392 LEADER
Tendinopathies compared apoptosis by using the TUNEL
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................................................................................... and DNA laddering techniques in the
edges of torn rotator cuff supraspinatus
Understanding tendinopathies tendons removed at surgery with normal
appearing samples of subscapularis ten-
dons also taken at surgery. There was a
G A Murrell threefold increase in apoptosis in torn
................................................................................... tendinopathic rotator cuff tendon com-
pared with the control tendon. The
Is apoptosis the heart of the problem? proportion of cells undergoing apoptosis
increased with age and was also greater
in the “normal” subscapularis tendons
O
ne of the “banes” of most health larger than normal in cross sectional
of patients with torn rotator cuff tendons
professionals who look after ath- area and had deteriorated mechanical
compared with subscapularis tendons of
letes and workers is tendinopa- properties. Specifically, they had a de-
patients with intact supraspinatus ten-
thies. What causes them? What gets creased modulus of elasticity and a
dons.
them better? Recently there have been decreased maximum stress at failure.
several advances that may contribute to If over-exercise is so important, then
our understanding of these disorders. the next question is how stress translates “ . . .there is indeed increased
We all know that tendinopathies occur into these degenerative changes? Arnoc- apoptosis or programmed cell
in the tendinous portion of musculo- zky et al3 4 have recently shown in death in human rotator cuff
tendinous units that cross joints, often cultured canine patellar tendon cells that tendons with tendinopathy”
two joints—for example, the extensor there is a direct relation between the
carpi radialis brevis in tennis elbow, the amount of stress the tendon cells see and We can hypothesise therefore that
patellar tendon in jumpers knee—and the induction of a stress activated pro- tendinopathy may follow a pathway
that they occur in situations of repetitive, tein kinase (c-Jun N-terminal kinase illustrated in fig 1. An increase in the
high, often eccentric loading. The classic (JNK)). Cyclic strain resulted in an amount and duration of load that a ten-
pathology is a loss of the normal immediate activation of JNK, which don cell sees may result in activation of
collagenous architecture and replace- peaked at 30 minutes. This activation intracellular stress activated protein ki-
ment with an amorphous mucinous was regulated by a magnitude depend- nases, which when persistently activated
material that lacks the parallel, longitu- ent, but not frequency dependent, cal- cause the tendon cells to undergo apop-
dinal architecture of normal tendon.1 cium dependent mechanotransduction tosis or programmed cell death. In-
Soslowsky et al2 made a major advance pathway. Whereas transient JNK activa- creased cell death results in a collagen-
when they developed an animal model tion is associated with normal cell proc- ous matrix which is weaker and more
that could reproduce many of the micro- esses, persistent JNK activation has been prone to tearing. With time, this tendon
scopic changes of supraspinatus tendin- linked to the initiation of apoptosis—or may rupture.
opathy. The model involved running rats programmed cell death.5 Clearly, there are many details to
on a treadmill for up to an hour a day for This work links nicely with some of insert into this pathway but there is hope
4–16 weeks. Supraspinatus tendons in our recent work,6 7 which shows that that if we can flesh out the fine details of
the exercised animals had an increase in there is indeed increased apoptosis or the pathway, then we may be able to
cellularity and loss of their normal colla- programmed cell death in human rotator develop strategies to break the cycle at
gen fibre organisation. The tendons were cuff tendons with tendinopathy. We one or more points and prevent and/or
treat tendinopathy more effectively.
ACKNOWLEDGEMENTS
This work was supported in part by South
Eastern Sydney Area Health Service/St
George Hospital and NiCox Corporation.
Br J Sports Med 2002;36:392–393
.....................
Author’s affiliation
G A Murrell, Orthopaedic Research Institute,
St George Hospital, University of New South
Wales, Sydney, Australia
Correspondence to: Professor Murrell, Research
and Education Center, 4–10 South St, Kogarah,
Sydney, NSW 2217, Australia;
[email protected] REFERENCES
1 Khan KM, Cook JL, Bonar F, et al.
Histopathology of common tendinopathies.
Update and implications for clinical
management. Sports Med 1999;27:393–
408.
2 Soslowsky LJ, Thomopoulos S, Tun S, et al.
Figure 1 A schematic representation of how tendinopathies may arise. An increase in the Neer Award 1999. Overuse activity injures
the supraspinatus tendon in an animal model:
amount and duration of load that a tendon cell experiences may result in activation of protein a histologic and biomechanical study.
kinases, which when persistently activated cause the tendon cells to undergo apoptosis Shoulder Elbow Surg 2000;9:79–84.
