Pearce, Christopher J.; Tan, Audrey
Non-insertional Achilles tendinopathy is a degenerative condition characterised by pain on activity. Eccentric stretching is the most effective treatment. Surgical treatment is reserved for recalcitrant cases. Minimally-invasive and tendinoscopic treatments are showing promising results. Cite this article: Pearce CJ, Tan A. Non-insertional Achilles tendinopathy. EFORT Open Rev 2016;1:383-390. DOI: 10.1302/2058-5241.1.160024. PMID:28461917
Nawoczenski, Deborah A; DiLiberto, Frank E; Cantor, Maxwell S; Tome, Josh M; DiGiovanni, Benedict F
Studies have demonstrated improved ankle dorsiflexion and pain reduction following a gastrocnemius recession (GR) procedure. However, changes in muscle performance during functional activities are not known. The purpose of this study was to determine the effect of an isolated GR on ankle power and endurance in patients with Achilles tendinopathy. Fourteen patients with chronic unilateral Achilles tendinopathy and 10 healthy controls participated in this study. Patient group data were collected 18 months following GR. Pain was compared to preoperative values using a 10-cm visual analog scale (VAS). Patient-reported outcomes for activities of daily living (ADL) and sports were assessed using the Foot and Ankle Ability Measure (FAAM). Kinematic and kinetic data were collected during gait, stair ascent (standard and high step), and repetitive single-limb heel raises. Between-group and side-to-side differences in ankle plantarflexor muscle power and endurance were evaluated with appropriate t tests. Compared with preoperative data, VAS pain scores were reduced (pre 6.8, post 1.6, P < .05). Significant differences were observed between GR and Control groups for FAAM scores for both ADL (GR 90.0, Control 98.3, P = .01) and Sports subscales (GR 70.6, Control 94.6, P = .01). When compared to controls, ankle power was reduced in the involved limb of the GR group for all activities (all P < .05). Between-group and side-to-side deficits (GR group only) were also found for ankle endurance. The gastrocnemius recession procedure provided significant pain reduction that was maintained at the 18-month follow-up for patients with chronic Achilles tendinopathy who failed nonoperative interventions. There were good patient-reported outcomes for activities of daily living. However, compared to controls, ankle plantarflexion power and endurance deficits in the GR group were noted. The functional implications of the muscle performance deficits are unclear, but may be reflective of
Tendons transmit force between muscles and bones and, when stretched, store elastic energy that contributes to movement.(1) The tendinous portion of the gastrocnemius and soleus muscles merge to form the Achilles tendon, which is the largest and strongest in the body, but one of the most frequently injured.(2,3) Conservative management options for chronic Achilles tendinopathy include eccentric (lengthening) exercises, extracorporeal shockwave therapy (ESWT), topical nitroglycerin, low level laser therapy, orthoses, splints or injections (e.g. corticosteroids, hyperosmolar dextrose, polidocanol, platelet-rich plasma), while a minority of patients require surgery (using open, percutaneous or endoscopic methods).(4-8) Here we assess the management options for patients with chronic Achilles tendinopathy (lasting over 6 weeks).
Vulcano, Ettore; Mani, Sriniwasan B; Mani, Sriniwasan; Do, Huong; Bohne, Walter H; Ellis, Scott J
Plantar spurs and Achilles tendinopathy are common causes of heel pain. In the authors' practice, it was anecdotally noted that patients with Achilles tendinopathy often presented with plantar spurs. Nonetheless, there is a shortage of studies investigating whether Achilles tendinopathy and plantar spurs exist concomitantly. A better understanding of the association between the 2 pathologies might help physicians recognize and treat both conditions, educate patients about Achilles tendinopathy and plantar spurs, and ultimately investigate possible underlying causes of both pathologies that could be addressed together. The authors examined the prevalence of plantar spurs in patients diagnosed with Achilles tendinopathy as well as demographic differences within the unilateral and bilateral Achilles tendinopathy populations. A total of 785 patient records were retrospectively reviewed. Mean patient age was 56.2±15.5 years (46.9% men and 53.1% women). Seventy-two (9.2%) patients were affected bilaterally by Achilles tendinopathy. Lateral radiographs were reviewed by an orthopedic surgeon to identify the presence of plantar spurs. A total of 329 (41.9%) patients with Achilles tendinopathy were found to have a concomitant plantar spur. Patients with unilateral Achilles tendinopathy and a plantar spur were more likely to be women (58.7% vs 49.8%, P=.020) and older (62.7 vs 51.7 years, P<.001). In the bilateral Achilles tendinopathy group, there were 46 (63.9%) patients with at least one foot presenting with a plantar spur. The study's findings suggest a significant association between Achilles tendinopathy and plantar spurs. Older women with Achilles tendinopathy are at greater risk of being affected by plantar spurs.
Bullock, Mark J; Mourelatos, Jan; Mar, Alice
Haglund's syndrome is impingement of the retrocalcaneal bursa and Achilles tendon caused by a prominence of the posterosuperior calcaneus. Radiographic measurements are not sensitive or specific for diagnosing Haglund's deformity. Localization of a bone deformity and tendinopathy in the same sagittal section of a magnetic resonance imaging scan can assist with the diagnosis in equivocal cases. The aim of the present cross-sectional study was to determine the prevalence of Haglund's syndrome in patients presenting with Achilles tendinopathy and note any associated findings to determine the criteria for a diagnosis of Haglund's syndrome. We reviewed 40 magnetic resonance imaging scans with Achilles tendinopathy and 19 magnetic resonance imaging scans with Achilles high-grade tears and/or ruptures. Achilles tendinopathy was often in close proximity to the superior aspect of the calcaneal tuberosity, consistent with impingement (67.5%). Patients with Achilles impingement tendinopathy were more often female (p < .04) and were significantly heavier than patients presenting with noninsertional Achilles tendinopathy (p = .014) or Achilles tendon rupture (p = .010). Impingement tendinopathy occurred medially (8 of 20) and centrally (10 of 20) more often than laterally (2 of 20) and was associated with a posterior prominence or hyperconvexity with a loss of calcaneal recess more often than a superior projection (22 of 27 versus 8 of 27; p < .001). Haglund's deformity should be reserved for defining a posterior prominence or hyperconvexity with loss of calcaneal recess because this corresponds with impingement. Achilles impingement tendinopathy might be more appropriate terminology for Haglund's syndrome, because the bone deformity is often subtle. Of the 27 images with Achilles impingement tendinopathy, 10 (37.0%) extended to a location prone to Achilles tendon rupture. Given these findings, insertional and noninsertional Achilles tendinopathy are not mutually
Zwiers, Ruben; Wiegerinck, Johannes I; van Dijk, C Niek
In Achilles tendinopathy, differentiation should be made between paratendinopathy, insertional- and midportion Achilles tendinopathy. Midportion Achilles tendinopathy is clinically characterized by a combination of pain and swelling at the affected site, with impaired performance as an important consequence. The treatment of midportion Achilles tendinopathy contains both non-surgical and surgical options. Eccentric exercise has shown to be an effective treatment modality. Promising results are demonstrated for extracorporeal shockwave therapy. In terms of the surgical treatment of midportion Achilles tendinopathy, no definite recommendations can be made. IV.
Grigg, Nicole L; Wearing, Scott C; O'Toole, John M; Smeathers, James E
Previous research has demonstrated that ground reaction force (GRF) recorded during eccentric ankle exercise is characterized by greater power in the 8- to 12-Hz bandwidth when compared with that recorded during concentric ankle exercise. Subsequently, it was suggested that vibrations in this bandwidth may underpin the beneficial effect of eccentric loading in tendon repair. However, this observation has been made only in individuals without Achilles tendinopathy. This research compared the force frequency characteristics of eccentric and concentric exercises in individuals with and without Achilles tendinopathy. Eleven male adults with unilateral midportion Achilles tendinopathy and nine control male adults without tendinopathy participated in the research. Kinematics and GRF were recorded while the participants performed a common eccentric rehabilitation exercise protocol and a concentric equivalent. Ankle joint kinematics and the frequency power spectrum of the resultant GRF were calculated. Eccentric exercise was characterized by a significantly greater proportion of spectral power between 4.5 and 11.5 Hz when compared with concentric exercise. There were no significant differences between limbs in the force frequency characteristics of concentric exercise. Eccentric exercise, in contrast, was defined by a shift in the power spectrum of the symptomatic limb, resulting in a second spectral peak at 9 Hz, rather than 10 Hz in the control limb. Compared with healthy tendon, Achilles tendinopathy was characterized by lower frequency vibrations during eccentric rehabilitation exercises. This finding may be associated with changes in neuromuscular activation and tendon stiffness that have been shown to occur with tendinopathy and provides a possible rationale for the previous observation of a different biochemical response to eccentric exercise in healthy and injured Achilles tendons.
McClinton, Shane; Luedke, Lace; Clewley, Derek
Midsubstance Achilles tendinopathy is one of the most common lower leg conditions. Most patients can recover with nonsurgical treatment that focuses on tendon loading exercises and, when necessary, symptom modulating treatments such as topical, oral, or injected medication, ice, shoe inserts, manual therapy, stretching, taping, or low-level laser. If unresponsive to initial management, a small percentage of patients may consider shockwave or sclerosing treatment and possibly surgery.
