40% of patients reported residual long-term symptoms and dysfunction 6.5 years after initial ankle
sprain.15 Since recurrence rates are high ranging from 3% to 34% of the patients for periods ranging from 2 weeks to 96 months
post injury,6 the current approach to ankle sprain could benefit from new modalities and interventions.
Some approaches to longer-term prevention of recurrent sprains have focused on prophylactic external bracing and rehabilitative
training but have shown variable results.13 Further, prophylactic approaches may impact performance and even increase risk
of other injury. What is missing is a targeted approach to ankle sprain that would provide superior efficacy, low risk of AEs, and
improved rates of recurrence.
Hyaluronic acid is a naturally occurring biological substance which has been shown to have a positive clinical impact in
intra-articular as well as intradermal indications.16 As hyaluronic acid relieves pain and stiffness related to its rheologic
modification of intra-articular matrix as well as “filling” intradermal space, it may be hypothesized to have a similar effect
on the extra-articular complex including ligamentous structures affected by acute ankle sprain, including structural and
inflammatory interruption. Further, hyaluronic acid injected locally at the site of injury would not precipitate systemic risk of AEs.
We previously reported the short-term efficacy and safety of periarticular hyaluronic acid in acute ankle sprain versus placebo.17
Periarticular hyaluronic acid was not only superior in terms of pain relief and patient satisfaction, but resulted in a faster return-
to-sport activity. In the current study, we report for the first time the long-term efficacy, safety, return-to-sport, and subsequent
recurrence rate of ankle sprain at 2 years post injury.

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71
Methods
This randomized controlled study was conducted between March 2003 and December 2005 with follow-up to June 2008 in
3 primary care sport medicine facilities in Ontario, Canada. The study and follow-up was approved by the institutional ethics
committee and was conducted according to the Declaration of Helsinki Good Clinical Practice guidelines. All patients signed
informed consent prior to participation.
The study methodology was previously described.17 Briefly, the study included a screening phase where patients were assessed
based on selected inclusion and exclusion criteria. Prior to enrollment, a diagnosis of first or second-degree ankle sprain was
made by athletic trainers affiliated with university athletic programs, emergency physicians at affiliated local hospitals, and family
physicians in the referral base for the 3 sport medicine clinics. Enrolled patients were required to report to the sport medicine
clinics within 48 hours of their injury. Pain severity at enrollment was assessed using a pain visual analog scale (VAS) and
included eligibility of a VAS at rest of > 4.5 cm (0–10 cm). Patients were excluded if they had bilateral ankle sprain, third-degree
ankle sprain, or had previous sprain in the last 6 months. An x-ray of the ankle joint was performed prior to enrollment
to exclude other pathologies. Patients were randomized (1:1) to 1 of the 2 treatment groups using a computer-generated
randomization schedule: periarticular hyaluronic acid (HA) (MW range, 750–1 million kDal, 20 mg) + usual standard of care
RICE or periarticular placebo (PL) + usual standard of care RICE. The first dose of study treatment was administered on
Day 1 (within 48 hours of injury) and the second dose was administered on Day 4 (±1 day).
Assessments were done at baseline, and Days 4, 8, 30, 90, and 712 (Table 1). Efficacy measures included patients’ VAS
of pain on weight bearing (0–10 cm) and walking 20 m (0–10 cm), patients’ global assessment of ankle injury (5-point
categorical scale), patients’ assessment of return to normal function/activity in sport (5-point categorical scale), patients’
satisfaction assessment (10-point categorical scale), number of recurrent ankle sprains, number of other injuries, number
of days missing from incident sport due to ankle sprain and AEs as per World Health Organization (WHO) definition.
Following measurement of the outcome assessments, those randomized to HA treatment received a single injection of HA
(0.7–1.2 mL) or placebo (normal saline 0.7–1.2 mL). Injections were performed using previously18,19 described blinded syringes
affixed to a 27-gauge, 1-inch needle.17 Briefly, skin was prepped using Betadine 1%. Injections were delivered by the study
physician using a standard approach along the anterior talofibular ligament using clinical landmarks.

The injection (1.2 mL total) was delivered during a single penetration along 3 planes from anteroposterior, medial, and lateral from
the proximal ligamentous landmark. Assessments and injections were repeated on Day 4 (± 1 day). All randomized patients received
standard care consisting of RICE, assistive devices as determined by the study physician including crutches, taping, or bracing
but not physiotherapy, and oral or topical medications such as NSAIDs. These latter interventions could be used after Day 8 at the
patient’s discretion.
Rescue medication (500 mg acetaminophen tablets, up to 4 tablets daily) was allowed in both groups but not for the 24 hours
prior to study visit. Patients were free to withdraw at any time during the trial.
Follow-up assessments were completed at Days 8 (± 2 days), 30 (± 7 days), 90 (± 7 days), and 712 (± 7 days). Adverse events
and concomitant medications were assessed throughout the patients’ participation in the study.
Demographic and baseline data were compared within the 2 groups using Student’s t-tests for continuous and χ2 statistics for
noncontinuous variables. Statistical analysis was based on the intent to treat (ITT) population. Efficacy and safety variables were
analyzed between groups using appropriate statistical methods including Student’s t-test for quantitative, χ2 test for nominal, and
Mann-Whitney U test for ordinal variables. The data analysis was performed using the SAS® version 8.2 (SAS Institute, Cary, NC).
All statistical tests were 2-tailed at a 5% level of significance.

