Study Title: Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy Author(s): Cook JL, Purdam CR Publication Information: British Journal of Sports Medicine 2009; 43: 409-416. BACKGROUND INFORMATION Tendon injuries are extremely common and encountered frequently in all manual medicine settings, including chiropractic offices. Many years ago, the pain in chronic tendon overuse injuries was believed to be the direct result of a chronic inflammatory process, but because inflammatory cells could be consistently demonstrated in damaged tendons, the opinion changed from inflammation (implied by the older term ‘‘tendinitis’’) to degeneration (rep-resented by the newer terms ‘‘tendinosis’’ or “tendinopathy”). There is controversy, however – although most histologic findings in tendinopathy represent chronic degeneration, regen-eration, and microtears of the tendinous tissue, newer studies using immunohistochemistry and flow cytometry have shown inflammatory cells. The goal of this review paper was to discuss these findings in the framework of a new continuum pathology model for load-induced tendinopathies. General Considerations In general, tendon injuries can occur in the mid-tendon or at the attachment of the ten-don to the bone, also called the enthesis. Although the mid-portion and insertion sites of tendons are structurally different when normal, the onset of pathology creates cell and matrix alterations that are virtually indistinguishable. That being said, the reader should Dr. Shawn Thistle is the founder and president of Research Review Service Inc., an online, subscription-based service designed to help busy practitioners to integrate current, relevant scientific evidence into their practice. Shawn graduated from CMCC and holds an Hon-ours Degree in Kinesiology from McMaster University. He also holds a certificate in Contemporary Medi-cal Acupuncture from McMaster University, and is a Certified Active Release Techniques (ART®) Pro-vider. For more information about the Research Review Service, visit www.researchreviewservice.com. be reminded that in some regions (specifically the Achilles) – insertional and mid-portion tendinopathies respond differently to the same treatment intervention. Despite the obvious importance of load in tendon injuries, it is rarely considered when implementing treatment – the authors propose that their model will take this into account and assist the clinician to tailor treatment to the pathology. The authors propose the following pathological continuum model that has three phases:j 1. Reactive Tendinopathy 2. Tendon Disrepair (failed healing) 3. Degenerative Tendinopathy CONCLUSIONS AND PRACTICAL APPLICATIONS The authors of this paper have presented a simple and succinct model for load-induced tendinopathy that appropriately includes contemporary, multidisciplinary literature on this topic. The authors wisely reiterate that this is merely a model of pathology, and that clinicians should remember that load tolerance and soft tissue healing are individual factors with wide variability. That being said, they have provided an excellent and simple framework for us to work with. They also emphasize the need for more research on early-stage tendon pathology, the area that is currently most lacking. • For full review, including more detailed tendinopathy concepts, a full description of the most recent model of tendon pathology and treatment considerations, study limitations and additional references, please visit www.canadianchiropractor.ca. This brief review is a sample of the content posted weekly on Research Review Service and is one of over 60 reviews available per year of the latest scientific literature in chiropractic. RRS is approved for 4.0 CEUs/year by CMCC. 42 • CANADIAN CHIROPRACTOR | JULY/AUGUST 2010 www.canadianchiropractor.ca Shawn Thistle, BKin (Hons), DC, CSCS
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