Editorials
Current Understanding of Tendinopathies and Treatment Options
See related article on page 843.
Overuse tendon injuries (i.e., tendinopathies) commonly occur in recreational and competitive athletes but can also occur in nonathletes. In this issue of American Family Physician, the article on lateral epicondylitis by Johnson and colleagues includes numerous treatment options for tendinopathies; however, no clear-cut option emerges as the best evidence-based approach.1 Despite the high prevalence of reported tendinopathies and the many treatment options, the underlying pathology that affects a particular tendon and its surrounding structures can be unclear.
The understanding of tendon injury has evolved over the past decade. Previously, it was thought that tendon injury was caused by inflammation (tendinitis). Tendon injury is now considered to be a spectrum of disorders, and persistent inflammation is not typically associated with overuse tendon injuries.
Acute tendon injuries have a classic in-flammatory response; however, it is difficult to determine when the injury has progressed from the inflammatory stage to failed healing or tendinosis. Microscopic changes such as fibrin deposition, lack of neutrophils and macrocytes, neovascularization, and increased collagen synthesis and breakdown commonly occur in chronically painful tendon and peritendinous injuries.2 This failed healing response is thought to be caused by poor blood supply or ongoing mechanical forces on the lesion. The term tendinopathy has been adopted to encompass the various tendon pathologies such as tendinitis, tendinosis, and paratendinitis when histopathologic evidence is unavailable to definitively determine the stage of injury.
Tendons are composed of collagen bundles, tendon cells (tenocytes), and proteoglycans. Collagen provides tensile strength, proteoglycans provide structural support, and tenocytes are a load-responsive network stimulated by increases in mechanical load. The collagen bundles; elastin; and an inner synovial lining surrounded by vascular, lymphatic, and nerve structures form the peritendon.3 Repetitive mechanical forces or poor technique during work- or activity-related movement can break down the peritendinous structures.
Tensile, compressive, or shearing forces cause mechanical loading on the tendon and its associated structures. Tensile forces from repetitive microtrauma are the most common loads placed on tendons.4 This can occur in the elbows of athletes who participate in throwing sports, but it is just as common in the elbows of mothers who carry their babies for long periods. Compressive forces occur when tendons wrap around bony prominences such as the acromion process, or occur within narrow spaces such as the carpal tunnel. Chronic compression of the tendon causes stiffer, less-tensile movement, which predisposes the tendon to injury.5 The effect of shearing forces most often occurs at points of friction.
Treatment options for tendinopathies range from a wait-and-see approach to surgical debridement of chronic lesions.1 The numerous options support the theory that no one treatment stands out as the superior choice.6-8 Questions remain about whether the same treatment approaches can be applied to all types of tendinopathies or if certain treatment combinations are more effective than others.
Physicians should first look for correctable causes of injury such as muscle imbalances, biomechanical issues, or errors in an athlete's training technique. Muscle imbalances commonly contribute to tendinopathies of the rotator cuff, where the chest wall muscles are usually stronger than the back muscles. Physical therapy that focuses on strengthening the scapular and upper back muscles often can help prevent future rotator cuff injury. Similarly, correcting biomechanical issues (e.g., pes planus, leg length discrepancies) with custom-made orthotics can help alleviate many lower extremity tendinopathies.
Educating patients about training techniques related to their sports will help prevent many tendon injuries. Concepts such as gradual increases in training intensity and duration and avoiding the "no pain, no gain" mantra are good starting points. More in-depth advice can be provided by viewing a video of the athlete participating in the sport and analyzing the athlete's gait and motion or by having the athlete participate in expert coaching sessions.
Outside the acute setting, tendon injuries are typically not inflammatory in nature; keeping this in mind may prompt physicians to avoid using nonsteroidal anti-inflammatory drugs alone for the treatment of these injuries. Symptom reduction through the judicious use of modalities such as physical therapy, topical and oral analgesics (including acetaminophen), corticosteroid injections, topical nitrates, bracing, and ultrasonography appears to provide subjective pain relief and improved function. Although there is no strong evidence to support this benefit,6-8 these modalities should be continued if clinically appropriate until better options are available.
Future research is needed to bridge the gap between physicians' basic scientific knowledge and their clinical experience in the treatment of tendinopathies. In the meantime, treatment should focus on the correction of underlying causes to reduce the risk of progression to a chronic condition, and on appropriately controlling the patient's discomfort.
Address correspondence to Carrie A. Jaworski, MD, at cjaworski@reshealthcare.org. Reprints are not available from the author.
Author disclosure: Nothing to disclose.
REFERENCES
1. Johnson GW, Cadwallader K, Scheffel SB, Epperly TD. Treatment of lateral epicondylitis. Am Fam Physician 2007;76:843-8, 849, 851.
2. Scott A, Khan KM, Roberts CR, Cook JL, Duronio V. What do we mean by the term "inflammation"? A contemporary basic science update for sports medicine. Br J Sports Med 2004;38:372-80.
3. Scott A, Ashe MC. Common tendinopathies in the upper and lower extremities. Curr Sports Med Rep 2006;5:233-41.
4. Scott A, Khan KM, Heer J, Cook JL, Lian O, Duronio V. High strain mechanical loading rapidly induces tendon apoptosis: an ex vivo rat tibialis anterior model. Br J Sports Med 2005;39:e25.
5. Almekinders LC, Weinhold PS, Maffulli N. Compression etiology in tendinopathy. Clin Sports Med 2003;22:703-10.
6. Newcomer KL, Laskowski ER, Idank DM, McLean TJ, Egan KS. Corticosteroid injection in early treatment of lateral epicondylitis. Clin J Sports Med 2001;11:214-22.