Tompra, Nefeli; van Dieën, Jaap H; Coppieters, Michel W
Tendinopathy is often a chronic condition. The mechanisms behind persistent tendon pain are not yet fully understood. It is unknown whether, similar to other persistent pain states, central pain mechanisms contribute to ongoing tendon pain. We investigated the presence of altered central pain processing in Achilles tendinopathy by assessing the conditioned pain modulation (CPM) effect in people with and without Achilles tendinopathy. 20 people with Achilles tendinopathy and 23 healthy volunteers participated in this cross-sectional study. CPM was assessed by the cold pressor test. The pressure pain threshold (PPT) was recorded over the Achilles tendon before and during immersion of the participant's hand into cold water. The CPM effect was quantified as the absolute difference in PPT before and during the cold pressor test. An increase in PPT was observed in the Achilles tendinopathy and control group during the cold pressor test (p<0.001). However, the CPM effect was stronger in the control group (mean difference=160.5 kPa, SD=84.9 kPa) compared to the Achilles tendinopathy group (mean difference=36.4 kPa, SD=68.1 kPa; p<0.001). We report a reduced conditioned pain modulation effect in people with Achilles tendinopathy compared to people without Achilles tendinopathy. A reduced conditioned pain modulation effect reflects altered central pain processing which is believed to contribute to the persistence of pain in other conditions. Altered central pain processing may also be an important factor in persistent tendon pain that has traditionally been regarded to be dominated by peripheral mechanisms. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
Shimozono, Yoshiharu; Kawano, Hirotaka
Introduction. Disorders of the Achilles tendon can be broadly classified into acute and chronic entities. Few studies have established chronic Achilles tendinopathy as a precursor to acute Achilles ruptures. In this study, we assessed the relationship between Achilles tendinopathy and rupture, clarifying the incidence of rupture in the setting of underlying tendinopathy. Methods. The United Healthcare Orthopedic Dataset from the PearlDiver Patient Record Database was used to identify patients with ICD-9 codes for Achilles rupture and/or Achilles tendinopathy. The number of patients with acute rupture, chronic tendinopathy, and rupture following a prior diagnosis of tendinopathy was assessed. Results. Four percent of patients with an underlying diagnosis of Achilles tendinopathy went on to sustain a rupture (7,232 patients). Older patients with tendinopathy were most vulnerable to subsequent rupture. Conclusions. The current study demonstrates that 4.0% of patients who were previously diagnosed with Achilles tendinopathy sustained an Achilles tendon rupture. Additionally, older patients with Achilles tendinopathy were most vulnerable. These findings are important as they can help clinicians more objectively council patients with Achilles tendinopathy. PMID:28540301
Alfredson, Håkan; Cook, J
Achilles tendinopathy affects athletes, recreational exercisers and even inactive people. The pathology is not inflammatory; it is a failed healing response. The source of pain in tendinopathy could be related to the neurovascular ingrowth seen in the tendon's response to injury. The treatment of Achilles tendinopathy is primarily conservative with an array of effective treatment options now available to the primary care practitioner. If conservative treatment is not successful, then surgery relieves pain in the majority of cases. Directing a patient through the algorithm presented here will maximise positive treatment outcomes. PMID:17311806
Magnan, Bruno; Bondi, Manuel; Pierantoni, Silvia; Samaila, Elena
Achilles tendinopathy is a degenerative, not an inflammatory, condition. It is prevalent in athletes involved in running sports. A systematic literature review on Achilles tendon tendinopathy has been performed according to the intrinsic (age, sex, body weight, tendon temperature, systemic diseases, muscle strength, flexibility, previous injuries and anatomical variants, genetic predisposition and blood supply) and extrinsic risk factors (drugs and overuse), which can cause tendon suffering and degeneration. Different theories have been found: Neurogenic, Angiogenic, Impingement and "Iceberg" Hypotheses. Multiple databases were utilized for articles published between 1964 and 2013. The different hypothesis were analyzed, differently considering those concerning the pathogenesis of tendinopathy and those concerning the etiology of complaints in patients. This review of the literature demonstrates the heterogeneity of Achilles tendinopathy pathogenesis. Various risk factors have been identified and have shown an interaction between them such as genes, age, circulating and local cytokine production, sex, biomechanics and body composition.
Hawks, Matthew Kendall
Background: Achilles tendinopathy is a common injury for active patient populations and is challenging to treat. Acupuncture tendon-based therapy was first described in the Yellow Emperor's Classic of Internal Medicine. In modern times, specific techniques have been described poorly in the literature. The aim of this case report is to describe a new technique of acupuncture for the treatment of Achilles tendinopathy and provide 2 illustrative cases. Cases: Treatments for the 2 patients were performed in a deployed military treatment facility. SERIN® 0.25 mm × 40 mm needles placed at BL 60, BL 61, KI 3, and KI 4, with needles directed into the Achilles tendon of each patient. Needles were inserted until a firm catch of the needle entering the tendon was discerned. Energy was placed from KI 3(-) → KI 4(+) and BL61 (-) → BL 60(+) at 30 Hz for 15 minutes. Results: Both patients reported symptomatic reduction in Achilles tendinopathy pain and functional improvement following the described treatments. Conclusions: This case series describes two cases of successful Achilles tendinopathy therapy using direct tendon needle insertion with electrostimulation. This novel technique may provide an effective adjunct to traditional therapies in the treatment of Achilles tendinopathy.
Abstract Background: Achilles tendinopathy is a common injury for active patient populations and is challenging to treat. Acupuncture tendon–based therapy was first described in the Yellow Emperor's Classic of Internal Medicine. In modern times, specific techniques have been described poorly in the literature. The aim of this case report is to describe a new technique of acupuncture for the treatment of Achilles tendinopathy and provide 2 illustrative cases. Cases: Treatments for the 2 patients were performed in a deployed military treatment facility. SERIN® 0.25 mm × 40 mm needles placed at BL 60, BL 61, KI 3, and KI 4, with needles directed into the Achilles tendon of each patient. Needles were inserted until a firm catch of the needle entering the tendon was discerned. Energy was placed from KI 3(–) → KI 4(+) and BL61 (–) → BL 60(+) at 30 Hz for 15 minutes. Results: Both patients reported symptomatic reduction in Achilles tendinopathy pain and functional improvement following the described treatments. Conclusions: This case series describes two cases of successful Achilles tendinopathy therapy using direct tendon needle insertion with electrostimulation. This novel technique may provide an effective adjunct to traditional therapies in the treatment of Achilles tendinopathy. PMID:28736593
Carmont, Michael R; Maffulli, Nicola
Achilles tendinopathy is understood to be a failed healing response. Operative management is utilised following the failure of non-operative methods. We present a case of Achilles tendon rupture, sustained whilst isometrically loading the Achilles tendon during an eccentric loading exercise programme. Bilateral surgical exploration and debridement had previously been performed after conservative management of bilateral Achilles tendinopathy had been unsuccessful.
Cresswell, F V; Tomlins, J; Churchill, D R; Walker-Bone, K; Richardson, D
A multitude of rheumatologic manifestations have been associated with HIV infection and protease inhibitors use. We describe two cases that display a temporal relationship between initiating Kaletra and developing Achilles tendinopathy. Immediate and dramatic resolution of symptoms occurred on switching from Kaletra to an alternative agent. Clinicians may want to consider a trial of an alternative agent in individuals on Kaletra who experience Achilles tendinopathy. Adverse events must be formally reported so that our understanding of antiretrovirals may continually evolve and aid decisions about antiretroviral prescribing. © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.
Counsel, Peter; Comin, Jules; Davenport, Marcus; Connell, David
The Achilles tendon is composed of fascicles from the soleus and gastrocnemius muscles, which are identifiable as discrete components at anatomical dissection. The pattern of fascicular involvement in Achilles tendinopathy may be characterized at ultrasound, and this characterization is reliable between different observers. Cross-sectional diagnostic study. Level 3. One hundred cases of Achilles tendinopathy were retrospectively evaluated by 2 blinded musculoskeletal radiologists. Using a short-axis anatomical map, each case was categorized as involving the fascicular territories of the medial head of gastrocnemius, lateral head of gastrocnemius, soleus, or combinations of these, or as indeterminate. Both radiologists agreed on the fascicular involvement pattern in 93 of 100 cases; 20 involved only medial gastrocnemius territories, 8 lateral gastrocnemius, 15 soleus, 3 medial and lateral gastrocnemius, 21 medial gastrocnemius and soleus, 9 soleus and lateral gastrocnemius, and 16 the entire tendon, and 1 case was classified as indeterminate. In 7 cases, the interpretations were discordant. The kappa value was calculated as 0.92 (95% CI, 0.86-0.98) in keeping with a high level of interobserver agreement. As assessed at ultrasound, most cases of Achilles tendinopathy involve the medial head of gastrocnemius and/or soleus fascicles. The provided observational data will increase understanding of patterns of Achilles tendinopathy. © 2015 The Author(s).
Counsel, Peter; Comin, Jules; Davenport, Marcus; Connell, David
Background: The Achilles tendon is composed of fascicles from the soleus and gastrocnemius muscles, which are identifiable as discrete components at anatomical dissection. Hypothesis: The pattern of fascicular involvement in Achilles tendinopathy may be characterized at ultrasound, and this characterization is reliable between different observers. Study Design: Cross-sectional diagnostic study. Level of Evidence: Level 3. Methods: One hundred cases of Achilles tendinopathy were retrospectively evaluated by 2 blinded musculoskeletal radiologists. Using a short-axis anatomical map, each case was categorized as involving the fascicular territories of the medial head of gastrocnemius, lateral head of gastrocnemius, soleus, or combinations of these, or as indeterminate. Results: Both radiologists agreed on the fascicular involvement pattern in 93 of 100 cases; 20 involved only medial gastrocnemius territories, 8 lateral gastrocnemius, 15 soleus, 3 medial and lateral gastrocnemius, 21 medial gastrocnemius and soleus, 9 soleus and lateral gastrocnemius, and 16 the entire tendon, and 1 case was classified as indeterminate. In 7 cases, the interpretations were discordant. The kappa value was calculated as 0.92 (95% CI, 0.86-0.98) in keeping with a high level of interobserver agreement. Conclusion: As assessed at ultrasound, most cases of Achilles tendinopathy involve the medial head of gastrocnemius and/or soleus fascicles. Clinical Relevance: The provided observational data will increase understanding of patterns of Achilles tendinopathy. PMID:26502418
Tendinopathy is of distinct interest as it describes a painful tendon disease with local tenderness, swelling and pain associated with sonographic features such as hypoechogenic texture and diameter enlargement. Recent research elucidated microcirculatory changes in tendinopathy using laser Doppler flowmetry and spectrophotometry such as at the Achilles tendon, the patellar tendon as well as at the elbow and the wrist level. Tendon capillary blood flow is increased at the point of pain. Tendon oxygen saturation as well as tendon postcapillary venous filling pressures, determined non-invasively using combined Laser Doppler flowmetry and spectrophotometry, can quantify, in real-time, how tendon microcirculation changes over with pathology or in response to a given therapy. Tendon oxygen saturation can be increased by repetitive, intermittent short-term ice applications in Achilles tendons; this corresponds to 'ischemic preconditioning', a method used to train tissue to sustain ischemic damage. On the other hand, decreasing tendon oxygenation may reflect local acidosis and deteriorating tendon metabolism. Painful eccentric training, a common therapy for Achilles, patellar, supraspinatus and wrist tendinopathy decreases abnormal capillary tendon flow without compromising local tendon oxygenation. Combining an Achilles pneumatic wrap with eccentric training changes tendon microcirculation in a different way than does eccentric training alone; both approaches reduce pain in Achilles tendinopathy. The microcirculatory effects of measures such as extracorporeal shock wave therapy as well as topical nitroglycerine application are to be studied in tendinopathy as well as the critical question of dosage and maintenance. Interestingly it seems that injection therapy using color Doppler for targeting the area of neovascularisation yields to good clinical results with polidocanol sclerosing therapy, but also with a combination of epinephrine and lidocaine.
Roche, A J; Calder, J D F
The two main categories of Achilles tendon disorder are broadly classified by anatomical location to include non-insertional and insertional conditions. Non-insertional Achilles tendinopathy is often managed conservatively, and many rehabilitation protocols have been adapted and modified, with excellent clinical results. Emerging and popular alternative therapies, including a variety of injections and extracorporeal shockwave therapy, are often combined with rehabilitation protocols. Surgical approaches have developed, with minimally invasive procedures proving popular. The management of insertional Achilles tendinopathy is improved by recognising coexisting pathologies around the insertion. Conservative rehabilitation protocols as used in non-insertional disorders are thought to prove less successful, but such methods are being modified, with improving results. Treatment such as shockwave therapy is also proving successful. Surgical approaches specific to the diagnosis are constantly evolving, and good results have been achieved.