(programmed cell death). Increased cell death results in poor collagen synthesis and matrix 3 Arnoczky S, Tiam T, Schuler P, et al.
remodelling and a collagenous matrix that is weaker and more prone to tearing. With time, Upregulation of stress-activated protein
this tendon may rupture. kinases (SAPK) in response to increased
www.bjsportmed.com
LEADER 393
cystolic calcium levels due to cyclic strain: a (SAPK) in tendon cells following cyclic strain: 6 Yuan J, Murrell G, Wei A-Q, et al. Apoptosis
Br J Sports Med: first published as 10.1136/bjsm.36.6.392 on 1 December 2002. Downloaded from http://bjsm.bmj.com/ on 18 August 2019 by guest. Protected by copyright.
potential cellular mechnaism for repetitive the effects of strain frequency, strain in rotator cuff tendonopathy. In: 47th Annual
stress injuries in tendons. In: 47th Annual magnitude, and cytosolic calcium. J Orthop Meeting, Orthopaedic Research Society;
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2001 February 25–28; San Francisco. 5 Wisdom R, Johnson RS, Moore C. c-Jun 2001:0115.
2001:0020. regulates cell cycle progression and apoptosis 7 Yuan J, Murrell GAC, Wei A-Q, et al.
4 Arnoczky SP, Tiam T, Lavagnino M, et al. by distinct mechanisms. EMBO J Apoptosis in rotator cuff tendonopathy. J
Activation of stress-activated protein kinases 1999;18:188–97. Orthop Res 2002:in press.
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394 LEADER
Boxing is no loss of consciousness (grade II),
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................................................................................... after a medical examination the boxer is
taken to hospital for a neurological
Safety measures in amateur boxing examination and computed tomography.
If there is any loss of consciousness,
either brief (seconds) or prolonged
P Jako (minutes), the boxer is immediately
................................................................................... transferred to the nearest emergency
department by ambulance. Return to
Amateur boxing has become one of the safest contact sports boxing depends on the severity of the
concussion, but a 28 day rest period is
the minimum. Before a boxer is allowed
to fight again, he must be passed fit by a
“It must be satisfactory to all true lovers International Amateur Boxing Associ-
neurologist, after examinations by com-
of the Art, as a national and progressive ation (AIBA) recorded the statistics of
puted tomography or magnetic reso-
institution, to feel that the past few years five Olympic Games and eight World
nance imaging (MRI). The decision of
have witnessed changes—mostly in the Championships between 1980 and
the neurologist is recorded in the boxer’s
right direction—in the science of Box- 1999 (4043 boxers, 3887 bouts). In
record book.
ing.” This was written by Allanson-Winn 1980 at the Olympic Games, 11% of
Repetitive concussion or subconcus-
in 1897.1 Since then, more than 1200 bouts ended in KO and 6.4% in RSC-H,
sive blows to the brain may lead to
articles have been published on medical and bouts were stopped because of
chronic traumatic brain injury.4 Al-
and ethical aspects of boxing, usually not injury (mostly to facial areas) in 12.2%.
though studies indicate that amateur
differentiating between amateur and At the World Championships in 1999,
boxers do not exhibit any particular
professional. Most of the studies have the equivalent values were 0.3%, 1.5%,
signs of neuropsychological5 or cerebral
methodological problems: few cases and 0.3%.3
blood flow dysfunction,6 to minimise the
were analysed; there was a lack of risk of this, after repeated KO or RSC-H
adequate controls; in many studies the HOW DID AMATEUR BOXING the rest period is one year or even
boxers were about 60 years old and were BECOME SAFER SO THAT TODAY enforced retirement.
boxing before safety rules and careful IT IS NO MORE DANGEROUS It is debatable whether headguards
medical supervision had been intro- THAN ANY OTHER CONTACT diminish the impact of a blow, but it is
duced; the authors could not distinguish SPORT? indisputable that, since their mandatory
between the late impact of the blows and The main reasons are: use in amateur boxing, the rate of facial
the effects of the ageing process or other
• very careful medical control; injuries has dramatically diminished.
factors, such as alcohol consumption, In amateur boxing the referees watch
that produce similar clinical and mor- • use of protective equipment;
the athletes more closely than in many
phological changes in the brain. • improved refereeing;
other contact sports, and they stop the
During the last two decades, amateur • new AIBA regulations; bout immediately if a boxer is unfit to
and professional boxing have become • sophisticated diagnostic imaging and continue. The increasing rate of RSC
completely separate. The main differ- neuropsychological tests. (referee stopping the contest) indicates
ences are as follows. All novice boxers undergo a compre- the increased control in the ring.
