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© 1998 The Journal of Bone and Joint Surgery, Inc.
CorrespondenceTO THE EDITOR: We read with interest the Instructional Course Lecture "Tendon Problems in Athletic Individuals" (79-A: 138–152, Jan. 1997), by Teitz et al. The authors should be congratulated for their overview of this subject. However, in general, we find that the evidence presented is very biased toward the American literature, and, with some notable exceptions, the scientific output from the other side of the Atlantic has not been considered. We disagree with several of the points raised by Teitz et al. Our present practice and our scientific work indicate that lateral tendinopathy of the elbow, commonly known as tennis elbow, is not a homogeneous diagnosis7. We have shown that the pain, tenderness, and functional impairment seen with tennis elbow can be caused by several different lesions that at times are associated. With the use of real-time high-resolution ultrasonography, we were able to show that tennis elbow may be caused by an enthesopathy, tendinitis, peritendinitis, bursitis, intramuscular hematoma, or a mixed lesion. The type of lesion may have bearing on the treatment of the condition, as bursitis and intramuscular hematoma are more likely to have a benign course and do well with non-operative treatment. Real-time high-resolution ultrasonography, although mentioned in the section on jumper's knee, was totally ignored in the section on dysfunction of the Achilles tendon; however, we have shown that real-time high-resolution ultrasonography can identify the various lesions that may involve the Achilles tendon5,6. We have also shown that, with patellar tendinopathy, ultrasonography was useful for identification of the pathological lesions, while computerized tomography seemed to give a better indication of whether the lesion would respond to non-operative treatment1. The procedure advocated by Nirschl and Pettrone10 was the only one described for the operative treatment of tennis elbow. However, we have found that this operation is technically demanding and does not address the underlying etiology of the condition. Tennis elbow can be considered a traction tendinopathy. The operation that we have performed in several hundreds of patients is simple detachment of the origin of the common extensor14. In fact, one of us has had this operation without any adverse effect, and he has returned to orthopaedic teaching and to elite performance in judo and wrestling. We were surprised to see that our work on the diagnosis and operative treatment of patellar tendinopathy1-3 was ignored in favor of the study by Roels et al.11, which dealt with only ten patients and was published nearly two decades ago. Our present operative treatment consists of a longitudinal incision in the midline or just medial to the medial border of the patellar ligament. The ligament is exposed and the paratenon is excised. We consider excision of the paratenon an important part of the procedure as almost all of our failures have been due to only partial excision of the paratenon. In our experience, intraoperative palpation is sufficient to identify the degenerated area, which is then excised through a longitudinal tenotomy. We do not advocate, and frankly discourage, closure of the tendon with sutures, especially absorbable sutures. Absorbable material can be absorbed only through an inflammatory process, and this may act as an additional focus of intratendinous pathological change. We fully agree with Teitz et al. that the present terminology of Achilles tendinopathy is misleading. We recognize that most patients who eventually consult an orthopaedic surgeon do not have a tendinitis (an inflammatory condition) but rather have a tendinosis (a degenerative condition). However, it is possible that after an acute bout of exercise an acute inflammatory process causes a tendinitis, which, thanks to local vascularity, tends to chronicity and degeneration. We disagree with the definition of tendinitis as an inflammation of the tendon sheath without intrinsic tendinous changes. Kvist and Kvist4 as well as Williams15 (who, despite having reported the largest series of operatively treated Achilles tendinopathy of which we are aware, was not cited by Teitz et al.) showed clearly that the paratenon is involved in the pathological process on its own. In our experience, an intratendinous lesion can be associated with a paratendinous one. In these cases, it is necessary to address both problems. Stripping of the paratenon is a necessary part of operative treatment. Unfortunately, in our experience, paratenonitis does not always respond to non-operative treatment. In these cases, we advocate operative treatment. With regard to physical examination, a simple test described by Williams15, which is well known in North America9, is the painful arc sign. This is helpful for distinguishing between paratenonitis and a tendinopathy, and it can identify an association between the two. We were surprised at the complexity of the operative techniques described for treatment of dysfunction of the Achilles tendon. In patients who have focal tendinopathy, we approach the tendon through a longitudinal medial paratendinous excision; we excise the paratenon, taking care not to interfere with the mesotenon; and, with palpation, we identify the diseased area. This area is then excised through a longitudinal tenotomy, and the margins of the tendons are left open. If the lesion involves the whole tendon, we do not attempt to excise it and we do not reconstruct the tendon. Instead, we perform multiple parallel longitudinal tenotomies12. We recently assessed our results with longitudinal percutaneous tenotomies for focal lesions8. Finally, we were surprised at how conservative the postoperative treatment was for such patients. We perform these operations on a day-case (outpatient) basis, and patients are able to bear weight on the day of the operation. Patients are allowed to walk with weight-bearing as tolerated for two to four weeks. During this phase, it is essential to regain the full range of motion of the ankle before a strengthening program is begun. By then the patient will have started cycling and swimming, and he or she can resume gentle jogging ten to twelve weeks after the operation and return to full activities six months postoperatively. Professional soccer players may play within three months after the operation. We are aware of the differences in clinical practice among countries, but in this age of evidence-based medicine it is probably better if we acknowledge and analyze these differences instead of ignoring them.