Sobhani, Sobhan; Zwerver, Johannes; van den Heuvel, Edwin; Postema, Klaas; Dekker, Rienk; Hijmans, Juha M
Relative rest and pain relief play an important role in the management of Achilles tendinopathy, and might be achieved by reducing the load on the Achilles tendon. Previous studies have provided evidence that rocker shoes are able to decrease the ankle internal plantar flexion moment in healthy runners during walking and running. Since plantar flexion moment is related to the Achilles tendon loading, rocker shoes might be considered in the conservative management of Achilles tendinopathy. Therefore, the aim of this study was to investigate the biomechanics of running and walking in a group of patients with Achilles tendinopathy wearing standard shoes versus rocker shoes. Cross-over. Thirteen Achilles tendinopathy patients (mean age 48 ± 14.5 years) underwent three-dimensional gait analysis wearing standard running shoes and rocker shoes during running and walking. Surface electromyography of triceps surae and tibialis anterior was recorded simultaneously. Patients had symptoms for an average of 22.5 months (median 11.5 months) and VISA-A scores were 54 ± 16. With the rocker shoes, the peak plantar flexion moment was reduced by 13% in both running (0.28 N m/kg, p<0.001) and walking (0.20 N m/kg, p<0.001). The peak activity of tibialis anterior was increased by 35% (p=0.015) for the rocker shoes in walking. There was no difference between electromyography peak amplitudes of triceps surae between two shoe sessions in both activities. When used by patients with chronic Achilles tendinopathy, rocker shoes cause a significant reduction in plantar flexion moment in the late stance phase of running and walking without substantial adaptations in triceps surae muscular activity. Copyright © 2014 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
Docking, Sean I; Rosengarten, Samuel D; Daffy, John; Cook, Jill
A high proportion of Achilles tendinopathy patients develop bilateral symptoms with human and animal studies showing bilateral histological changes associated with overuse/pathology in one tendon. The current study examined changes in tendon structure, assessed semi-quantitatively using ultrasound tissue characterisation, in both the symptomatic and asymptomatic tendon in unilateral Achilles tendinopathy patients in comparison to individuals with no history of tendinopathy. Cross-sectional case-control study. Participants with Achilles tendinopathy (n=21), with varying severity and length of clinical symptoms, and six participants with no history of tendinopathy were recruited. Tendons were scanned using ultrasound tissue characterisation, which captures contiguous transverse ultrasound images every 0.2mm and renders a 3-dimensional image. Ultrasound tissue characterisation quantifies tendon structure by measuring the stability of echopattern over contiguous transverse images. Four echo-types were discriminated and expressed as a percentage. Antero-posterior diameter of all tendons was measured. Significant differences were observed in the proportion of normal tendon structure between all three groups (p<0.01), with the symptomatic tendon containing the least amount of normal tendon structure (symptomatic - 79.5%, asymptomatic - 81.8%, control - 86.4%). The asymptomatic tendon contained significantly less normal tendon in comparison to the control tendon (p=0.008), suggesting the asymptomatic tendon is structurally compromised despite the absence of symptoms. Both Achilles tendons are structurally compromised in patients with unilateral Achilles tendinopathy. Future studies need to investigate whether these changes increase the risk of developing symptoms. Copyright © 2014 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
Maffulli, Nicola; Via, Alessio Giai; Oliva, Francesco
Tendinopathy of the Achilles tendon involves clinical conditions in and around the tendon and it is the result of a failure of a chronic healing response. Although several conservative therapeutic options have been proposed, few of them are supported by randomized controlled trials. The management is primarily conservative and many patients respond well to conservative measures. If clinical conditions do not improve after 6 months of conservative management, surgery is recommended. The management of chronic ruptures is different from that of acute ruptures. The optimal surgical procedure is still debated. In this article chronic Achilles tendon disorders are debated and evidence-based medicine treatment strategies are discussed.
Gouveia-Figueira, Sandra; Nording, Malin L.; Gaida, Jamie E.; Forsgren, Sture; Alfredson, Håkan; Fowler, Christopher J.
Background Linoleic acid-derived oxidation products are found in experimental pain models. However, little is known about the levels of such oxylipins in human pain. In consequence, in the present study, we have undertaken a lipidomic profiling of oxylipins in blood serum from patients with Achilles tendinopathy and controls. Methodology/Principal findings A total of 34 oxylipins were analysed in the serum samples. At a significance level of P<0.00147 (<0.05/34), two linoleic acid-derived oxylipins, 13-hydroxy-10E,12Z-octadecadienoic (13-HODE) and 12(13)-dihydroxy-9Z-octadecenoic acid (12,13-DiHOME) were present at significantly higher levels in the Achilles tendinopathy samples. This difference remained significant when the dataset was controlled for age, gender and body-mass index. In contrast, 0/21 of the arachidonic acid- and 0/4 of the dihomo-γ-linolenic acid, eicosapentaenoic acid or docosahenaenoic acid-derived oxylipins were higher in the patient samples at this level of significance. The area under the Receiver-Operator Characteristic (ROC) curve for 12,13-DiHOME was 0.91 (P<0.0001). Levels of four N-acylethanolamines were also analysed and found not to be significantly different between the controls and the patients at the level of P<0.0125 (<0.05/4). Conclusions/Significance It is concluded from this exploratory study that abnormal levels of linoleic acid-derived oxylipins are seen in blood serum from patients with Achilles tendinopathy. Given the ability of two of these, 9- and 13-HODE to activate transient receptor potential vanilloid 1, it is possible that these changes may contribute to the symptoms seen in Achilles tendinopathy. PMID:25875933
Papa, John A.
Objective: To chronicle the conservative treatment and management of a 77-year old female patient presenting with chronic pain of 8 months duration in the midportion of the achilles tendon diagnosed as achilles tendinopathy. Clinical features: The main clinical feature was pain in the midportion of the achilles tendon, 2 to 6 cm proximal to the calcaneal insertion. Symptom onset was gradual and unrelated to any acute trauma or overt injury mechanism. Intervention and outcome: The conservative treatment approach consisted of medical acupuncture with electrical stimulation, Graston Technique®, eccentric calf training, and rehabilitative exercise prescription. Outcome measures included verbal pain rating scale, lower extremity functional scale (LEFS), and a return to activities of daily living (ADLs). The patient attained long-term resolution of her complaint and at 12 month follow-up reported no recurrence of symptoms. Conclusion: A combination of conservative rehabilitation strategies may be used by chiropractors to treat midportion achilles tendinopathy and allow an individual to return to pain free ADLs in a timely manner. PMID:22997472
Lin, Heng An; Chong, Heng An; Yeo, William
To report the one-year outcome of 44 patients treated with a novel technique of calcaneoplasty and reattachment of the Achilles tendon. 15 men and 29 women (mean age, 53 years) with insertional tendinopathy of the Achilles tendon underwent calcaneoplasty, retrocalcaneal bursa excision, debridement and reattachment of the Achilles tendon with suture anchors via a lateral approach. Outcome was measured using the visual analogue score (VAS) for pain, the SF-36 health survey, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores. Patient expectation and satisfaction were also assessed. Of the 44 patients, 37, 43, and 21 were followed up at 3, 6, and 12 months. The mean VAS for pain and AOFAS ankle-hindfoot score improved significantly up to 6 months. The mean SF-36 score improved significantly up to 6 months for physical functioning, role functioning (physical), and bodily pain. Patient expectation and satisfaction also improved significantly. No patient had postoperative infections or rupture. Three patients had delayed wound healing, which resolved after simple dressings. Calcaneoplasty and reattachment of the Achilles tendon via a lateral approach for insertional tendinopathy enables early weight bearing and achieves good outcome and pain relief.
Papa, John A
To chronicle the conservative treatment and management of a 77-year old female patient presenting with chronic pain of 8 months duration in the midportion of the achilles tendon diagnosed as achilles tendinopathy. The main clinical feature was pain in the midportion of the achilles tendon, 2 to 6 cm proximal to the calcaneal insertion. Symptom onset was gradual and unrelated to any acute trauma or overt injury mechanism. The conservative treatment approach consisted of medical acupuncture with electrical stimulation, Graston Technique®, eccentric calf training, and rehabilitative exercise prescription. Outcome measures included verbal pain rating scale, lower extremity functional scale (LEFS), and a return to activities of daily living (ADLs). The patient attained long-term resolution of her complaint and at 12 month follow-up reported no recurrence of symptoms. A combination of conservative rehabilitation strategies may be used by chiropractors to treat midportion achilles tendinopathy and allow an individual to return to pain free ADLs in a timely manner.
Pingel, Jessica; Petersen, M Christine H; Fredberg, Ulrich; Kjær, Søren G; Quistorff, Bjørn; Langberg, Henning; Hansen, Jacob B
Achilles tendinopathy is a painful inflammatory condition characterized by swelling, stiffness and reduced function of the Achilles tendon. Kager's fat pad is an adipose tissue located in the area anterior to the Achilles tendon. Observations reveal a close physical interplay between Kager's fat pad and its surrounding structures during movement of the ankle, suggesting that Kager's fat pad may stabilize and protect the mechanical function of the ankle joint. The aim of this study was to characterize whether Achilles tendinopathy was accompanied by changes in expression of inflammatory markers and metabolic enzymes in Kager's fat pad. A biopsy was taken from Kager's fat pad from 31 patients with chronic Achilles tendinopathy and from 13 healthy individuals. Gene expression was measured by reverse transcription-quantitative PCR. Focus was on genes related to inflammation and lipid metabolism. Expression of the majority of analyzed inflammatory marker genes was increased in patients with Achilles tendinopathy compared to that in healthy controls. Expression patterns of the patient group were consistent with reduced lipolysis and increased fatty acid β-oxidation. In the fat pad, the pain-signaling neuropeptide substance P was found to be present in one third of the subjects in the Achilles tendinopathy group but in none of the healthy controls. Gene expression changes in Achilles tendinopathy patient samples were consistent with Kager's fat pad being more inflamed than in the healthy control group. Additionally, the results indicate an altered lipid metabolism in Kager's fat pad of Achilles tendinopathy patients.
Maquirriain, Javier; Ayerza, Miguel; Costa-Paz, Matías; Muscolo, D Luis
The objective of this prospective study was to evaluate preliminary results of an endoscopic-assisted surgical technique for patients suffering from chronic Achilles tendinopathies. Case series. Endoscopic operations were performed on 7 consecutive patients involved in recreational sports suffering from chronic Achilles tendon (AT) lesions in whom conservative treatment had failed. Diagnoses included 2 patients with pure peritendinitis, 4 with peritendinitis and degenerative tendinosis, and 1 with a chronic partial tear. Patients were preoperatively and postoperatively evaluated at a mean follow-up period of 16 months (range, 6 to 27 months) with a 0-100 points rating system. All patients were studied preoperatively with magnetic resonance imaging (MRI) and 6 were re-evaluated with the same procedure after surgery. All surgical interventions were performed on an ambulatory basis and 5 under local anesthesia. The surgical endoscopic technique consisted of peritenon release and debridement in cases with pure peritendinitis. In addition, 2 longitudinal tenotomies were performed in cases with degenerative tendinosis or partial tears. According to the scoring system used, all 7 patients had improved final outcome after surgery from a mean of 39 points preoperatively to 88 points postoperatively. The patient with an AT partial tear achieved the lowest score. The only complications were a minor hematoma and edema that resolved spontaneously. Postoperative MRI in patients with tendinosis failed to show evidence of degenerative areas. Endoscopic surgery may be a valid alternative to treat Achilles tendinopathies unresponsive to conservative treatment because of potential lower morbidity.
