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      Review: Emerging concepts in the pathogenesis of tendinopathy

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          Abstract

          Tendinopathy is a common clinical problem and has a significant disease burden attached, not only in terms of health care costs, but also for patients directly in terms of time off work and impact upon quality of life. Controversy surrounds the pathogenesis of tendinopathy, however the recent systematic analysis of the evidence has demonstrated that many of the claims of an absence of inflammation in tendinopathy were more based around belief than robust scientific data. This review is a summary of the emerging research in this topical area, with a particular focus on the role of neuronal regulation and inflammation in tendinopathy.

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          Epidemiology, natural history, and indications for treatment of rotator cuff tears.

          Robert Z. Tashjian (2012)
          The etiology of rotator cuff disease is likely multifactorial, including age-related degeneration and microtrauma and macrotrauma. The incidence of rotator cuff tears increases with aging with more than half of individuals in their 80s having a rotator cuff tear. Smoking, hypercholesterolemia, and genetics have all been shown to influence the development of rotator cuff tearing. Substantial full-thickness rotator cuff tears, in general, progress and enlarge with time. Pain, or worsening pain, usually signals tear progression in both asymptomatic and symptomatic tears and should warrant further investigation if the tear is treated conservatively. Larger (>1-1.5 cm) symptomatic full-thickness cuff tears have a high rate of tear progression and, therefore, should be considered for earlier surgical repair in younger patients if the tear is reparable and there is limited muscle degeneration to avoid irreversible changes to the cuff, including tear enlargement and degenerative muscle changes. Smaller symptomatic full-thickness tears have been shown to have a slower rate of progression, similar to partial-thickness tears, and can be considered for initial nonoperative treatment due to the limited risk for rapid tear progression. In both small full-thickness tears and partial-thickness tears, increasing pain should alert physicians to obtain further imaging as it can signal tear progression. Natural history data, along with information on factors affecting healing after rotator cuff repair, can help guide surgeons in making appropriate decisions regarding the treatment of rotator cuff tears. The management of rotator cuff tears should be considered in the context of the risks and benefits of operative versus nonoperative treatment. Tear size and acuity, the presence of irreparable changes to the rotator cuff or glenohumeral joint, and patient age should all be considered in making this decision. Initial nonoperative care can be safely undertaken in older patients (>70 years old) with chronic tears; in patients with irreparable rotator cuff tears with irreversible changes, including significant atrophy and fatty infiltration, humeral head migration, and arthritis; in patients of any age with small ( 1 cm-1.5 cm) acute tears or young patients with full-thickness tears who have a significant risk for the development of irreparable rotator cuff changes.
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            The demographic and morphological features of rotator cuff disease. A comparison of asymptomatic and symptomatic shoulders.

            Leesa Galatz, Gary Middleton, C Hildebolt … (2006)
            Very little comparative information is available regarding the demographic and morphological characteristics of asymptomatic and symptomatic rotator cuff tears. This information is important to provide insight into the natural history of rotator cuff disease and to identify which factors may be important in the development of pain. The purpose of the present study was to compare the morphological characteristics and prevalences of asymptomatic and symptomatic rotator cuff disease in patients who presented with unilateral shoulder pain. Five hundred and eighty-eight consecutive patients in whom a standardized ultrasonographic study had been performed by an experienced radiologist for the assessment of unilateral shoulder pain were evaluated with regard to the presence and size of rotator cuff tears in each shoulder. The demographic factors that were analyzed included age, gender, side, and cuff thickness. All of these factors were evaluated with regard to their correlation with the presence of pain. Of the 588 consecutive patients who met the inclusion criteria, 212 had an intact rotator cuff bilaterally, 199 had a unilateral rotator cuff tear (either partial or full thickness), and 177 had a bilateral tear (either partial or full thickness). The presence of rotator cuff disease was highly correlated with age. The average age was 48.7 years for patients with no rotator cuff tear, 58.7 years for those with a unilateral tear, and 67.8 years for those with a bilateral tear. Logistic regression analysis indicated a 50% likelihood of a bilateral tear after the age of sixty-six years (p < 0.01). In patients with a bilateral rotator cuff tear in whom one tear was symptomatic and the other tear was asymptomatic, the symptomatic tear was significantly larger (p < 0.01). The average size of a symptomatic tear was 30% greater than that of an asymptomatic tear. Overall, patients who presented with a full-thickness symptomatic tear had a 35.5% prevalence of a full-thickness tear on the contralateral side. There is a high correlation between the onset of rotator cuff tears (either partial or full thickness) and increasing age. Bilateral rotator cuff disease, either symptomatic or asymptomatic, is common in patients who present with unilateral symptomatic disease. As the size of a tear appears to be an important factor in the development of symptoms, we recommend surveillance at yearly intervals for patients with known rotator cuff tears that are treated nonoperatively.
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              Glutamine and glutamate--their central role in cell metabolism and function.

              Tania Pithon-Curi, Rui Curi, Joaquim Procopio … (2003)
              Glucose is widely accepted as the primary nutrient for maintenance and promotion of cell function. However, we propose that the 5-carbon amino acids, glutamine and glutamate, should be considered to be equally important for maintenance and promotion of cell function. The functions of glutamine are many and include: substrate for protein synthesis, anabolic precursor for muscle growth, acid-base balance in the kidney, substrate for ureogenesis in the liver, substrate for hepatic and renal gluconeogenesis, an oxidative fuel for intestine and cells of the immune system, inter-organ nitrogen transport, precursor for neurotransmitter synthesis, precursor for nucleotide and nucleic acid synthesis and precursor for glutathione production. Many of these functions are connected to the formation of glutamate from glutamine. We propose that the unique properties regarding concentration and routes of metabolism of these amino acids allow them to be used for a diverse array of processes related to the specialized function of each of the glutamine utilizing cells. In this review we highlight the specialized aspects of glutamine/glutamate metabolism of different glutamine-utilizing cells and in each case relate key aspects of metabolism to cell function. Copyright 2002 John Wiley & Sons, Ltd.
              Article 0 comments Cited 161 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Benjamin J.F. Dean
                Stephanie G. Dakin
                Neal L. Millar
                Andrew J. Carr
                Journal
                Journal ID (nlm-ta): Surgeon
                Journal ID (iso-abbrev): Surgeon
                Title: The Surgeon
                Publisher: Publications Office, The Royal College of Surgeons of Edinburgh
                ISSN (Print): 1479-666X
                Publication date PMC-release: 1 December 2017
                Publication date (Print): December 2017
                Volume: 15
                Issue: 6
                Pages: 349-354
                Affiliations
                [a ]Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK
                [b ]Institute of Infection, Immunity and Inflammation, College of Medicine, Veterinary and Life Sciences University of Glasgow, Glasgow, Scotland, UK
                Author notes
                [∗ ] Corresponding author. bendean1979@ 123456gmail.com
                Article
                Publisher ID: S1479-666X(17)30091-4
                DOI: 10.1016/j.surge.2017.05.005
                PMC ID: 5714045
                PubMed ID: 28619548
                SO-VID: 19046d04-f204-4b45-9d50-72dbfb25eeb8
                Copyright © © 2017 The Authors
                License:

                This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

                History
                Date received : 5 May 2017
                Date revision received : 19 May 2017
                Date accepted : 22 May 2017
                Categories
                Subject: Article

                Keywords: tendon,tendinopathy,tendinitis,inflammation,pain,pathogenesis
                Data availability:
                Keywords: tendon, tendinopathy, tendinitis, inflammation, pain, pathogenesis

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