Nicola Maffulli, M.D., M.S., Ph.D., F.R.C.S.(Orth): Department of Orthopaedic Surgery, University of Aberdeen Medical School, Polwarth Building, Foresterhill, Aberdeen AB9 2ZD, Scotland Peter M. Binfield, F.R.C.S.: South Warwickshire Hospital, Lakin Road, Warwick CV34 5BW, England John B. King, F.R.C.S.: The Academic Department of Sports Medicine, The Royal London Hospital (Mile End), Bancroft Road, London E1 4DG, England
Dr. Teitz, Dr. Garrett, Dr. Miniaci, Dr. Lee, and Dr. Mann reply: Dr. Maffulli et al. state that tennis elbow may be caused by "an enthesopathy, tendinitis, peritendinitis, bursitis, intramuscular hematoma, or a mixed lesion." In a study published in 19907, they noted six different types of ultrasonographic findings in patients who had clinical signs of tennis elbow. However, they provided little or no correlation to the operative findings, having operated on only four of the forty-one patients who had an ultrasonographic examination. As we mentioned in the section on jumper's knee, or so-called patellar tendinosis, we have also used ultrasonography to identify abnormal intratendinous lesions13. However, we found at the operation that the hypoechoic areas did not correspond with hematomas but rather with fibrinoid necrosis. We agree that ultrasonography can be useful in the diagnosis of Achilles tendinopathy, as can magnetic resonance imaging. However, in most cases, the diagnosis can be made on a clinical basis. The ultrasonography studies mentioned by Maffulli et al. help us to understand the pathological anatomy but are not indicated except in the rare case in which the diagnosis is in doubt. We have not used computerized tomography scanning in the diagnosis of tendinitis. With regard to excision of paratenon, we have not done this partly because of concern regarding decreasing the vascular supply to the tendon further, the potential for adhesions, and our good results without excision of the paratenon. The supposition of Maffulli et al. that absorbable sutures will act as an additional focus of intratendinous pathological change is interesting. However, we have not noted this, and their reports5-7 provide no data to support it. Perhaps a multicenter trial to look at these issues specifically would be enlightening. As we mentioned in the second to last paragraph of our article: "Perhaps in some patients, a microscopic tear in the tendon initiates an inflammatory response that, if not treated, is replaced by tissue that resembles a failed repair or degenerative process." This is similar to what Maffulli et al. called an acute inflammatory process followed by chronicity and degeneration. The predominant difference is in semantics (microscopic tear compared with tendinitis). In most cases, so-called tendinitis or, preferably, peritendinitis is basically an inflammation affecting the tendon sheath. While there may occasionally be changes within the substance of the tendon, these are uncommon, as reported by Kvist and Kvist4. In fact, the only mention of tendon involvement in their series of more than 100 patients was an occasional small lesion, which was thought possibly to be a subclinical tear in the substance of the tendon. Maffulli et al. suggest a different operative approach from ours for patients who have focal Achilles tendinopathy. They excise the paratenon and perform multiple parallel longitudinal tenotomies. However, as their article describing this procedure was in press at the time of this writing, we cannot comment on it. The operative treatment that we described for a localized area of Achilles tendinosis, namely, the weaving of the plantaris through the involved area, probably accomplishes the same goal—that is, stimulation of an inflammatory healing response—as multiple parallel longitudinal tenotomies. Maffulli et al. also commented that our postoperative treatment for Achilles tendinosis seemed conservative. In our experience, most of these patients still have sufficient discomfort around the operative site postoperatively to delay unrestricted weight-bearing for two to four weeks. We agree that after this type of operative procedure the patient's activities may progress as symptoms permit and that non-impact-type activities, such as cycling and swimming, are more advisable at first. The program of resumption of gentle jogging ten to twelve weeks postoperatively and a return to full activity six months later as suggested by Maffulli et al. is virtually identical to that mentioned in our article (a return to increased activity in three to six months). We thank Maffulli et al. for drawing our attention to their work. We were not ignoring them but rather were basing our written material on our clinical findings. Furthermore, our article was not meant to be an exhaustively referenced original research article but rather a transcript of an Instructional Course Lecture in which we based our instruction on both our research and our clinical findings.
Carol C. Teitz, M.D.: Division of Sports Medicine, Department of Orthopaedics, University of Washington, 300 HEC Edmundson Pavilion, Box 354060, Seattle, Washington 98195-4060 William E. Garrett, Jr., M.D., Ph.D.: Duke University Medical Center, Box 3435, Durham, North Carolina 27710 Anthony Miniaci, M.D.; M. H. Lee, M.D.: Toronto Western Hospital, 399 Bathurth Street, Suite ECW 1-038, Toronto, Ontario M5T 2S8, Canada Roger A. Mann, M.D.: 330 Webster Street, Suite 1200, Oakland, California 94609
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