7. Woodley BL, Newsham-West RJ, Baxter GD. Chronic tendinopathy: effectiveness of eccentric exercise. Br J Sports Med 2007;41:188-98.
8. Murrell GA. Using nitric oxide to treat tendinopathy. Br J Sports Med 2007;41:227-31.
Principles of the Patient-Centered Medical Home
See related editorial on page 775.
An article on this topic appears in the September 2007 issue of Family Practice Management.
The American Academy of Family Physicians (AAFP), American College of Physicians (ACP), American Academy of Pediatrics (AAP), and American Osteopathic Association (AOA), representing about 333,000 physicians, have developed joint principles to describe the characteristics of the patient-centered medical home.
Research has shown that primary care matters in terms of access, cost, and quality. Patients who have an ongoing relationship with a primary care physician have better outcomes and lower costs. When care is managed effectively by primary care physicians in the ambulatory setting, patients with chronic diseases have fewer complications, which leads to fewer avoidable hospitalizations.1 The following principles have been adopted by each organization and form the cornerstone of advocacy in the public and private sectors:
Principles
Personal physician: each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous, and comprehensive care.
Physician-directed medical practice: the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.
Whole-person orientation: the personal physician is responsible for providing for all of the patient's health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life, acute care, chronic care, preventive services, and end-of-life care.
Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient's community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange, and other means to ensure that patients get the indicated care, when and where they need and want it, in a culturally and linguistically appropriate manner.
Quality and safety are hallmarks of the medical home.
• Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care planning process driven by a compassionate, robust partnership among physicians, patients, and the patient's family.
• Evidence-based medicine and clinical decision-support tools guide decision making. Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement. Patients actively participate in decision making, and feedback is sought to ensure that patients' expectations are being met.
• Information technology is used appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication.
• Practices go through a voluntary recognition process by an appropriate nongovernmental entity to demonstrate that they have the capabilities to provide patient-centered services consistent with the medical home model.
• Patients and families participate in quality-improvement activities at the practice level.
Enhanced access to care is available through systems such as open scheduling, expanded hours, and new options for communication between patients, their personal physician, and practice staff.
Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home. The payment structure should be based on the following framework:
• It should reflect the value of physician and nonphysician staff patient-centered care management work that falls outside the face-to-face visit.
• It should pay for services associated with coordination of care within a given practice and between consultants, ancillary providers, and community resources.
• It should support adoption and use of health information technology for quality improvement.
• It should support provision of enhanced communication access such as secure e-mail and telephone consultation.
• It should recognize the value of physician work associated with remote monitoring of clinical data using technology.
• It should allow for separate fee-for-service payments for face-to-face visits (payments for care management services that fall outside of the face-to-face visit, as described above, should not result in a reduction in the payments for face-to-face visits).
• It should recognize case mix differences in the patient population being treated within the practice.
• It should allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting.
• It should allow for additional payments for achieving measurable and continuous quality improvements.
Background of the Medical Home Concept
The AAP introduced the medical home concept in 1967, initially referring to a central location for archiving a child's medical record. In its 2002 policy statement, the AAP expanded the medical home concept to include these operational characteristics: accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective care.
The AAFP and the ACP have since developed their own models for improving patient care called the "medical home" (AAFP, 2004) or "advanced medical home" (ACP, 2006).
For More Information
American Academy of Family Physicians
http://www.futurefamilymed.org
American Academy of Pediatrics
http://aappolicy.aappublications.org/policy_statement/index.dtl#M
American College of Physicians
http://www.acponline.org/advocacy/?hp
American Osteopathic Association
http://www.osteopathic.org
Address correspondence to Rick Kellerman, MD, at rkellerman@aafp.org. Reprints are not available from the authors.
Author disclosure: Nothing to disclose.
REFERENCES
1. American Academy of Family Physicians. Value of Family Medicine. Accessed August 7, 2007, at: http://www.aafp.org/online/en/home/policy/familymedvalue.html.
Improving Care with the Patient-Centered Medical Home
See related editorial on page 774.
An article on this topic appears in the September 2007 issue of Family Practice Management.
The joint principles of the patient-centered medical home (PC-MH), released by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association, is a landmark guideline of interprofessional cooperation.1 This guideline is a timely statement of the evidence-based principles of medical care that improve outcomes and lower health care costs for patients. It is also a visionary statement of the principles that professional primary care organizations believe will guarantee continuous practice improvement for decades to come.
The PC-MH captures the family physician's traditional spirit of caring and the contemporary spirit of innovation and integration that goes beyond the walls of a physical office. It is a philosophy that encompasses everything that family physicians do for their patients in their communities-in the office, in the hospital, in partnerships with other organizations, through communication with patients, and through patient advocacy. The PC-MH is currently embraced by many members of the U.S. Congress as the centerpiece for health care system and payment reform.
Family physicians should have a sound understanding of the principles outlined in the joint guideline and should use the terminology to promote the type of care that improves health care equity and quality. Characteristics of an effective medical home are prominently described. In addition to these characteristics, family physicians can also advocate for two other important characteristics: (1) family orientation (the degree to which family members are cared for by the same physician or in the same medical home); and (2) community orientation (the degree to which the practice assesses community health care needs and develops and measures interventions).
Family physicians now have an unprecedented opportunity to join their generalist colleagues with a strong, common voice to influence change in the health care system that will benefit patients and the nation in the coming years.
Address correspondence to Jerry Kruse, MD, MSPH, at jkruse@siumed.edu. Reprints are not available from the author.
Author disclosure: Nothing to disclose.
REFERENCES
1. American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint principles of the patient-centered medical home. March 2007. Accessed July 6, 2007, at: www.medicalhomeinfo.org/Joint%20Statement.pdf.
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