Howell, Michael A; Catanzariti, Alan R
Calcific insertional Achilles tendinopathy can result in significant pain and disability. Although some patients respond to nonoperative therapy, many patients are at risk for long-term morbidity and unpredictable clinical outcomes. There is no evidence-based data to support the timing of operative invention, choice of procedures, or whether equinus requires treatment. This article suggests the need for a classification system based on physical examination and imaging to help guide treatment. There is an obvious need for evidence-based studies evaluating outcomes and for properly conducted scientific research to establish appropriate treatment protocols. Copyright © 2016 Elsevier Inc. All rights reserved.
Tumilty, Steve; Munn, Joanne; Haxby Abbott, J.; Mcdonough, Suzanne; Hurley, Deirdre A.; Basford, Jeffrey R.; David Baxter, G.
Background: Low Level Laser Therapy (LLLT) has emerged as a possible treatment modality for tendinopathies. Human studies have investigated LLLT for Achilles Tendinopathy and the effectiveness remains contentious. Purpose: To assess the clinical effectiveness of Low-Level Laser Therapy (LLLT) in the management of Achilles Tendinopathy. Method: Forty patients were randomised into an active laser or placebo group; all patients, therapists and investigator were blinded to allocation. All patients were given an eccentric exercise program and irradiated 3 times per week for 4 weeks with either an active or placebo laser at 6 standardized points over the affected tendons. Irradiation parameters in the active laser group were: 810 nm, 100 mW, applied to 6 points on the tendon for 30 seconds giving a dose of 3 J per point and 18 J per session; power density 100 mW/cm2. Outcome measures were the VISA-A questionnaire and a visual analogue scale of pain. Patients were measured before treatment, at 4 and 12 weeks. ANCOVA was used to analyze data, using the effects of baseline measurements as a covariate. Results: Within groups, there were significant improvements (p<0.05) at 4 and 12 weeks for all outcome measures, except pain for the laser group at 4 weeks (p = 0.13). Between groups differences at both 4 and 12 weeks showed no significant difference between groups (p>0.05). Conclusion: This use of the above parameters demonstrated no added benefit of LLLT over that of eccentric exercise in the treatment of Achilles Tendinopathy.
Wynter Bee, W; Ubhi, J; Kumar, B
To evaluate the association between tendon structure and clinical severity. Looking specifically at location of pathology, comparing ventral versus dorsal tendinopathy. Patients were recruited from a tertiary tendinopathy center between Jan 2015 - June 2016. Inclusion criteria included patients with midportion Achilles tendinopathy, aged between 1870. Patients with insertional Achilles tendinopathy or other suspected etiology were excluded. Patients were assessed using ultrasound tissue characterization (UTC) scanning. UTC software was used to analyse a 2 cm block 24 cm from the calcaneum for percentage of echo type I, II, III and IV. With percentage echo type I+II used as the primary outcome. A doctor also categorised patients into predominately dorsal or ventral pathology based on UTC imaging. VISAA and VAS scores were used for clinical outcome measures. Statistics were undertaken using SPSS, data was not normally distributed RESULTS: Overall 33 tendons with mid portion Achilles tendinopathy were analysed, the overall percentage echo type I+II showed no correlation to either VISAA (p=0.745, r=0.0600) or VAS (p=0.157, r=0.248). When divided into dorsal and ventral Achilles tendinopathy there was a significant difference between baseline VISAA scores with a lower VISAA score 35 (SD±19) in dorsal group compared with the ventral group 60 (SD±17.1) (p=0.009). There was also a higher VAS score in the dorsal group (mean = 6, SD±2.28) at baseline compared with ventral (mean = 5, SD±3.07), although this was not significant (p=0.416). This highlights the possibility of using UTC to subcategories patients into ventral and dorsal which seems to correlate to increased clinical severity in the dorsal group. This is perhaps due to increased tension and stretching acting through this part of the tendon on loading and thus more nociceptive stimulation and greater dysfunction of the tendon. This could be used to help determine differing rehabilitation interventions in future
Gerdesmeyer, Ludger; Mittermayr, Rainer; Fuerst, Martin; Al Muderis, Munjed; Thiele, Richard; Saxena, Amol; Gollwitzer, Hans
Chronic Achilles tendinopathy has been described as the most common overuse injury in sports medicine. Several treatment modalities such as activity modification, heel lifts, arch supports, stretching exercises, nonsteroidal anti-inflammatories, and eccentric loading are known as standard treatment mostly without proven evidence. After failed conservative therapy, invasive treatment may be considered. Extracorporeal shock wave therapy (ESWT) has been successfully used in soft-tissue pathologies like lateral epicondylitis, plantar fasciitis, tendinopathy of the shoulder and also in bone and skin disorders. Conclusive evidence recommending ESWT as a treatment for Achilles tendinopathy is still lacking. In plantar fasciitis as well as in calcific shoulder tendinopathy shock wave therapy is recently the best evaluated treatment option. This article analysis the evidence based literature of ESWT in chronic Achilles tendinopathy. Recently published data have shown the efficacy of focused and radial extracorporeal shock wave therapy. Copyright © 2015 IJS Publishing Group Limited. All rights reserved.
Fredberg, Ulrich; Kjær, Søren G.; Quistorff, Bjørn; Langberg, Henning; Hansen, Jacob B.
Background Achilles tendinopathy is a painful inflammatory condition characterized by swelling, stiffness and reduced function of the Achilles tendon. Kager’s fat pad is an adipose tissue located in the area anterior to the Achilles tendon. Observations reveal a close physical interplay between Kager’s fat pad and its surrounding structures during movement of the ankle, suggesting that Kager’s fat pad may stabilize and protect the mechanical function of the ankle joint. Aim The aim of this study was to characterize whether Achilles tendinopathy was accompanied by changes in expression of inflammatory markers and metabolic enzymes in Kager’s fat pad. Methods A biopsy was taken from Kager’s fat pad from 31 patients with chronic Achilles tendinopathy and from 13 healthy individuals. Gene expression was measured by reverse transcription-quantitative PCR. Focus was on genes related to inflammation and lipid metabolism. Results Expression of the majority of analyzed inflammatory marker genes was increased in patients with Achilles tendinopathy compared to that in healthy controls. Expression patterns of the patient group were consistent with reduced lipolysis and increased fatty acid β-oxidation. In the fat pad, the pain-signaling neuropeptide substance P was found to be present in one third of the subjects in the Achilles tendinopathy group but in none of the healthy controls. Conclusion Gene expression changes in Achilles tendinopathy patient samples were consistent with Kager’s fat pad being more inflamed than in the healthy control group. Additionally, the results indicate an altered lipid metabolism in Kager’s fat pad of Achilles tendinopathy patients. PMID:25996876
Debenham, James; Butler, Prue; Mallows, Adrian; Wand, Benedict M
Study Design Controlled laboratory study, preliminary case-control design. Background The mechanisms that contribute to Achilles tendinopathy remain poorly understood. The disparity between pain experience and peripheral pathology demonstrated in patients with Achilles tendinopathy suggests that changes in central nervous system function may be involved. Objectives To investigate whether lower-limb tactile acuity is impaired in people with nonacute Achilles tendinopathy. Methods Thirteen consecutive participants with nonacute midportion Achilles tendinopathy and 13 healthy controls were enrolled. Two-point discrimination thresholds over the affected Achilles tendon, unaffected tendon, and tendon of healthy controls were evaluated. Independent and dependent t tests were used to compare group means. Results Two-point discrimination distance over the affected limb in participants with Achilles tendinopathy was significantly increased when compared to the unaffected limb (mean difference, 11.7 mm; 95% confidence interval [CI]: 1.9, 21.5; P = .02) and to healthy controls (mean difference, 13.1 mm; 95% CI: 1.6, 24.6; P = .03). There was no significant difference between the healthy controls and the unaffected side in people with Achilles tendinopathy (mean difference, 1.4 mm; 95% CI: -7.9, 5.1; P = .66). Conclusion These data provide the first evidence of reduced 2-point discrimination over the affected tendon in patients with Achilles tendinopathy. Further research is needed to determine the cause for the change in tactile acuity. J Orthop Sports Phys Ther 2016;46(12):1061-1064. Epub 30 Oct 2016. doi:10.2519/jospt.2016.6514.
Andersson, Gustav; Backman, Ludvig J; Christensen, Jens; Alfredson, Håkan
In a condition of pain in the Achilles tendon insertion there are multiple structures involved, such as the Achilles tendon itself, the retrocalcaneal bursa and a bony protrusion at the calcaneal tuberosity called Haglund's deformity. The innervation patterns of these structures are scarcely described, and the subcutaneous calcaneal bursa is traditionally not considered to be involved in the pathology. This study aimed at describing the innervation patterns of the four structures described above to provide a better understanding of possible origins of pain at the Achilles tendon insertion. Biopsies were taken from 10 patients with insertional Achilles tendinopathy, which had pathological changes in the subcutaneous and retrocalcaneal bursae, a Haglund deformity and Achilles tendon tendinopathy as verified by ultrasound. The biopsies were stained using immunohistochemistry in order to delineate the innervation patterns in the structures involved in insertional Achilles tendinopathy. Immunohistochemical examinations found that the subcutaneous bursa scored the highest using a semi-quantitative evaluation of the degree of innervation when compared to the retrocalcaneal bursa, the Achilles tendon, and the calcaneal bone. These findings suggest that the subcutaneous bursa, which is traditionally not included in surgical treatment, may be a clinically important factor in insertional Achilles tendinopathy.
Achilles tendinopathy is one of the most frequently ankle and foot overuse injuries, which is a clinical syndrome characterized by the combination of pain, swelling, and impaired performance. The two main categories of Achilles tendinopathy are classified according to anatomical location and broadly include insertional and noninsertional tendinopathy. The etiology of Achilles tendinopathy is multifactorial including both intrinsic and extrinsic factors. Failed healing response and degenerative changes were found in the tendon. The failed healing response includes three different and continuous stages (reactive tendinopathy, tendon disrepair, and degenerative tendinopathy). The histological studies have demonstrated an increased number of tenocytes and concentration of glycosaminoglycans in the ground substance, disorganization and fragmentation of the collagen, and neovascularization. There are variable conservative and surgical treatment options for Achilles tendinopathy. However, there has not been a gold standard of these treatments because of the controversial clinical results between various studies. In the future, new level I researches will be needed to prove the effect of these treatment options. PMID:27885357
Li, Hong-Yun; Hua, Ying-Hui
Achilles tendinopathy is one of the most frequently ankle and foot overuse injuries, which is a clinical syndrome characterized by the combination of pain, swelling, and impaired performance. The two main categories of Achilles tendinopathy are classified according to anatomical location and broadly include insertional and noninsertional tendinopathy. The etiology of Achilles tendinopathy is multifactorial including both intrinsic and extrinsic factors. Failed healing response and degenerative changes were found in the tendon. The failed healing response includes three different and continuous stages (reactive tendinopathy, tendon disrepair, and degenerative tendinopathy). The histological studies have demonstrated an increased number of tenocytes and concentration of glycosaminoglycans in the ground substance, disorganization and fragmentation of the collagen, and neovascularization. There are variable conservative and surgical treatment options for Achilles tendinopathy. However, there has not been a gold standard of these treatments because of the controversial clinical results between various studies. In the future, new level I researches will be needed to prove the effect of these treatment options.