Results
A total of 499 patients were screened and the ITT population was 158 patients (Figure 1). The average age was 26 ± 7 years
and 24 ± 8 years for the HA and PL groups, respectively, with equal male to female representation between groups. Thirty percent
of sprains were first events and 65% were Grade 1 with no difference between groups. There was no difference between the groups

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at baseline. We obtained 100% compliance with the injection series throughout the treatment phase and 70% to 75% retention at
2 years (Figure 1). Time to intervention was not different between groups (39 ± 4 hours).
Theprimaryefficacycriterionwasthedecreasefrombaseline to visit 2 (Day 8 ± 1) in weight-bearing pain calculated in the ITT population
(Table 2). This, and changes in walking pain, were -3.16 ± 1.18 cm and -1.83 ± 1.1 cm (%) (weight-bearing pain) and -4.99 ± 2.02
cm and -3.76 ± 2.43 cm (%) (walking pain) in the HA and PL groups, respectively (P < 0.0001), giving an inter-group difference of
1.31 cm and 1.23 cm in favor of treatment.
The differences between groups were also significant at visit 3 (Day 30), visit 4 (Day 90), and visit 5 (Day 712) in favor of the treatment
group (Table 2).
Globally, all efficacy parameters improved during the study in both groups. However, intergroup comparisons showed a statistically
significant difference in favor of HA on most efficacy parameters (Table 2). For parameters where such a difference was not obtained
for all visits, the improvement was more marked in the HA than in the control. The results for the secondary efficacy variables were
therefore globally consistent with those concerning the primary outcomes.
Fewer recurrent sprains were observed in the HA (7) versus PL (16) group at 2 years (Figure 2). Further, this was associated with
fewer days missing (21) versus (41) for the HA and PL groups, respectively (Figure 3). There was a small but nonsignificant difference
favoring HA in number of total MSK injuries (18 vs 24) reported at 2 years, suggesting that missing days from sport in patients post
ankle sprain is primarily driven by recurrent ankle sprain.

Abbreviations: HA, hyaluronic acid group; PL, usual care group; SD, standard deviation.
Sprain grade is percent presenting with Grade 1 sprain;VAS pain on weight bearing is the score decrease from baseline in cm on 10-point Likert scale;VAS pain on walking is the score decrease from
baseline in cm on 10-point Likert scale; patient global assessment of ankle injury is self reported score from 1–5 where 1 = very poor assessment of injury on health and 5 = very good assessment
of injury on health; patient assessment of return to normal activity in sport is self reported score from 1 = severely restricted to 5 = normal activity; patient satisfaction with treatment is self reported
score from 1 = not satisfied to 10 = completely satisfied with treatment; adverse events are the self reported adverse events at each study visit.
*Statistically significant differences within treatment groups for these parameters.

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Patient satisfaction with treatment scores among subjects showed that 75% versus 48% and 77% versus 57% were satisfied at
Days 4 and 8 while 95% versus 76% were satisfied at Day 30, 93% vs 67% at Day 90, and 95% versus 60% at Day 712 (χ2 test,
P < 0.001) (Table 2).
Three AEs were observed among all subjects and consisted of pain requiring the self-medication with NSAID (2 HA, 1 PL) including
1 mild erythema and pain (HA) at the injection site not requiring further intervention at Day 4, and 3 pain and 1 mild erythema at the
injection site in the HA vs 2 erythema, 1 pain and 1 swelling at Day 8 in PL (Table 2). The pain AEs in the 2 groups did not differ in
intensity. At 712 days, 3 pain AEs for HA and 5 pain AEs for PL were reported (Table 2). There were no serious AEs.
No difference in concomitant treatment or physical therapy between groups was observed to Day 90. At Day 712 more patients in
PL had used at least 7 days of NSAID compared with HA (P < 0.001) and more had utilized physical therapy (P < 0.001).

