This is the title of an interesting editorial in this week’s British Medical Journal (now there’s a contradiction in terms). The gist of it is that most medics, including sports medics, believe that overuse of tendons such as the Achilles and patellar tendons leads to a mostly inflammatory process in the tissues. The “itis” bit in the name just denotes inflammation of the affected part. However, studies of affected tendons show damage to and separation of the constituent parts (collagen fibrils), with an increase in repair cells but no inflammatory cells. Therefore, contrary to received wisdom (and 10 of the 11 best-known sports medicine textbooks), it’s a damage process not an inflammatory one.

So what? You may well ask. The least important consequence is that the name is wrong: it should be “tendinosis”. More importantly, anti-inflammatory drugs, including the non-steroidal anti-inflammatory drugs (NSAIDs) usually prescribed, are a waste of time. Even more importantly, neither these nor any other drug available will accelerate the repair process needed for the affected tendon to heal. Steroid injections might provide some pain relief – although the evidence is mixed – but could actually delay healing. The authors conclude that “… by accepting the need to allow time for collagen turnover and remodelling inherent in the pathology of tendinosis, doctors would be free to provide patients with a realistic prognosis… these conditions take months rather than weeks to resolve”.

From the various statements released by the club, I am sure that the approach adopted by our sports medicine/physio team is a brief period of rest coupled with NSAIDs (and maybe some initial local measures like cooling). I don’t think we are alone in adopting that approach. It does worry me however that trying to reduce the rest period for tendon (and other) injuries with NSAIDs and steroid injections to rush players back just results in them breaking down again in short order. How many times have we seen that over recent years? We can all see the pressure to get Craig Bellamy (patellar tendonosis) back to playing, but we might be jeopardising his and our longer term future by adopting the wrong approach to it.

-- Anonymous, March 19, 2002

Answers

Anti Pharmacology?

-- Anonymous, March 19, 2002

You say 'tendinitis', I say 'tendinosis'... :-)

There is always a danger of a conflict of interest with health and sports, so it might be argued that this is a occupational hazard. And the club might not be sympathetic to calls for a 3 month layoff when the player can run and play. A risk worth taking for the £30k a week?

BTW - I've found my right knee starts to hurt after running for about 20 mins. It's improved after some 4 weeks of non-impact exercise (i.e. not treadmill, using elecpital machine instead). Is this tendinosis? Thanks for the free consultation ;-)

-- Anonymous, March 19, 2002

one of the best posts for ages. definitely leave him out until next season. he could be an even better player given rest.

-- Anonymous, March 19, 2002

The wily Magpies boss also revealed that renowned knee surgeon Dr Richard Steadman - responsible for saving Alan Shearer's career - has been consulted. "We're in touch with Dr Steadman," he added. "In conjunction with what he is telling us, we're doing the right thing with Craig. "He is allowing us to push him on a bit and see if there is any reaction. We're trying to get him fit as soon as we can.''

-- Anonymous, March 19, 2002

Very interesting Dr Bill. So how sure is the BMJ that this "received wisdom" is incorrect? I notice that the title of the editorial has a "?" which suggests that the jury is still out on the issue? Mind, in terms of the anecdotal evidence from SJP the new theory might indicate some truth.

You mention these steroid injections and NSAIDS. Does sports medicine clash with the rules on the use of drugs by players in any way? Obviously some steroids are banned - what's the difference here? Is there a constant battle in drawing the line between approved and banned drugs in this field? Or is a question of quantities used?

Anyway, I still think you should brush up that CV of yours Bill, and get in there and sort the SJP medical staff out.

Now, about my bad back ....

-- Anonymous, March 19, 2002

As a long-term user of NSAID's and a Finnish international in sitting volleyball, there does not seem to be any problems with these drugs and sport. The NSAID's I know and use are not banned substances and are easy and trouble-free to use. I have been tested for doping a couple of times and given all-clear. As far as I know, steroids given locally are not a problem doping-wise.