[Purpose] This study aimed to identify changes in muscle activation by comparing muscle activities of the affected side (AS) and non-affected side (NAS) during eccentric and concentric exercises in runners with unilateral Achilles tendinopathy. [Subjects] The study included 18 participants consisting of men and women with chronic Achilles tendinopathy in a single leg who had more than 1 year of running experience. [Methods] All subjects performed concentric and eccentric exercise with the Achilles tendon moving from full plantar flexion to full dorsiflexion for 8 seconds, and electromyography data was obtained. [Results] All muscles examined showed a significant increase in %maximal voluntary contraction (MVC) with concentric exercise compared with eccentric exercise. Compared with the NAS, the AS showed significant increases in %MVC of the rectus femoris, tibialis anterior, and lateral gastrocnemius. All interaction effects of exercise methods and injuries showed statistically significant changes. [Conclusion] Runners with Achilles tendinopathy show increases in medial gastrocnemius activity when performing eccentric exercise. PMID:25276014
Kozlovskaia, Maria; Vlahovich, Nicole; Ashton, Kevin J; Hughes, David C
Achilles tendinopathy is the most prevalent tendon disorder in people engaged in running and jumping sports. Aetiology of Achilles tendinopathy is complex and requires comprehensive research of contributing risk factors. There is relatively little research focussing on potential biomedical risk factors for Achilles tendinopathy. The purpose of this systematic review is to identify studies and summarise current knowledge of biomedical risk factors of Achilles tendinopathy in physically active people. Research databases were searched for relevant articles followed by assessment in accordance with PRISMA statement and standards of Cochrane collaboration. Levels of evidence and quality assessment designation were implemented in accordance with OCEBM levels of evidence and Newcastle-Ottawa Quality Assessment Scale, respectively. A systematic review of the literature identified 22 suitable articles. All included studies had moderate level of evidence (2b) with the Newcastle-Ottawa score varying between 6 and 9. The majority (17) investigated genetic polymorphisms involved in tendon structure and homeostasis and apoptosis and inflammation pathways. Overweight as a risk factor of Achilles tendinopathy was described in five included studies that investigated non-genetic factors. COL5A1 genetic variants were the most extensively studied, particularly in association with genetic variants in the genes involved in regulation of cell-matrix interaction in tendon and matrix homeostasis. It is important to investigate connections and pathways whose interactions might be disrupted and therefore alter collagen structure and lead to the development of pathology. Polymorphisms in genes involved in apoptosis and inflammation, and Achilles tendinopathy did not show strong association and, however, should be considered for further investigation. This systematic review suggests that biomedical risk factors are an important consideration in the future study of propensity to the development
Al-Abbad, Hani; Simon, Joel Varghese
Achilles tendinopathy is a pathological state resulting from repetitive loading or stress on the tendon. Extracorporeal shock wave therapy (ESWT) is hypothesized to be an effective alternative intervention to surgery when other conservative therapies fail. This systematic review investigated the effectiveness of ESWT in the treatment of insertional and noninsertional Achilles tendinopathies. Articles were electronically searched from the Cochrane Controlled Trials Register, MEDLINE, CINAHL, EMBASE, and SPORTDiscus using a comprehensive search strategy. Studies were included if they were prospective clinical trials examining the effectiveness of ESWT for insertional or noninsertional Achilles tendinopathies. Methodological quality of included studies was assessed using PEDro scale and Modified McMaster tool. The strength of the evidence was reported using the National Health and Medical Research Council body of evidence framework. A narrative summary of the findings was presented. Four of the included studies were randomized controlled trials, and 2 were pre-post study designs. Common methodological deficiencies included not blinding the clinician and participants. There was consistent evidence from 4 reviewed studies on the effectiveness of ESWT in the management of patients with chronic Achilles tendinopathies at a minimum 3 months' follow-up. Overall, our review showed satisfactory evidence for the effectiveness of low-energy ESWT in the treatment of chronic insertional and noninsertional Achilles tendinopathies at a minimum 3 months' follow-up before considering surgery if other conservative management fails. However, combining ESWT with eccentric loading appears to show superior results. Level 1, systematic meta-analysis.
Risch, L.; Cassel, M.; Messerschmidt, J.; Intziegianni, K.; Fröhlich, K.; Kopinski, S.; Mayer, F.
Purpose: The purpose of this study was to investigate the consistency between different Doppler ultrasound (DU) modes as well as the intra- and inter-observer reliability of investigators with different experience level in assessing intratendinous blood flow (IBF) in Achilles tendinopathy patients. Material and Methods: 18 participants (36 Achilles tendons, AT) with Achilles tendinopathy (24 AT) were examined with power Doppler ultrasound (PDU), colour Doppler ultrasound (CDU) and “Advanced Dynamic Flow” (ADF) (Toshiba Xario SSA-660 A; 14MHz transducer) by 2 investigators (experienced, EI; inexperienced, II) in a test-retest design (M1/M2). A modified Öhberg score was used to quantify IBF. Data was analysed descriptively (absolute and relative). Consistency of the 3 modes was presented by Kendall’s Coefficient of Concordance (Kendall’s W). Intra- and inter-observer reliability were calculated by use of Kendall’s tau b correlation coefficient. Results: IBF was detected in 79–92% of symptomatic AT and in 33–50% of contralateral asymptomatic AT. Comparing the 3 modes, Kendall’s W ranged from 0.97–0.98. Analysis of intra-observer reliability resulted in Kendall’s tau 0.90–0.92 for EI and 0.84–0.87 for II. Inter-observer reliability resulted in Kendall’s tau 0.64–0.69 in M1 and 0.68–0.70 in M2. Conclusion: The very good consistency between PDU, CDU and ADF indicates a comparable applicability for assessing IBF in ATs. Intra-observer reliability was high for both investigators, independent of experience. The moderate inter-observer reliability reflects the challenge in sonographic detection of intratendinous blood flow (IBF) amount. PMID:27689161
Giombini, A; Dragoni, S; Di Cesare, A; Di Cesare, M; Del Buono, A; Maffulli, N
Lower limb tendon changes detected at imaging are common among asymptomatic athletes. We aimed to prospectively assess the clinical status, tendon structure, and vascularity of lower limb tendons of elite fencers, and predict the risk of developing symptoms over time. Clinical examination, changes at ultrasonography (US), and Power Doppler (PD) flow of both the Achilles, patellar, and quadriceps tendon were assessed in 37 elite fencers in January 2007 and 3 years after. Two hundred and twenty-two tendons were examined. At the last appointment, patellar tendons diagnosed as abnormal at baseline were more likely to develop symptoms than those normal at baseline (P < 0.05, Fisher's exact test), while US and PD abnormalities on Achilles and quadriceps tendons were no predictive for development of symptoms over years. A very low percentage of tendons diagnosed as normal at baseline (1.45%) showed US abnormalities at 3-year follow-up. In asymptomatic elite fencers, structural changes are relatively common at US and PD assessment of Achilles, quadriceps, and patellar tendons. It seems unlikely that additional PD investigations provide further information or change prognosis in patients with US diagnosis of tendinopathy.
Furia, John P
High-energy extracorporeal shock wave therapy has been shown to be an effective treatment for chronic insertional Achilles tendinopathy. The results of high-energy shock wave therapy for chronic noninsertional Achilles tendinopathy have not been determined. Shock wave therapy is an effective treatment for noninsertional Achilles tendinopathy. Case control study; Level of evidence, 3. Thirty-four patients with chronic noninsertional Achilles tendinopathy were treated with a single dose of high-energy shock wave therapy (shock wave therapy group; 3000 shocks; 0.21 mJ/mm(2); total energy flux density, 604 mJ/mm(2)). Thirty-four patients with chronic noninsertional Achilles tendinopathy were treated not with shock wave therapy but with additional forms of nonoperative therapy (control group). All shock wave therapy procedures were performed using regional anesthesia. Evaluation was by change in visual analog score and by Roles and Maudsley score. One month, 3 months, and 12 months after treatment, the mean visual analog scores for the control and shock wave therapy groups were 8.4 and 4.4 (P < .001), 6.5 and 2.9 (P < .001), and 5.6 and 2.2 (P < .001), respectively. At final follow-up, the number of excellent, good, fair, and poor results for the shock wave therapy and control groups were 12 and 0 (P < .001), 17 and 9 (P < .001), 5 and 17 (P < .001), and 0 and 8 (P < .001), respectively. A chi(2) analysis revealed that the percentage of patients with excellent ("1") or good ("2") Roles and Maudsley scores, that is, successful results, 12 months after treatment was statistically greater in the shock wave therapy group than in the control group (P < .001). Shock wave therapy is an effective treatment for chronic noninsertional Achilles tendinopathy.
Lohrer, Heinz; Nauck, Tanja
The results of operative treatment for recalcitrant midportion Achilles tendinopathy and recalcitrant retrocalcaneal bursitis were evaluated using the patient administered, disease specific, and validated VISA-A-G questionnaire. A cohort of 89 patients was prospectively followed. These patients underwent operations for sport induced midportion Achilles tendinopathy (39 procedures) or retrocalcaneal bursitis (55 procedures). Depending on the individual intraoperative findings the patients of either disease were treated with two respective operative modifications (tendon repair or no tendon repair). Preoperative and follow-up status (3, 6, and 12 months) were investigated using the VISA-A-G questionnaire. Preoperatively, the four groups scored from 37.0 ± 17.6 to 45.9 ± 15.2 (p = 0.376-0.993) on the VISA-A-G questionnaire. Six and 12 months postoperatively, the VISA-A-G scores improved significantly (p < 0.001). Twelve months postoperatively, the groups' scores were not different (p = 0.100-0.952) and ranged from 80.8 ± 17.9 to 90.3 ± 10.6. Retrocalcaneal bursitis and midportion Achilles tendinopathy responded equally well to operative treatment. When repaired, additional tendon lesions did not influence this result. We demand to differentiate not only between midportion Achilles tendinopathy and retrocalcaneal bursitis but also to identify additional Achilles tendon lesions to specifically address these lesions during operative procedures.
Calder, James D F; Stephen, Joanna M; van Dijk, C Niek
It is becoming increasingly apparent that the plantaris can contribute to symptoms in at least a subset of patients with midportion Achilles tendinopathy. However, the nature of its involvement remains unclear. To determine whether excised plantaris tendons from patients with midportion Achilles tendinopathy display tendinopathic changes and whether the presence of such changes affect clinical outcomes. Case series; Level of evidence, 4. Sixteen plantaris tendons in patients with midportion Achilles tendinopathy recalcitrant to conservative management underwent histological examination for the presence of tendinopathic changes. All patients had imaging to confirm the presence of the plantaris tendon adherent to or invaginated into the focal area of Achilles tendinosis. Visual analog scale (VAS) and Foot and Ankle Outcome Score (FAOS) results were recorded pre- and postoperatively. Sixteen patients (mean age, 26.2 years; range, 18-47 years) underwent surgery, with a mean follow-up of 14 months (range, 6-20 months). The plantaris tendon was histologically normal in 13 of 16 cases (81%). Inflammatory changes in the loose peritendinous connective tissue surrounding the plantaris tendon were evident in all cases. There was significant improvement in mean VAS scores (P < .05) and all domains of the FAOS postoperatively (P < .05). The absence of any tendinopathic changes in the excised plantaris of 13 patients who clinically improved suggests plantaris involvement with Achilles tendinopathy may not yet be fully understood and supports the concept that this may be a compressive or a frictional phenomenon rather than purely tendinopathic.
