Abstract
The pathogenesis of tendon degeneration and tendinopathy is still partially unclear. However, an active role of metalloproteinases (MMP), growth factors, such as vascular endothelial growth factor (VEGF) and a crucial role of inflammatory elements and cytokines was demonstrated. Mechanical stimulation may play a role in regulation of inflammation. In vitro studies demonstrated that both pulsed electromagnetic fields (PEMF) and extracorporeal shock wave therapy (ESWT) increased the expression of pro-inflammatory cytokine such as interleukin (IL-6 and IL-10). Moreover, ESWT increases the expression of growth factors, such as transforming growth factor β(TGF-β), (VEGF), and insulin-like growth factor 1 (IGF1), as well as the synthesis of collagen I fibers. These pre-clinical results, in association with several clinical studies, suggest a potential effectiveness of ESWT for tendinopathy treatment. Recently PEMF gained popularity as adjuvant for fracture healing and bone regeneration. Similarly to ESWT, the mechanical stimulation obtained using PEMFs may play a role for treatment of tendinopathy and for tendon regeneration, increasing in vitro TGF-β production, as well as scleraxis and collagen I gene expression. In this manuscript the rational of mechanical stimulations and the clinical studies on the efficacy of extracorporeal shock wave (ESW) and PEMF will be discussed. However, no clear evidence of a clinical value of ESW and PEMF has been found in literature with regards to the treatment of tendinopathy in human, so further clinical trials are needed to confirm the promising hypotheses concerning the effectiveness of ESWT and PEMF mechanical stimulation.
Highlights
Tendon disorders include both acute and chronic diseases, such as tendinopathy
Along with tenocytes, the human tendons are composed by tendon stem/progenitor cells (TSPCs), that guarantee to the Mechanical stimulation and tendon regeneration tendon the ability to repair and regenerate and help in maintaining the homeostasis (Bi et al, 2007)
Despite the lack of recent literature sustaining a long-term positive effect of pulsed electromagnetic fields (PEMF) in treating shoulder and elbow tendon disorders (Uzunca et al, 2007; Bisset et al, 2011; Dingemanse et al, 2014), a positive effect of PEMF in reducing lateral epicondylitis pain was described at a short term follow-up (3 months)
Summary
Tendon disorders include both acute and chronic diseases, such as tendinopathy. It is know that the tendon tissue is poorly cellularized, with 5% of the normal tissue occupied by tenocytes that produce the extracellular matrix (ECM), based on type I collagen. The rationale of the study was to maintain cell-to-cell contacts and cell interactions with the ECM during ESWT, as it is a crucial point in the mechano-trasduction process Physical forces, such as soft-focused ESWT, may influence conformational changes in membrane proteins, such as integrines, resulting in an intracellular signal with a modification of gene expression and growth factors release (de Girolamo et al, 2014). An increased expression of SCX, collagen type I genes (regulated by SCX expression), TGF-β, anti-inflammatory cytokines IL-6 and Il-10 and VEGF (stimulated by IL-6 and IL-10) was observed during the first 7 days after exposure to soft-focused ESW, SCX transcription decreased rapidly during the first 4 days All these results suggest that soft-focused ESWT may positively modulate the initial beneficial inflammatory phase of the tendon healing process (Visco et al, 2014) and “normalize” the anabolic activities of tendon cells.
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