Discussion
Conservative treatment of acute ankle sprain may limit disability to an average of 8 days for a Grade 1 and 15 days for a
Grade 2,3,4 but this treatment is not ideal as it remains that a significant number of patients will have ongoing disability
including instability, recurrent sprains, and time away from sport. Further, while NSAIDs effectively reduce the pain and
swelling associated with acute ankle sprain,8–12 they are nonselective and may cause significant AEs including gastro-
intestinal intolerance, serious events such as ulcers and bleeding, as well as potential negative cardio-renal effects.
Hence, therapeutic options for ankle sprains have been limited while both the short and long-term recovery suggest that
alternative treatments, particularly those that improve return-to-sport with minimal sequelae, are needed.
Hyaluronic acid is a naturally occurring biological substance representing an unbranched, high-molecular-weight
polysaccharide as a major component of ligamentous, cartilaginous, and synovial ultrastructure16 with no demonstrated
effect on gastrointestinal and platelet function. It has proven efficacy and safety in the treatment of osteoarthritis.20 We
have previously reported the short-term efficacy and safety of periarticular administration of HA in acute ankle sprain
compared with standard of care treatment.17

In the current study, we extend our previous findings that periarticular HA was associated with fewer recurrent ankle sprains and
fewer injury days missing from sport compared with PL. This is the first study to our knowledge, regardless of management, that
has demonstrated impact on future ankle injury and morbidity from a standardized treatment of acute ankle sprain. The primary
efficacy criterion was a decrease in pain in the first 8 days in the ITT population. Based on this criterion, periarticular HA was found
to be significantly more effective than control. This change of 3 cm is considered clinically significant.11 Furthermore, almost all
the secondary criteria, including patient global satisfaction, were also improved during the trial compared with control, even up to
90 days.
Further, clinical implications of our results were confirmed by the fact that the number of patients who withdrew for AE or lack
of efficacy was small for both groups, and that our short-term results are consistent with other treatments of ankle sprain with
topical NSAIDs 10,21,22 and oral NSAIDs and COX-2 inhibitors.9,12 Importantly, we reported a very low incidence of AEs with
high satisfaction both in the short and longer-term. Further, less use of concomitant medication for ankle pain and fewer physical
therapy sessions was observed at 2 years in the HA versus PL group, suggesting that this new treatment modality could have added
value to clinicians and their patients. Currently, those with ankle instability after an acute sprain may be advised that wearing a
prophylactic external brace to reduce the risk of a future sprain, although the results including costs and performance to date are
not clear.13 Investigation of the costs and benefits of periarticular HA versus conventional therapy requires attention to return to-
sport and recurrent ankle injury across the range of sport settings, including amateur to professional, to allow clinicians and athletes
to make informed decisions regarding their therapy options.

Summary
Our results showed superior short and long-term therapeutic response of periarticular HA in patients with acute ankle
sprain versus standard of care treatment. Further, periarticular HA resulted in fewer recurrent ankle sprains, less use of
concomitant treatments, and fewer days missing from sport 2 years after the initial injury. Given that this treatment is easily
performed in primary care sport medicine and has high patient satisfaction, these results suggest that periarticular HA in
acute ankle should be considered an important alternative by physicians and their patients.

Acknowledgments
Theauthorsacknowledgetheparticipationofstudyinvestigators at the Fowler-Kennedy Sport Medicine Clinic, London, Canada.

Conflict of Interest Statement

Michael J. Petrella, PhD, Anthony Cogliano, MD, and Robert
J. Petrella, MD, PhD declare no conflicts of interest.

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 Referinte
Hyaluronic acid increases tendon derived cell viability and collagen type
I expression in vitro: Comparative study of four different Hyaluronic acid
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Management of Tennis Elbow with sodium hyaluronate periarticular
injections (pag. 66)

Author details
1Dept Medicine, Canadian Centre for Activity and Aging, 801 Commissioners Road, London, N6C5J1, Canada. 2Dept Medicine, Fowler-Kennedy Sport Medi-
cine Clinic, 1490 Richmond St, London, N6C2 M3, Canada. 3Dept Kinesiology, Canadian Centre for Activity and Aging, 801 Commissioners Road, London,
N6C5J1, Canada. 4Dept Family Medicine, 801 Commissioners
Road, London, N6C5J1, Canada. 5Sport Medicine, University of Waterloo, 1100 University Ave, Waterloo, Canada.

Authors’ contributions
RJP contributed to the study design, data collection, analysis and manuscript preparation.
AC contributed to the data collection.
JD contributed to the study design, data collection and manuscript preparation
NM contributed to the data collection. RL contributed to the data collection.
All authors read and approved of the final manuscript.

Competing interests
The authors declare that they have no competing interests.

Received: 4 October 2009

Accepted: 2 February 2010 Published: 2 February 2010

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doi:10.1186/1758-2555-2-4
Cite this article as: Petrella et al.: Management of Tennis Elbow with
sodium hyaluronate periarticular injections. Sports Medicine, Arthroscopy,
Rehabilitation, Therapy & Technology 2010 2:4.

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