Calder, James D. F.; Stephen, Joanna M.; van Dijk, C. Niek
Background: It is becoming increasingly apparent that the plantaris can contribute to symptoms in at least a subset of patients with midportion Achilles tendinopathy. However, the nature of its involvement remains unclear. Purpose: To determine whether excised plantaris tendons from patients with midportion Achilles tendinopathy display tendinopathic changes and whether the presence of such changes affect clinical outcomes. Study Design: Case series; Level of evidence, 4. Methods: Sixteen plantaris tendons in patients with midportion Achilles tendinopathy recalcitrant to conservative management underwent histological examination for the presence of tendinopathic changes. All patients had imaging to confirm the presence of the plantaris tendon adherent to or invaginated into the focal area of Achilles tendinosis. Visual analog scale (VAS) and Foot and Ankle Outcome Score (FAOS) results were recorded pre- and postoperatively. Results: Sixteen patients (mean age, 26.2 years; range, 18-47 years) underwent surgery, with a mean follow-up of 14 months (range, 6-20 months). The plantaris tendon was histologically normal in 13 of 16 cases (81%). Inflammatory changes in the loose peritendinous connective tissue surrounding the plantaris tendon were evident in all cases. There was significant improvement in mean VAS scores (P < .05) and all domains of the FAOS postoperatively (P < .05). Conclusion: The absence of any tendinopathic changes in the excised plantaris of 13 patients who clinically improved suggests plantaris involvement with Achilles tendinopathy may not yet be fully understood and supports the concept that this may be a compressive or a frictional phenomenon rather than purely tendinopathic. PMID:28203584
Cassel, M; Baur, H; Hirschmüller, A; Carlsohn, A; Fröhlich, K; Mayer, F
Achilles (AT) and patellar tendons (PT) are commonly affected by tendinopathy in adult athletes but prevalence of symptoms and morphological changes in adolescents is unclear. The study aimed to determine prevalence of tendinopathy and intratendinous changes in ATs and PTs of adolescent athletes. A total of 760 adolescent athletes (13.0 ± 1.9 years; 160 ± 13 cm; 50 ± 14 kg) were examined. History, local clinical examination, and longitudinal Doppler ultrasound analysis for both ATs and PTs were performed including identification of intratendinous echoic changes and vascularization. Diagnosis of tendinopathy was complied clinically in case of positive history of tendon pain and tendon pain on palpation. Achilles tendinopathy was diagnosed in 1.8% and patellar tendinopathy in 5.8%. Vascularizations were visible in 3.0% of ATs and 11.4% of PTs, hypoechogenicities in 0.7% and 3.2% as well as hyperechogenicities in 0% and 0.3%, respectively. Vascularizations and hypoechogenicities were statistically significantly more often in males than in females (P ≤ 0.02). Subjects with patellar tendinopathy had higher prevalence of structural intratendinous changes than those without PT symptoms (P ≤ 0.001). In adolescent athletes, patellar tendinopathy is three times more frequent compared with Achilles tendinopathy. Longitudinal studies are necessary to investigate physiological or pathological origin of vascularizations and its predictive value in development of tendinopathy. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
Saxena, Amol; Ramdath, Sona; O'Halloran, Patrick; Gerdesmeyer, Ludger; Gollwitzer, Hans
Achilles tendinopathy is common and extracorporeal shockwaves have become a popular treatment for this condition, even though previous research has not provided conclusive results regarding its efficacy in cases of Achilles tendinopathy. Our aim was to evaluate 3 weekly shockwave treatments in patients with Achilles tendinopathy, as quantified by the Roles and Maudsley score. A total of 74 tendons in 60 patients were assessed at baseline and at least 1 year posttreatment, including 32 (43.24%) paratendinoses, 23 (31.08%) proximal tendinoses, and 19 (25.68%) insertional tendinoses. The mean age of the participants was 48.6 ± 12.94 years, and patients with paratendinosis (41.44 ± 14.01 years) were statistically significantly younger than those with proximal (53 ± 8.9 years) and insertional (54.26 ± 9.74 years) tendinopathy, and these differences were statistically significant (P = .0012 and P = .0063, respectively). Overall, 58 (78.38%) tendons improved by at least 1 year posttreatment, including 75% in the paratendinosis, 78.26% in the proximal tendinosis, and 84.21% in the insertional tendinosis groups, and no adverse effects were observed. The Roles and Maudsley score improved from 3.22 ± 0.55 to 1.84 ± 1.05 (P < .0001) in the paratendinosis group, 3.39 ± 0.5 to 1.57 ± 0.66 (P < .0001) in the proximal tendinopathy group, and 3.32 ± 0.58 to 1.47 ± 0.7 (P = .0001) in the insertional tendinopathy group. Based on these results, we believe that shockwave therapy serves as a safe, viable, and effective option for the treatment of Achilles tendinopathy. Copyright © 2011 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Alfredson, Håkan; Spang, Christoph; Forsgren, Sture
Bilateral midportion Achilles tendinopathy/tendinosis is not unusual, and treatment of both sides is often carried out. Experiments in animals suggest of the potential involvement of central neuronal mechanisms in Achilles tendinosis. To evaluate the outcome of surgery for Achilles tendinopathy. This observational study included 13 patients (7 men and 6 women, mean age 53 years) with a long duration (6-120 months) of chronic painful bilateral midportion Achilles tendinopathy. The most painful side at the time for investigation was selected to be operated on first. Treatment was ultrasound-guided and Doppler-guided scraping procedure outside the ventral part of the tendon under local anaesthetic. The patients started walking on the first day after surgery. Follow-ups were conducted and the primary outcome was pain by visual analogue scale. In an additional part of the study, specimens from Achilles and plantaris tendons in three patients with bilateral Achilles tendinosis were examined. Short-term follow-ups showed postoperative improvement on the non-operated side as well as the operated side in 11 of 13 patients. Final follow-up after 37 (mean) months showed significant pain relief and patient satisfaction on both sides for these 11 patients. In 2 of 13 patients operation on the other, initially non-operated side, was instituted due to persisting pain. Morphologically, it was found that there were similar morphological effects, and immunohistochemical patterns of enzyme involved in signal substance production, bilaterally. Unilateral treatment with a scraping operation can have benefits contralaterally; the clinical implication is that unilateral surgery may be a logical first treatment in cases of bilateral Achilles tendinopathy. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
De Jonge, S; Warnaars, J L F; De Vos, R J; Weir, A; van Schie, H T M; Bierma-Zeinstra, S M A; Verhaar, J A N; Tol, J L
Neovascularization is frequently observed in tendinopathy. Previous studies have focused on the role of neovascularization in Achilles tendinopathy, but have been conducted in small series. It is still unclear whether the degree of neovascularization is related to severity of symptoms. The purpose was to study the relationship between ultrasonographic neovascularization and clinical severity in patients with Achilles tendinopathy. In this prospective cohort study, data on 127 patients (141 tendons) were assembled from databases of three clinical trials. All patients followed an eccentric exercise program. The Öhberg neovascularization score (0-4+) and Victorian Institute of Sports Assessment-Achilles (VISA-A) score (split into domains: pain, function and activity) were collected during baseline and follow-up. The relationship between neovascularization and VISA-A score was calculated. At baseline, 107 tendons (76%) showed some degree of neovascularization. In 556 coupled measurements, neovascularization was weakly related to the VISA-A score [Exp (B) 1.017, 95% confidence interval (CI), 1.007-1.026]. No significant relationship was found between neovascularization and the pain domain (P = 0.277) and the activity domain (P = 0.283), but there was between neovascularization and the function domain of the VISA-A score [Exp (B) = 1.067, 95% CI 1.018-1.119]. In conclusion, neovascularization in Achilles tendinopathy is weakly related to clinical severity, mainly based on the function domain of the VISA-A score.
Silbernagel, Karin Grävare; Crossley, Kay M
Synopsis Achilles tendinopathy is a common overuse injury in athletes involved in running and jumping activities and sports. The intervention with the highest level of evidence is exercise therapy, and it is recommended that all patients initially be treated with exercise for at least 3 months prior to considering other treatment options. Recovery from Achilles tendinopathy can take up to a year, and there is a high propensity for recurrence, especially during the return-to-sport phase. The extent of the tendon injury, the age and sex of the athlete, the magnitude of pain/symptoms, the extent of impairments, and the demands of the sport all need to be considered when planning for return to sport. This clinical commentary describes an approach to return to sport for patients with midportion Achilles tendinopathy. The aim of the return-to-sport program is to facilitate the decision-making process in returning an athlete with midportion Achilles tendinopathy back to full sport participation and to minimize the chances for recurrence of the injury. J Orthop Sports Phys Ther 2015;45(11):876-886. Epub 21 Sep 2015. doi:10.2519/jospt.2015.5885.
Di Matteo, B; Filardo, G; Kon, E; Marcacci, M
Platelet-rich plasma (PRP) has been introduced in the clinical practice to treat a growing number of different musculoskeletal pathologies. It is currently applied in the treatment of Achilles and patellar tendinopathies, which are common sport-related injuries very challenging to manage. Aim of the present paper was to review systematically the available clinical evidence concerning the application of PRP in the treatment of patellar and Achilles tendinopathy. A systematic review of the literature was performed according to the following inclusion criteria for relevant articles: (1) clinical reports of any level of evidence, (2) written in the English language, (3) with no time limitation and (4) on the use of PRP to treat conservatively Achilles and patellar tendinopathy. Twenty-two studies were included and analyzed. Two studies on patellar tendinopathy were randomized controlled trials (RCTs), whereas just one RCT was published on Achilles tendon. All the papers concerning patellar tendon reported positive outcome for PRP, which proved to be superior to other traditional approaches such as shock-wave therapy and dry needling. In the case of Achilles tendon, despite the encouraging findings reported by case series, the only RCT available showed no significant clinical difference between PRP and saline solution. The main finding of this study was the paucity of high-level literature regarding the application of PRP in the management of patellar and Achilles tendinopathy. However, the clinical data currently available, although not univocal, suggest considering PRP as a therapeutic option for recalcitrant patellar and Achilles tendinopathies.
Ross, Georgia; Macfarlane, Chris; Vaughan, Brett
Mid-portion Achilles tendinopathy is a common injury in sporting populations. There is conflicting evidence about the best approach to conservative management. This report focuses on the rehabilitation of an Achilles tendinopathy utilising osteopathic manual therapy (OMT) and a structured exercise program in a semi-professional volleyballer. The patient presented with a 4-month history of right mid-portion Achilles tendon pain that begun after a lateral inversion sprain of the right ankle. The primary complaint was pain impacting the patients vertical jump performance. The patient complained of pain that was greatest in the morning and at the beginning of a training session prior to warming up. The inventory therapy was a combination of OMT. The manual therapy was complemented with a rehabilitation program. Outcomes were assessed with the Victorian Institute of Sport Assessment- Achilles (VISA-A), visual analogue scales (VAS), painful arc, London Hospital Test, soleus lunge test and maximum vertical jump. This case presented many challenging management options including a resolving right ankle lateral inversion sprain, a past history of contralateral Achilles tendinopathy and a high training load. The case demonstrated the importance of patientcentred practice. It was integral that the patient's role as a semi-professional athlete on the volleyball court was analyzed closely in order to replicate different facets of his game, so that the rehabilitation program could support a return to performance at the highest level. Once the initial deficits in mobility and strength were addressed, the rehabilitation program focus moved to injury prevention.
