This document provides information on tendinopathy and tendon repair. It defines tendons and their connection between muscle and bone. It describes the stages of tendon healing as inflammation, repair/proliferation, and remodeling. Types of tendon injuries discussed include tendonitis and tendonosis. Common sites of tendinopathy include the shoulder, elbow, wrist, hip, knee, and ankle. Suture techniques for tendon repair include Kessler, Savage, and Lee methods. The nature of sutures and suture placement is also covered, along with tendon retubularization procedures.

1. TENDINOPATHY
AND
TENDON REPAIR
BY
Dr. MWEBAZA VICTOR ( MBChB)
mwebazavictor1997@gmail.com
Uganda
21ST /May/2023

2. A tendon or sinew is a tough, high-tensile-strength
band of dense fibrous connective tissue that
connects muscle to bone.
It is able to efficiently transmit the mechanical
forces of muscle contraction to the skeletal
system without sacrificing its ability to withstand
significant amounts of tension.

3. Tendons are similar to ligaments; both are made
of collagen. Ligaments connect one bone to
another, while tendons connect muscle to
bone

4. Each muscle has two tendons, one proximally
and one distally. The point at which the tendon
forms attachment to the muscle is also known
as the myotendinous junction (MTJ) and the
point at which it attaches to the bone is known
as the osteotendinous junction (OTJ).

5. Tendon cells, or tenocytes, are elongated fibroblast
type cells. The cytoplasm is stretched between the
collagen fibres of the tendon. They have a central
cell nucleus with a prominent nucleolus. Tendon
cells have a well-developed rough endoplasmic
reticulum and they are responsible for synthesis
and turnover of tendon fibres and ground
substance.

6. Healing
The tendons in the foot are highly complex and
intricate, the healing process for a broken
tendon is long and painful. Most people who
don’t receive medical attention within the first
48 hours of the injury will suffer from severe
swelling, pain, and a burning sensation where
the injury occurred.

7. The three main stages of tendon healing are;
1. Inflammation,
2. Repair or proliferation,
3. Remodeling.
which can be further divided into consolidation
and maturation. These stages can overlap
with each other.

8. In the first stage, inflammatory cells such as
neutrophils are recruited to the injury site,
along with erythrocytes.
Monocytes and macrophages are recruited
within the first 24 hours, and phagocytosis of
necrotic materials at the injury site occurs.
After the release of vasoactive and chemotactic
factors, angiogenesis and the proliferation of
tenocytes are initiated.

9. Tenocytes then move into the site and start to
synthesize collagen III. After a few days, the
repair or proliferation stage begins. In this
stage, the tenocytes are involved in the
synthesis of large amounts of collagen and
proteoglycans at the site of injury, and the
levels of GAG and water are high.

10. After about six weeks, the remodeling stage
begins. The first part of this stage is
consolidation, which lasts from about six to
ten weeks after the injury.
Then final maturation stage occurs after ten
weeks, and during this time there is an
increase in crosslinking of the collagen fibrils,
which causes the tissue to become stiffer.
Gradually, over about one year, the tissue will
turn from fibrous to scar-like.

11. Types of tendon injury
( TENDINOPATHY)
1. Tendonitis. This type of tendon overuse
injury occurs when tiny tears develop in your
tendon, which leads to pain and
inflammation.
2. Tendonosis. This tendon condition often
occurs after tendonitis and is characterized
by a breakdown of collagen in your tendons.

12. Tendinopathy, also known as tendinitis or
tendonitis, is a type of tendon disorder that
results in pain, swelling, and impaired function.
The pain is typically worse with movement. It
most commonly occurs around the shoulder
(rotator cuff tendinitis, biceps tendinitis), elbow
(tennis elbow, golfer's elbow), wrist, hip, knee
(jumper's knee), or ankle (Achilles tendinitis)

13. SIGNS AND SYMPTOMS
Symptoms includes
1. tenderness on
palpation,
2. swelling,
3. pain, often
when exercising
or with a
specific
movement
CAUSES
1. Causes may include an injury or
repetitive activities. Groups at risk
include people who do manual
labor, musicians, and athletes.
2. Less common causes include
infection, arthritis,gout, thyroid
disease, and diabetes. Despite the
injury of the tendon there is poor
healing.

14. Quinolone antibiotics are associated with
increased risk of tendinitis and tendon rupture.
A 2013 review found the incidence of tendon
injury among those taking fluoroquinolones to
be between 0.08 and 0.2%. Fluoroquinolones
most frequently affect large load-bearing
tendons in the lower limb, especially the Achilles
tendon which ruptures in approximately 30 to
40% of cases.
Stephenson, AL; Wu, W; Cortes, D; Rochon, PA (September 2013). "Tendon Injury and Fluoroquinolone Use: A Systematic
Review". Drug Safety. 36 (9): 709–21. doi:10.1007/s40264-013-0089-8. PMID 23888427.
FDA May 12, 2016 FDA Drug Safety Communication: FDA advises restricting fluoroquinolone antibiotic use for certain uncomplicated infections; warns about
disabling side effects that can occur Archived 2016-08-25 at the Wayback Machine
Bolon, Brad (2017-01-01). "Mini-Review: Toxic Tendinopathy". Toxicologic Pathology. 45 (7): 834–837. doi:10.1177/0192623317711614.
ISSN 1533-1601. PMID 28553748.

