OSTENIL® TENDON – The Preferred Treatment for Paratenonitis? 

Patella tendinopathy and Achilles tendinopathy are common disabling disorders, limiting both daily and sporting activities. The pathogenic process is attributed to tendon overload and overuse, often seen in elite athletes and individuals who pursue recreational sports. Different pathological stages of the tendon disease have been defined thanks to the Cook and Purdam pathology model of tendon disease1, although the authors of this widely cited continuum model have recently offered further consideration regarding the complex inter-relationships between structure, pain, and function within any model of tendinopathy, and how these factors may be useful in determining appropriate treatment modalities2.

Clinically it is often difficult to distinguish between pathological changes to the tendon itself and any accompanying paratenonitis. Thus, emphasis is typically placed on managing the tendinopathy rather than any associated paratenonitis. The paratenon is a thin membrane covering the whole of the Achilles tendon allowing for a free gliding of the tendon body within, and also serves as a vascular structure bringing the blood supply to the tendon.

Acute paratenonitis represents an acute inflammatory response within the paratenon, with fluid and accumulation of inflammatory cells and fibrin within the tendon sheath. The accumulation of fluid may impair normal tendon glide and there may be palpable or even audible crepitus. The fibrin in the tendon sheath can organize and lead to adhesions. Diagnosis in the acute phase is manifest with fluid within the paratenon with or without thickening of the paratenon. 

Due to the lubricating, anti-inflammatory and viscous properties of Ostenil® Tendon (2% Sodium Hyaluronate with Mannitol), the infiltrate provides for optimal distention or stripping of the paratenon in chronic paratenonitis, either on its own for smaller, localized adhesive disruption, or as an adjunct to high volume stripping. 

Figure 1, 2 and 3 (from left) Injecting into the paratenon with advancing needle tip and Ostenil® injectate *.


Case Report 1 

A 30 year old midfield footballer presented with symptoms of Achilles tendinosis of the right ankle. For the previous couple of months he had been experiencing some pain around his right Achilles, and had tried to manage the symptoms by essentially stretching, and employing physiotherapy-based modalities with some eccentric work. He was taking analgesics and described himself as being able to play at around 80% of his optimal level. 
On examination he was hyper-pronated bilaterally which was passively correctable. He was using orthotics in his shoes, and there was a slight length discrepancy between right and left legs. He was able to hop on each leg but tenderness was more pronounced on the right leg towards the mid part of the tendon. He had no tenderness at the Achilles insertion or retro-calcaneal bursa. 
He underwent treatment with Ostenil® Tendon following stripping of the paratenon, and tendon movement was visibly more normative and free-gliding on ultrasound visualisation following the injection. The player avoided any strenuous training for 2 days, but did follow a moderate physiotherapy regime. He returned to play a game 4 days after first treatment, reporting that his ankle felt much better. He subsequently had a second injection of Ostenil® Tendon and finished the season with the play offs (3-4 further games). 
(Contributed by Prof S Jari and Prof W Bhatti)



Case Report 2

 A 22 year old professional rugby player complained of increasing right medial knee pain on running and side stepping activity for a 2 week period after increasing activity levels in pre-season training; this reached the point where he was unable to run.

Clinical examination revealed no effusion; there was pain around the medial joint line and femoral attachment of the medial collateral ligament (MCL). There was pain but no click, on McMurray’s testing; the knee was ligamentously stable, specifically with a stable MCL. There was no pain around the pes anserinus or posteromedially around the pes tendons. The clinical diagnosis was a medial meniscal tear with synovitis related to the medial joint line, possibly related to an extruded medial meniscus.

Despite rest, anti-inflammatory medication and physiotherapy, the pain persisted and therefore prompted a magnetic resonance imaging (MRI) scan; this showed a complex tear of the medial meniscus with high signal around the menisco-femoral aspect of the MCL, underneath the superficial fibres.
 
Image of the MRI scan of the right knee showing the
complex medial meniscal tear (broken arrow)
with high signal consistent with deep seated synovitis
around the menisco-femoral aspect of the MCL. (Arrow)


Given the lack of an effusion, and the presence of joint line pain moving up towards the femoral MCL attachment, an ultrasound scan was performed to ascertain: the areas of inflammation correlating to areas of pain; any injury to the menisco-femoral part of the MCL; the presence of meniscal extrusion on dynamic ultrasound of the medial meniscus (Acebes et al.) and the presence of hypervascularity on Doppler testing (De Maeseneer et al.).
 
Image showing hypoechoic change consistent with deep
synovitis at the femoral MCL.
Arrow – Hypoechoic change underneath superficial MCL
MFC – Medial Femoral Condyle

 
Image showing the medial meniscus (M) with a hypoechoic cleft
consistent with a tear (broken arrow); there is a hypoechoic region
underneath the superficial MCL (white squares) on the femoral side (arrow).
T – Tibia
MFC – Medial Femoral Condyle

Ultrasound scanning was consistent with the MRI scan and confirmed the presence of deep MCL synovitis clinically. The menisco-femoral ligament was normal with surrounding hypoechoic change and hypervascularity consistent with synovitis. The meniscus was not extruding on dynamic testing (knee flexion) (Acebes et al.).

The patient was advised that, while he has a meniscal tear, the pain was most likely coming from the medial joint line and synovitis around the medial capsule and around the deep aspect of the menisco-femoral ligament as seen on ultrasound. An ultrasound guided injection of hyaluronic acid deep to the menisco-femoral ligament was therefore recommended as the next step in management.

Under ultrasound control, a 22 gauge needle was inserted around the focal area of synovitis of the femoral aspect of the medial joint line capsule, correlating to the area of hypoechoic change seen on initial ultrasound; five millilitres of 1% lignocaine was injected into the soft tissues beforehand. One 2ml syringe of 2% hyaluronic acid with Mannitol (Ostenil® Tendon) was then injected deep to the menisco-femoral MCL.

The player was kept off feet for 72hrs and retested at that stage and continued with physiotherapy treatments – there was marked clinical improvement in symptoms and he underwent a graduated return back to training activities with no reaction or recurrence.

The use of hyaluronic acid was discussed with the player and coaching staff – whilst the normal approach would be to inject corticosteroid, giving shorter recovery time, long term results are similar using hyaluronic acid (although it takes longer to have an initial effect) and avoided the use of a steroid injection in this case.
(Contributed by Dr Kal Parmar)


References: 

1. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med 2009;43:409–16.

2. Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research?
Cook JL, et al. Br J Sports Med 2016;0:1–7. doi:10.1136/bjsports-2015-095422


This article appeared in Issue 38 Spring 2017 of BASEM Today magazine. http://library.myebook.com/BASEM/basem-today-38-spring-2017/538/#page/8