Lohrer, Heinz; Nauck, Tanja
We questioned whether different forms of Achilles tendon overuse injuries can be differentiated by retrocalcaneal bursa pressure measurement. Retrocalcaneal bursa pressure was determined by using invasive pressure measurement in patients suffering from retrocalcaneal bursitis (n=13) or Achilles tendinopathy (n=15), respectively. Standardized measurements were taken with the subject lying prone. Initially, the foot and ankle was in a spontaneous, unsupported position. Then passive dorsiflexion was induced by an increasing pressure which was applied in five defined steps against the plantar forefoot. Mean pressures found in unloaded position were 30.5 (SD 28.9) mmHg in retrocalcaneal bursitis and -9.9 (SD 17.2) mmHg in Achilles tendinopathy (p<0.001). A stepwise increase in passive ankle dorsiflexion was associated with increasing pressure values in both groups. The differences were p=0.009 to 0.035 when dorsiflexion was initiated with 10, 20, 30, and 40N, respectively. Dorsiflexion induced by 50N load resulted in a mean pressure of 113.7 (SD 124.9) mmHg for retrocalcaneal bursitis and 32.5 (SD 48.9) mmHg for Achilles tendinopathy (p=0,051). Higher retrocalcaneal bursa pressure values were found in patients suffering from chronic retrocalcaneal bursitis. This result supports the hypothesis that retrocalcaneal bursa hypertension leads to an impingement lesion of the corresponding anterior Achilles tendon. Copyright © 2013 Elsevier Ltd. All rights reserved.
Kamineni, Srinath; Butterfield, Timothy; Sinai, Anthony
Tendinopathy is a common clinical pathology, with mixed treatment results, especially when chronic. In this study, we examine the effects of an ultrasonic debridement modality in a rabbit tendinopathy model. We asked four questions: (1) Was it possible to create and visualize with ultrasound a tendinopathy lesion in a rabbit Achilles tendon? (2) Was it possible to guide a 19-gauge ultrasonic probe into the tendinopathy lesion? (3) Following ultrasonic treatment, was tendinopathy debris histologically present? and (4) Was the collagen profile qualitatively and quantitatively normalized following treatment? Skeletally mature female New Zealand white rabbits (n = 12) were injected with, ultrasonography localization, 0.150 ml of collagenase into the Achilles tendon. The collagenase-induced Achilles tendinopathy (3 weeks) was treated with percutaneous ultrasonic debridement. The tendons were harvested, at 3 weeks after treatment, and were subjected to histological assessment (modified Movin score) and biochemical analysis (collagen isoform content). Histopathological examination revealed that all tendons injected with collagenase showed areas of hypercellularity and focal areas of tendon disorganization and degeneration. The treated tendons had lower (improved) histopathological scores than injured tendons (P < 0.001). Western blot analysis showed that ultrasonic therapy restored, within statistical limits, collagen type I, III, and X expressions in a treated tendon, to qualitative and semi-quantitative levels of a normal tendon. We were successfully able to create a collagenase-injected tendinopathy lesion in a rabbit Achilles tendon and visualize the lesion with an ultrasound probe. A 19-gauge ultrasonic probe was inserted into the tendinopathic lesion under direct ultrasound guidance, and minimal tendinopathic debris remained after treatment. The treated tendon demonstrated a normalized qualitative and semi-quantitative collagen profile and improved histological
Kaux, Jean-François; Delvaux, François; Oppong-Kyei, Julian; Dardenne, Nadia; Beaudart, Charlotte; Buckinx, Fanny; Croisier, Jean-Louis; Forthomme, Bénédicte; Crielaard, Jean-Michel; Bruyère, Oliver
The Victorian Institute of Sport Assessment - Achilles tendinopathy questionnaire (VISA-A) evaluates the clinical severity of Achilles tendinopathy. The aim of this study was to translate the VISA-A into French and to study the reliability and validity of this French version, the VISA-AF. The VISA-A was translated into French to produce the VISA-AF using a validated methodology in six steps. Thereafter, several psychometric properties of this French version such as test-retest reliability, internal consistency, construct validity and floor and ceiling effects were evaluated. Therefore, we recruited 116 subjects, distributed into 3 groups: pathological patients (n = 31), at-risk athletes (n = 63) and healthy people (n = 22). The final version of the VISA-AF was approved by an expert committee. On a scale ranging from 0 to 100, the average scores of the VISA-AF obtained were 59 (± 18) for the pathological group, 99 (± 1) for the healthy group and 94 (± 7) for the at-risk group. The VISA-AF shows excellent reliability, low correlations with the discriminant subscales of the SF-36 and moderate correlations with the convergent subscales of the SF-36. The French version of the VISA-A is equivalent to its original version and is a reliable and valid questionnaire for French-speaking patients with Achilles tendinopathy. Implication for Rehabilitation The VISA-AF questionnaire is a reliable translation of the original VISA-A, from English into French, which is one of the most widespread languages in the world. The VISA-AF questionnaire is now a valid instrument that can be used by clinicians and researchers to assess the severity of pain and disability of French-speaking subjects with Achilles tendinopathy. The VISA-AF is a questionnaire to assess the severity of Achilles tendinopathy symptoms but is not a diagnostic tool.
Tendinopathy is of distinct interest as it describes a painful tendon disease with local tenderness, swelling and pain associated with sonographic features such as hypoechogenic texture and diameter enlargement. Recent research elucidated microcirculatory changes in tendinopathy using laser Doppler flowmetry and spectrophotometry such as at the Achilles tendon, the patellar tendon as well as at the elbow and the wrist level. Tendon capillary blood flow is increased at the point of pain. Tendon oxygen saturation as well as tendon postcapillary venous filling pressures, determined non-invasively using combined Laser Doppler flowmetry and spectrophotometry, can quantify, in real-time, how tendon microcirculation changes over with pathology or in response to a given therapy. Tendon oxygen saturation can be increased by repetitive, intermittent short-term ice applications in Achilles tendons; this corresponds to 'ischemic preconditioning', a method used to train tissue to sustain ischemic damage. On the other hand, decreasing tendon oxygenation may reflect local acidosis and deteriorating tendon metabolism. Painful eccentric training, a common therapy for Achilles, patellar, supraspinatus and wrist tendinopathy decreases abnormal capillary tendon flow without compromising local tendon oxygenation. Combining an Achilles pneumatic wrap with eccentric training changes tendon microcirculation in a different way than does eccentric training alone; both approaches reduce pain in Achilles tendinopathy. The microcirculatory effects of measures such as extracorporeal shock wave therapy as well as topical nitroglycerine application are to be studied in tendinopathy as well as the critical question of dosage and maintenance. Interestingly it seems that injection therapy using color Doppler for targeting the area of neovascularisation yields to good clinical results with polidocanol sclerosing therapy, but also with a combination of epinephrine and lidocaine. PMID:18447938
Calder, James D F; Freeman, Richard; Pollock, Noel
Achilles tendinopathy is a serious and frequently occurring problem, especially in elite athletes. Recent research has suggested a role for the plantaris tendon in non-insertional Achilles tendinopathy. To assess whether excising the plantaris tendon improved the symptoms of Achilles tendinopathy in elite athletes. This prospective consecutive case series study investigated 32 elite athletes who underwent plantaris tendon excision using a mini-incision technique to treat medially located pain associated with non-insertional Achilles tendinopathy. Preoperative and postoperative visual analogue scores (VAS) for pain and the foot and ankle outcome score (FAOS) as well as time to return to sport and satisfaction scores were assessed. At a mean follow-up of 22.4 months (12-48), 29/32 (90%) of athletes were satisfied with the results. Thirty of the 32 athletes (94%) returned to sport at a mean of 10.3 weeks (5-27). The mean VAS score improved from 5.8 to 0.8 (p<0.01) and the mean FAOS improved in all domains (p<0.01). Few complications were seen, four athletes experienced short-term stiffness and one had a superficial wound infection. The plantaris tendon may be responsible for symptoms in some athletes with non-insertional Achilles tendinopathy. Excision carries a low risk of complications and may provide significant improvement in symptoms enabling an early return to elite-level sports. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
Hsu, Andrew R; Holmes, George B
Achilles tendinopathy is a degenerative process of the tendon associated with diminished vascularity, microtrauma, and aging. Nonoperative treatments such as activity modification, immobilization, night splints, and physical therapy have good outcomes for the majority of patients. However, there are cohorts of patients that remain symptomatic despite use of all nonoperative measures that eventually require surgical intervention. The present study reports the preliminary short-term clinical outcomes of low-intensity pulsed ultrasound (LIPUS) for treatment for Achilles tendinopathy. Fourteen patients with clinically diagnosed Achilles tendinopathy who failed previous nonoperative treatments underwent LIPUS stimulation directly over the area of maximum tendon tenderness for 20 min/d for 8 weeks total. No other treatment modalities were used during the period of LIPUS stimulation. All patients had serial clinical exams and evaluations with an average follow-up of 12 months (range, 6-50 months). Excellent clinical outcomes with complete resolution of pain and other symptoms were obtained in 7 patients (50%). Two patients (14%) had good outcomes with mild tendon irritation and stiffness not requiring further intervention. Five patients (36%) had minimal benefit with continued pain, swelling, and tenderness over the Achilles and functional deficits. No patients had worsening pain or progression of disability requiring surgery. LIPUS is an additional noninvasive treatment modality for chronic Achilles tendinopathy that may potentially help improve clinical symptoms and delay and/or prevent the need for surgical intervention. While LIPUS is easy to use, well-tolerated, and has promising early clinical results, further research is needed to determine the long-term benefits, disadvantages, and cost-effectiveness of this alternative treatment for tendinopathy. Therapeutic, Level IV: Case series. © 2015 The Author(s).