15. TYPES
1. Achilles tendinitis
2. Calcific tendinitis
3. Patellar tendinitis (jumper's knee)

16. 1. CALCIFIC TENDINITIS
A common condition where calcium deposits form
in a tendon.
sometimes causing pain at the affected site most
common in the rotator cuff of the shoulder.
Around 80% of those with deposits experience
symptoms, typically chronic pain during certain
shoulder movements, or sharp acute pain that
worsens at night.

17. Calcific tendinitis is typically diagnosed by
physical exam and X-ray imaging.
The disease often resolves completely on its
own, but is typically treated with non-steroidal
anti-inflammatory drugs to relieve pain, rest
and physical therapy to promote healing, and
in some cases various procedures to
breakdown and/or remove the calcium
deposits.

19. 2. ACHILLES TENDINITIS
achilles tendinopathy, occurs when the Achilles
tendon, found at the back of the ankle,
becomes inflamed. The most common
symptoms are pain and swelling around the
affected tendon. The pain is typically worse at
the start of exercise and decreases thereafter.
Stiffness of the ankle may also be present.
Onset is generally gradual.

20. It commonly occurs as a result of overuse such as
running. Other risk factors include trauma, a
lifestyle that includes little exercise, high-heel
shoes, rheumatoid arthritis, and medications of
the fluoroquinolone or steroid class. Diagnosis is
generally based on symptoms and examination.

22. 3. PATELLAR TENDINITIS, also known as
jumper's knee, is an overuse injury of the
tendon that straightens the knee. Symptoms
include pain in the front of the knee. Typically
the pain and tenderness is at the lower part of
the kneecap, though the upper part may also be
affected. Generally there is not pain when the
person is at rest. Complications may include
patellar tendon rupture.

24. Risk factors include being involved in athletics and
being overweight. It is particularly common in
athletes who are involved in jumping sports such
as basketball and volleyball.
The underlying mechanism involves small tears in
the tendon connecting the kneecap with the
shinbone.
Diagnosis is generally based on symptoms and
examination. Other conditions that can appear
similar include infrapatellar bursitis,
chondromalacia patella and patellofemoral
syndrome

25. CORE SUTURE TECHNIQUES

26. For tendon laceration or lengthening procedures, core
suture repair techniques may be employed. Many
variations of tendon repair exist, including some
described by
1. Kessler
2. Savage
3. Lee
4. Becker
5. Tajima
6. Tsuge
7. Krakow

28. Classic repair techniques, including Kessler and
Tajima techniques, had only 2 suture arms
spanning the repair site and represent weaker
repair constructs.
However, there are disadvantages of the multi-
strand repair, which include added bulk and
uneven repair due to the complexity of
multiple tendon passes. It is generally
recommended that 4 to 6 sutures cross the
repair site, in addition to a running epitenon
stitch.

31. Nature of suture in tendon repair
Suture type for tendon repair traditionally consisted
of non-absorbable braided synthetic polyester
material
More recent tendon repair descriptions have
employed non-absorbable monofilament
material as the suture of choice. For example,
prolene suture has been shown to generate less
friction and cause less tendon deformation than
braided suture.5

32. Suture placement must also been considered for
individual patient needs. Volar or plantar
suture placement has been shown to minimize
interruption of blood flow.
However, dorsal suture placement creates pull
out strength, which is 50% stronger than volar
suture placement

33. TENDON RETUBULARIZATION
Tendon retubularization is commonly performed
in podiatric surgery for a variety of etiologies.
A repair technique commonly employed by
The Podiatry Institute will be reviewed.

34. Once the appropriate tendon has been
identified, a step-wise approach for repair may
be implemented.
The tendon must first be visualized above and
below the suspected location of pathology.
It is also necessary to inspect the tendon along all
anatomic surfaces.

35. Tendon debridement follows visualization, with
removal of all nonviable or hypertrophic
portions of tendon.
If the tendon appears heavily diseased, it may
be necessary to perform an anastamosis to a
nearby tendon or graft the repair site, rather
than attempt salvage.

36. The area of tendon retubularization should then
have the superficial epitenon fibers
superficially debrided in order to promote
adhesion of the deep surfaces and increase
frictional force.
A running non-absorbable suture, such as #3-0
Ethibond, should be continuously run along the
interior surface with alternating superficial
suture passes, about 2 to 3mmon either side of
the tendonmidline

37. Next, a second pass may be made slightly more
laterally along the tendon in a similar manner as
described above. If the repair site does not have a
large width, then a single continuous suture line
may adequately allow for repair, but this must be
determined on an individual basis.
The purpose of these suture passes is to provide
retubularization to a flattened tendon with a non-
exposed or buried suture.

38. Additional retubularization techniques have
been described, including techniques for
Jones or Chrisman-Snook procedures. This
technique involves an interior running simple
stitch, which is converted into an outer
baseball stitch in the opposite direction.
This applicationmay also provide beneficial in
certain cases, but does not allow for a
combination of sutures

39. Pace’s technique for tendon retubularization. Double-over technique for tendon
shortening.
MTPJ capsular plication technique.

40. medical management of tendon rupture
1. Resting the tendon by using crutches.
2. Applying ice to the area.
3. Taking over-the-counter pain relievers.
4. Keeping the ankle from moving for the first few
weeks, usually with a walking boot with heel
wedges or a cast, with the foot flexed down.
5. Anti-inflammatory drugs.
o RICE (rest, ice, compression, and
elevation).