Interestingly, the NSAID I am using at the moment ('Nimed' or 'Nimesulid') has now been banned by the gov't watchdog in Finland. Presumably they have caused elevated liver content in the bloodstream with a number of patients and major liver problems with some patients. These findings have been contested by the manufacturer (well, what can you expect), and according to them the drug is safe. Dunno about safe, but it works like magic. A swollen ankle today, cured tomorrow. Brilliant.

-- Anonymous, March 19, 2002

This useful information just reinforces what I believe to be true. Top class footballers push themselves to the point where they break down. Top class clubs, without exception, have enough in their squads to rest players.

Take Shearer for example, he has had a number of really bad set backs in his time at NUFC yet still he has played every minute of every game since Sunderland in September, he would not have done this at every club in with a shout of the Champs league.

Top top players must be used only when they are most needed.

If we want to progress in the big time - what a sickener Saturdays result was BTW - we need the money the big time generates and to spend it wisely. Only then will we get the best use out of the fantastic talent on our books.

This may seem obvious but think of the cost of these players we need? I want our club to be the best it can be and I don’t mind playing the money for my season tix, but it’s expensive and I detect that footy is at the top of the curve at the moment, just look at some of the FAC crowds this season. NUFC have to be very very brave right now if the club is to get where we want it to be.

If Bellemy, Dyer or any other player needs rest than it is stupid not to rest them. To get the best out of our players we need more players.

Tough at the top alright.

-- Anonymous, March 19, 2002

Drugs and sport is very obviously a difficult area!

NSAIDs are not a problem from the doping point of view. They will reduce pain and swelling, especially if there is underlying inflammation, as Mika illustrates. The issue is whether they mask the underlying non-inflammatory overuse problem (tendinosis) and encourage people to overuse the affected part again before it's ready.

Steroids come in two basic flavours. Anabolic steroids, such as testosterone and its derivatives, cause muscle build up as well as other changes (including aggression). Hence, unfair advantage in sports, banned substances (but incredibly widely used, races between the development of chemistry to detect and chemistry to conceal, etc etc). Corticosteroids don't cause (much of) the same, but can cross- react on some tests if given systemically (eaten, injected into vein). However, they are widely used in medicine for a variety of reasons, one being to reduce inflammatory responses (again), ususally by local injection. If given locally, they should not cross-react with anabolic steroids or cause general problems, but can weaken the tissues.

I seem to remember that Private Eye used to have a character called Anna Bollock-Steroid, btw.

-- Anonymous, March 19, 2002

Mika - interesting stuff. You've kept all that very quiet. Any pictures of you on the web playing for the national team?

If this newish theory is correct Dr. Bill, then as you say we may be damaging Bellamy's longer term prospects (makes mental note - sell him to Manu in 2 years time) with the standard treatment. Which other players have suffered tendinosis and would have been subjected to this treatment in our recent history? Shearer? Any others? I'm just wondering if there is any anecdotal evidence to support the idea that present treatments are doing more harm than good.

My back is still giving me jip BTW...

Ron Knee (tight lipped and ashen-faced)

-- Anonymous, March 19, 2002

Thanks for the interest Jonno. There is plenty of photographic material in the 'photo gallery' at www.wovd.com, but couldn't find one representing myself, although I have been to some of the tournaments listed (well.. ehrm.. our squad has strength in depth).

It is good to discuss about the long-term effects of these treatments, and especially so in the case of a young player such as Bellamy. I think Shearer went through three (or was it two) jabs of cortisteroids before his surgery last year. I can distinctly remember all the speculation about his career ending because of his persistent tendinosis. Was all that due to his age, or due to his condition? In the latter case, with short-term treatment we might end up crocking the boy.

I know I'm crocked, and that is the reason why I get to play sitting volleyball at an international level. Young Bellers is better standing, and running.

-- Anonymous, March 19, 2002