Advances in

Understanding
Tendinopathy
George A. C. Murrell, MD,
PhD

ORTHOPAEDIC RESEARCH INSTITUTE

St George Hospital Campus
University of New South Wales
AUSTRALIA
 18
Mean age
Number of swimmers

16
14
12
10
8
6
4
2
0
13 14 15  16  17  18 19  20 21  22  23  25 
Years
 45
40
Number of swimmers

35
30
25
20
15
10
5
0

Club State National International

 Kilometers per Week
Median 40 kilometers

16
14
Number of swimmers

12
10
8
6
4
2
0
9 20 21 23 25 30 31 32 34 35 36 38 40 44 45 50 55 60 65 70 80 90 110

Kilometers
MRI Findings

69%
supraspinatus
tendinosis
 Supraspinatus Tendinosis
100%
90%
80%
70%
60% 52%
50%
40% 30%
30%
15%
20%
10% 2%
0%
Grade 0 Grade 1 Grade 2 Grade 3
 r = 0.49

***
40

35

30

25
Number of
swimmers 20
15
10
5 Tendinosis

0
No tendinosis
Impingement
No Impingement
 r = 0.35, p = 0.01
1.2

1.0
Supraspinatus tendinosis

YES
0.8

0.6

0.4
No
0.2

0.0

5 10 15 20 25 30 35
Hours swum per week
 r = 0.34, p =
0.01
1.2
Suprapsinatus tendinosis

1.0

YES
0.8

0.6

0.4

No
0.2

0.0

35
0 20 40 60 80 100

Kilometres swum per week

Athletes who
• trained > 15 hrs/wk were
twice as likely to have
supraspinatus tendinosis ( r =
0.48, p = 0.001)

•swam >35 km/wk were 4

times more likely to have
supraspinatus tendinosis
( r = 0.37, p = 0.01)
 Shoulder Laxity

35     Median 1.52 
mm
30
Number of swimmers

25
20
15
10
5
0
0-1 mm 1-2 mm 2-3 mm 3-4 mm 4-5 mm 5-6 mm

Laxity in millimeter
 No r = 0.24, p = 0.08
association
6.6
6.2
5.8
5.4
5
4.6
4.2
3.8
Shoulder laxity in mm

3.4
3
2.6
2.2
1.8
1.4
1
0.6
0.2
-0.2
-0.6
-1
-1 0 1 2 3

Grade 0 Grade 1 Grade 2 Grade 3

Supraspinatus  tendinosis
 No association

Between supraspinatus
tendinopathy and:
• Specific types of swimming
stroke
• Number of years with
coaching
• Training time spent with
each of the four main
strokes
 Overuse
Laxity

Impingement
 Aetiology
•Overus
e

 Soslowsky et al, 1999, 2000
 CA

Overuse
• Increased
cellularity
• Loss of
collagen fiber
organisation OV
• Larger
tendons
• Inferior
mechanical
properties

 Soslowsky et al, 1999, 2000
Overuse
How does overuse
cause tendon
degeneration?
Age and Rotator Cuff Tears
 Protein 
Kinases

Stress

APOPTOSIS

Tendon Degeneration
 Ai Wei, MD
Jun Yuan, MD

Is apoptosis involved in
tendon degeneration ?
Min Wang, PhD
 Materials

25 human
supraspinatus
tendons
 Materials

6 human
subscapularis
tendons
 Materials

Six pairs of
• subscapularis tendon
• supraspinatus tendon
 Methods

In situ DNA end labeling

assay
• TUNEL
 Methods

DNA laddering
assay
Negative Control
Vascular changes 400x
 Apoptosis
***
40

30

Percentage of apoptotic cells (%)

20

10

0
RCN RCT

Uninjured Torn
subscapularis supraspinatus
Apoptosis: Paired samples

Uninjured Torn
supraspinatus supraspinatus
 Apoptosis: In Subscapularis in patients…

30

Percentage of apoptotic cells (%)

*
25

20

15

10

0
-RCT + RCT

with an intact with a torn

supraspinatus supraspinatus
 DNA laddering assay

1 2 1 2

Lane 1: subscapularis tendon

Lane 2: supraspinatus tendon
Identification of fibroblast-like cells
with anti-human fibroblast antibodies (arrows)

400 x
 Protein 
Kinases

Stress

APOPTOSIS

Tendinopathy
Tendon  Tear
Degeneration