• Amateur boxing uses the same set of hensive medical evaluation, including The modifications of the AIBA rules
rules world wide, whereas profes- ophthalmic examination, resting electro- over the last two decades based on medi-
sional boxing has different sets of cardiogram, and laboratory tests. The cal considerations have served to protect
rules. medical examination is repeated annu- the boxers.3
• In amateur boxing the main objective ally. The results are recorded in the box- The importance of MRI in the early
is to score points, and the knockout or er’s record book. No boxer is allowed to detection of sport related head injuries is
knockdown is a byproduct. In profes- compete at any tournament without the well known. In the future new tech-
sional boxing knockout and/or knock- production of his/her record book. The niques (SPECT, functional MRI) should
down is an objective. AIBA medical handbook contains a list of provide more insights into the patho-
pathological findings that preclude a physiolgical and functional sequelae of
• In amateur boxing the wearing of a
person from becoming a boxer. injuries.7
headguard is mandatory, whereas in
During a tournament, on the day of Neuropsychological testing is a prom-
professional boxing the use of a head-
the bout the ringside doctor carries out a ising tool in the early detection of any
guard is prohibited.
physical examination before the compe- deterioration in neurocognitive status.8 If
• In amateur boxing the ringside doctor tition to ensure that the boxer is fully fit a brief, standardised method of neuro-
may suspend the action at any point to to box. This medical check up is also psychological testing applicable for
examine the boxer and his decision to recorded in the boxer’s record book. worldwide use should become available,
stop or continue a bout is binding, During the bout, the ringside doctor it should be introduced as part of the
whereas in professional boxing this has the right to stop the bout for medical annual medical examination of boxers.
rarely happens. reasons. In the case of a knockout, the This is not an official statement of the
• In amateur boxing if a boxer is “down” management follows the guidelines of AIBA but is based on AIBA articles and
and fails to resume boxing within 10 the Medical handbook of amateur boxing. If rules and on the recommendations of
seconds (KO) or if a boxer is unfit to there is transient confusion, no loss of the AIBA medical handbook (2000).
continue having received several hard consciousness, and the symptoms re- Br J Sports Med 2002;36:394–395
blows to the head (RSC-H), he is not solve in 15 minutes (grade I), the doctor
allowed to compete or workout in the should perform a thorough medical .....................
gym for a specified period of time (at examination to determine the need and
Author’s affiliation
least four weeks). In professional box- nature of further medical observation or P Jako, International amateur Boxing
ing, in theory this is done but not in all hospital admission. If the concussion Association (AIBA), Veress Palne u 33, 1053
cases.2 The medical commission of the symptoms last for 15 minutes, but there Budapest, Hungary
www.bjsportmed.com
LEADER 395
Correspondence to Dr Jako; 3 Jako P. Modifications of the rules in amateur 6 Rodriguez G, Vitali P, Nobili F. Long-term
Br J Sports Med: first published as 10.1136/bjsm.36.6.392 on 1 December 2002. Downloaded from http://bjsm.bmj.com/ on 18 August 2019 by guest. Protected by copyright.
[email protected] boxing and their effect reflected in the effects boxing and judo: choking on brain
statistics of Olympic Games and World function. Ital J Neurol Sci 1998;19:367–72.
Championships. Hungarian Review of Sports 7 Johnston KM, Ptito A, Chankowsky J, et al.
REFERENCES Medicine 2000;LXI:173–81. New frontiers in diagnostic imaging in
4 Rabadi MH, Jordan BD. The cumulative effect
1 Allanson-Winn RG. Boxing. London: AD of repetitive concussion in sports. Clin J Sport concussive head injury. Clin J Sport Med
Innes and Co, 1897. Med 2001;11:194–8. 2001;11:166–75.
2 Cantu RC. Boxing and medicine. 5 Butler RJ. Neuropsychological investigation 8 McCrea M. Standardized mental status
Champaign, IL: Human Kinetics, of amateur boxers. Br J Sports Med assesment of sport concussion. Clin J Sport
1995:11–16. 1994;28:187–90. Med 2001;11:176–81.
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