Optimal management of tendon overuse injuries in equine and human athletes should avoid the formation of excessive scar tissue, regenerate normal tendon matrix, and reduce re-injury rates. We hypothesized that the implantation of marrow-derived stromal stem cells (BM-MSCs), in far greater numbers than are present normally within tendon tissue, would synthesize a matrix more closely resembling tendon matrix than scar tissue, and hence increase the capacity to return to performance successfully. This article reviews the technique used clinically in the horse and the current outcome data for horses treated by the autologous implantation of BM-MSCs into moderate to severe acute superficial digital flexor tendon (SDFT) injuries. Bone marrow was aspirated from the sternum under standing sedation. The nucleated adherent cell population (containing the BM-MSCs) were isolated and expanded so that, after approximately three weeks, the cells were re-suspended in the supernatant from the bone marrow and implanted into injured SDFT under ultrasonographic guidance. The horses then entered a 48-week rehabilitation period consisting of an ascending exercise regime. By September 2006, 168 racehorses had undergone this regimen. For horses which had returned to full work, 18% had re-injured, which compared favourably to previous studies on conventional management (56% re-injury rate). No adverse effects were noted other than needle tracts visible ultrasonographically. Autologous implantation of mesenchymal stem cells into tendon injuries may therefore improve clinical outcome although definitive proof of efficacy, which is still lacking, will require randomized controlled trials.

Mesenchymal stem cell therapy for equine tendinopathy

The repair process of tendon injuries, which are common in both human and equine athletes, is slow and the quality of the repair tissue is often inferior to the original tendon tissue, which frequently leads to re-injury. The relatively poor vascularization of tendons is considered to be one of the reasons for their limited healing potential. Recently, platelet-rich plasma (PRP), an autologous concentrate of platelets, rich in growth factors, has been shown to enhance the repair process of injured tendons. This effect has been ascribed to the high levels of growth factors in PRP, several of which are known to be involved in tendon repair. Among many other growth factors, the vascular endothelial growth factor, a powerful stimulator of angiogenesis, is abundantly present in PRP, suggesting that enhancement of neovascularization might be one of the working mechanisms. In this study, the effect of PRP on neovascularization was studied in experimentally induced tendon injuries using color Doppler ultrasonography and immunological staining of Factor VIII. PRP induced significantly more neovascularization than the placebo treatment until at least 23 weeks after treatment, as detected by both Doppler ultrasonography and Factor VIII staining. Neovascularization might be one of the explanations for the long-lasting effect of a single intratendinous treatment with PRP.

The effect of platelet‐rich plasma on the neovascularization of surgically created equine superficial digital flexor tendon lesions

Importance of the field: Tendon disorders are frequent and are responsible for much morbidity, both in sport and the workplace. Although several therapeutic options are routinely used, very few well-conducted randomised prospective, placebo, controlled trials have been performed to assist in choosing the best evidence-based management.Areas covered in this review: We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL, and Embase databases over the years 1966 – 2010 to review the best evidence-based options for the management of patients with tendinopathy.What the reader will gain: The reader will obtain information on the available medical and surgical therapies used to manage tendinopathy-related symptoms. The effectiveness of therapies, the length of management and the adverse effects are examined.Take-home message: Management of tendinopathy is often anecdotic and lacking well-researched scientific evidence. Teaching patients to control the symptoms may be more beneficial than leadin...

Current treatment options for tendinopathy

Study Design A controlled, randomized, prospective study. Objective To assess the changes in paratendon microcirculation after 12 weeks of daily painful eccentric training in individuals with chronic Achilles tendinopathy. Background Changes in tendon and paratendon microcirculation are evident in insertional and midportion Achilles tendinopathy. Whether the paratendon is involved in eccentric training response is not known. Methods Twenty patients with chronic Achilles tendinopathy were recruited for a prospective, controlled trial using eccentric exercise. A laser Doppler system assessed capillary blood flow (flow), tissue oxygen saturation (S02), and postcapillary venous filling pressure (rHb) at 8 paratendon locations at depths of 2 and 8 mm. Results Pain in the eccentric-training group was reduced by 48% (from a mean of 4.1 ± 2.9 to 2.1 ± 2.2, P<.05). Deep paratendon blood flow decreased at the midportion paratendon location (P<.05). Superficial blood flow at the medial distal midportion position (by...

Eccentric training decreases paratendon capillary blood flow and preserves paratendon oxygen saturation in chronic achilles tendinopathy.

Despite the high incidence of superficial digital flexor tendon (SDFT) injury in racehorses, the pathobiology of the condition is not clearly defined. The SDFT improves locomotor efficiency by storing elastic energy, but as a result it has low mechanical safety margins. As with the Achilles tendon in humans, rupture during athletic activity often follows accumulation of exercise and age-induced degenerative change that is not repaired by tenocytes. There is limited understanding of tenocyte biology and pathology, including responses to high mechanical strains and core temperatures during exercise. Unfortunately, much of the current information on SDFT pathology is derived from studies of collagenase-induced injury, which is a controversial model. Following rupture the overlapping phases of reactive inflammation, proliferation, remodelling and maturation do not necessarily reconstitute normal structure and function, resulting in long-term persistence of scar tissue and high re-injury rates. Tissue engineering approaches are likely to be applicable to SDFT lesions, but will require significant advances in cell biology research.

The pathobiology of exercise-induced superficial digital flexor tendon injury in Thoroughbred racehorses

Recent research on chronic painful Achilles tendons in humans using ultrasonography and immunohistochemistry, has demonstrated an association between neurovascular ingrowth and tendon pain. In horses, chronic debilitating tendon conditions are well-known to be very difficult to treat, and the background to impaired function and pain is not scientifically clarified. In a collaborative research project between the Sports Medicine Unit in Umea and Stromsholm Equine Hospital, grey-scale ultrasonography (US) and colour Doppler (CD) examination were performed in ten horses with chronic tendon injuries (>3 months) and a control group of six healthy and asymptomatic horses. In all symptomatic tendons, but not in any of the tendons in the control group, neovessels were seen in the area with structural tendon changes. The neovessels found in the horse tendons looked similar to what has recently been presented in human Achilles tendons. These findings motivate evaluation of the same treatment, a sclerosing injection that was demonstrated recently to give promising results in the treatment of chronic Achilles tendon injuries (tendinosis) in humans.

Neovascularisation in chronic tendon injuries detected with colour Doppler ultrasound in horse and man: implications for research and treatment

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Neovascularisation in chronic tendon injuries detected with colour Doppler ultrasound in horse and man: implications for research and treatment