Eccentric training has been shown to reduce pain and gain function in patients with chronic Achilles tendinopathy. However, currently no data are available regarding any potential adverse effects of an eccentric training intervention on Achilles tendon microcirculation. 59 patients (49 (12) years; body mass index 27 (5); 49 mid-portion, 10 chronic insertional tendinopathy) with 64 symptomatic (54 mid-portion, 10 insertional) Achilles tendons were prospectively enrolled. Baseline tendon microcirculation at four distinct tendon positions from the insertion to the proximal mid-portion area was assessed using a laser Doppler system for capillary blood flow, tissue oxygen saturation and postcapillary venous filling pressure. A 12-week daily painful home-based eccentric training regimen was initiated (3x15 repetitions per tendon and day). Achilles tendon capillary blood flow was significantly reduced at the insertion (by 35%, p = 0.008) and the distal mid-portion area (by 45%, p = 0.015) at 2 mm and by 22% (p = 0.007) and 13% (p = 0.122) at 8 mm tissue depths, respectively. Achilles tendon oxygen saturation was not decreased after the 12-week eccentric training regimen throughout the insertion to the proximal mid-portion area (insertion 72 (13) vs 73 (10), proximal mid-portion 63 (13) vs 62 (11), both NS). Achilles tendon postcapillary venous filling pressures were significantly reduced at the insertion (51 (16) vs 41 (19), p = 0.001) and the distal mid-portion (36 (13) vs 32 (12), p = 0.037) at 2 mm and at the insertion at 8 mm (63 (19) vs 51 (13), p = 0.0001). Pain was reduced from 5.4 (2.1) to 3.6 (2.4; p = 0.001) in the mid-portion and from 6 (2.5) to 3.2 (2.7; p = 0.002) in the insertional tendinopathy group. No Achilles tendon rupture or any interruption during the eccentric training was noted among the 59 patients. Daily eccentric training for Achilles tendinopathy is a safe and easy measure, with beneficial effects on the microcirculatory tendon levels without
Watson, Paul J.; Barry, Simon
Background and Purpose Achilles tendinopathy can be a debilitating chronic condition for both active and inactive individuals. The identification of risk facors is important both in preventing but also treating tendinopathy, many factors have been proposed but there is a lack of primary epidemiological data. The purpose of this study was to develop a statement of expert consensus on risk factors for Achilles tendinopathy in active and sedentary patient populations to inform a primary epidemiological study. Study design Delphi study Methods and Measures An online Delphi study was completed inviting participation from world tendon experts. The consensus was developed using three rounds of the Delphi technique. The first round developed a complete list of potential risk factors, the second round refined this list but also separated the factors into two population groups – active/athletic and inactive/sedentary. The third round ranked this list in order of perceived importance. Results Forty-four experts were invited to participate, 16 participated in the first round (response rate 40%) and two dropped out in the second round (resulting in a response rate of 35%). A total of 27 intrinsic and eight extrinsic risk factors were identified during round one. During round two only 12 intrinsic and five extrinsic risk factors were identified as important in active/athletic tendinopathy while 14 intrinsic and three extrinsic factors were identified as important for inactive/sedentary tendinopathy. Conclusions Risk factors for Achilles tendinopathy were identified based on expert consensus, and these factors provide a basis for primary epidemiological studies. Plantarflexor strength was identified as the primary modifiable factor in the active/athletic group while systemic factors were identified as important in the inactive/sedentary group, many of the potential factors suggested for either group were non-modifiable. Non-modifiable factors include: previous tendinopathy
Beyer, Rikke; Kongsgaard, Mads; Hougs Kjær, Birgitte; Øhlenschlæger, Tommy; Kjær, Michael; Magnusson, S Peter
Previous studies have shown that eccentric training has a positive effect on Achilles tendinopathy, but few randomized controlled trials have compared it with other loading-based treatment regimens. To evaluate the effectiveness of eccentric training (ECC) and heavy slow resistance training (HSR) among patients with midportion Achilles tendinopathy. Randomized controlled trial; Level of evidence, 1. A total of 58 patients with chronic (>3 months) midportion Achilles tendinopathy were randomized to ECC or HSR for 12 weeks. Function and symptoms (Victorian Institute of Sports Assessment-Achilles), tendon pain during activity (visual analog scale), tendon swelling, tendon neovascularization, and treatment satisfaction were assessed at 0 and 12 weeks and at the 52-week follow-up. Analyses were performed on an intention-to-treat basis. Both groups showed significant (P < .0001) improvements in Victorian Institute of Sports Assessment-Achilles and visual analog scale from 0 to 12 weeks, and these improvements were maintained at the 52-week follow-up. Concomitant with the clinical improvement, there was a significant reduction in tendon thickness and neovascularization. None of these robust clinical and structural improvements differed between the ECC and HSR groups. However, patient satisfaction tended to be greater after 12 weeks with HSR (100%) than with ECC (80%; P = .052) but not after 52 weeks (HSR, 96%; ECC, 76%; P = .10), and the mean training session compliance rate was 78% in the ECC group and 92% in the HSR group, with a significant difference between groups (P < .005). The results of this study show that both traditional ECC and HSR yield positive, equally good, lasting clinical results in patients with Achilles tendinopathy and that the latter tends to be associated with greater patient satisfaction after 12 weeks but not after 52 weeks. © 2015 The Author(s).
Background There is a general opinion that a structured and specific rehabilitation is needed after treatment of midportion Achilles tendinopathy to minimize recurrence of the condition. There is sparse knowledge about the recurrence rates in large patient materials after specific treatments for midportion Achilles tendinopathy. Aim This study aimed to investigate the recurrence rates in a large number of patients with chronic painful midportion Achilles tendinopathy that had been surgically treated with the ultrasound (US) and Doppler (DP)-guided mini-surgical scraping technique. Postoperatively, a relatively simple rehabilitation protocol, including a range of movement exercises and gradually increased walking and biking before allowing free activity, was used. Materials and methods From a database, information about the recurrence rates after US + DP-guided mini-surgical scraping, performed by a single surgeon on 519 tendons with US + DP-verified chronic painful midportion Achilles tendinopathy, was obtained. Results Recurrence of painful midportion Achilles tendinopathy was found in 26 of 519 (5%) operated tendons, 13 from women and 13 from men. In 13 tendons, a close by located plantaris tendon was extirpated during the reoperation. Conclusion In this large material on patients treated with US + DP-guided mini-surgical scraping for midportion Achilles tendinopathy, there were few recurrences, although only a simple and nonspecific rehabilitation protocol was used. PMID:27274323
Khan, Wasim S; Malvankar, Seema; Bhamra, Jagmeet S; Pengas, Ioannis
AIM: To determine an association between when the study was performed, the robustness of the study and the outcomes for insertional and non-insertional Achilles tendinopathy surgery. METHODS: We performed a systematic review in accordance with the PRISMA guidelines to assess the methodology of studies investigating the outcome of surgery in chronic Achilles tendinopathy over the last 50 years to identify any trends that would account for the variable results. The Coleman Methodology Scores were correlated with the reported percentage success rates and with the publication year to determine any trends using Pearson’s correlation. RESULTS: We identified 62 studies published between 1964 and 2014 reporting on a total of 2923 surgically treated Achilles tendinopathies. The average follow-up time was 40 mo (range 5-204 mo), and the mean reported success rate was 83.5% (range 36%-100%). The Coleman Methodology Scores were highly reproducible (r = 0.99, P < 0.01), with a mean of 40.1 (SD 18.9, range 2-79). We found a negative correlation between reported success rate and overall methodology scores (r = -0.40, P < 0.001), and a positive correlation between year of publication and overall methodology scores (r = 0.46, P < 0.001). CONCLUSION: We conclude that although the success rate of surgery for chronic Acilles tendinopathy described in the literature has fallen over the last 50 years, this is probably due to a more rigorous methodology of the studies. PMID:26191496
Murawski, Christopher D; Smyth, Niall A; Newman, Hunter; Kennedy, John G
The purpose of this study was to evaluate a series of patients undergoing a single platelet-rich plasma (PRP) injection for the treatment of chronic midsubstance Achilles tendinopathy, in whom conservative treatment had failed. Thirty-two patients underwent a single PRP injection for the treatment of chronic midsubstance Achilles tendinopathy and were evaluated at a 6-month final follow-up using the Foot and Ankle Outcome Score and Short Form 12 general health questionnaire. Magnetic resonance imaging was performed on all patients prior to and 6 months after injection. Twenty-five of 32 patients (78%) reported that they were asymptomatic at the 6-month follow-up visit and were able to participate in their respective sports and daily activities. The remaining 7 patients (22%) who reported symptoms that did not improve after 6 months ultimately required surgery. Four patients went on to have an Achilles tendoscopy, while the other 3 had an open debridement via a tendon splitting approach. A retrospective evaluation of patients receiving a single PRP injection for chronic midsubstance Achilles tendinopathy revealed that 78% had experienced clinical improvement and had avoided surgical intervention at 6-month follow-up. Therapeutic, Level IV: Retrospective case series. © 2014 The Author(s).
Arnal-Burró, J; López-Capapé, D; Igualada-Blázquez, C; Ortiz-Espada, A; Martín-García, A
To present the surgical technique with release of peritendon and radiofrequency as an effective treatment for athletes with chronic tendinopathy of the Achilles tendon body. This is a retrospective case series descriptive type study. The series consists of 17 Achilles tendon surgeries in 13 patients, who habitually run. The study included patients with non-insertional Achilles tendinopathy refractory to conservative treatments. After a minimum follow-up of 12 months, clinical improvement of the athletes was assessed using the Nirschl pain scale, as well as athletic performance. An improvement was obtained in 94% of symptoms and a return to the previous performance in of 70% of cases in the 12 months follow-up. Peritendon release combined with bipolar radiofrequency is presented as an effective solution in this condition, for which there is currently no consensus on the best treatment. In patients in whom, after an appropriate conservative treatment for a sufficient period (at least 6 months) the non-insertional Achilles tendinopathy persists, open adhesiolysis combined with bipolar radiofrequency is a safe and with a high success rate clinical and functional intervention. In high performance athletes this technique allows a return to previous activity in a high percentage of cases. Copyright © 2015 SECOT. Published by Elsevier Espana. All rights reserved.
Tallerico, Valerie K; Greenhagen, Robert M; Lowery, Clinton
Many surgeries exist for treatment of insertional Achilles tendinopathy. Another surgical option to consider is an isolated gastrocnemius recession. Recent studies have demonstrated the success of a gastrocnemius recession for noninsertional Achilles tendinitis. We hypothesize that an isolated gastrocnemius recession can be a successful, effective, and less invasive surgery for patients with chronic insertional Achilles tendinopathy. This article presents a retrospective review of one surgeon's results of 11 patients (2010-2012), with an average age of 59 years who presented with chronic insertional Achilles tendinopathy. Gastrocnemius recessions, either endoscopic or open, were performed after an average of 6.2 months of conservative treatment. All patients' radiographs were reviewed preoperatively for any calcaneal spurs and divided into groups accordingly. Average follow-up time postoperatively was 13.8 months. Plantarflexion strength, equinus deformity, as well as the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot instrument was assessed. In all, 10/11 (91%) patients had high patient satisfaction, pain relief, no residual equinus deformity, loss in muscle strength and returned to regular activities successfully at 1-year follow up. All patients and groups had significant improvement in AOFAS scores. The median postoperative AOFAS score was 94.8. All patients and patient groups had significant improvement pre- to postoperatively. Patients without spurs appear to do better than patients with spurs. One patient developed recurrence of insertional heel pain and equinus deformity. Other complications included 2 sural nerve parasthesias, which resolved. An isolated gastrocnemius recession for chronic insertional Achilles tendinopathy can provide high satisfaction, pain relief, and a faster recovery period with few or no complications. Therapeutic, Level IV: Case series. © 2014 The Author(s).
Abate, Michele; Salini, Vincenzo; Schiavone, Cosima
Exercise is an important therapeutic tool in the management of diabetes in older people. Aim of this study was to assess the relationship among type II diabetes, sport, overweight, and symptomatic Achilles tendinopathy in elderly subjects. Thirty-eight patients suffering from Achilles tendinopathy and thirty-eight controls were enrolled. The prevalence of diabetes and sport practice as well as BMI and Glycated Hemoglobin (HbA1c) values were registered. An ultrasound evaluation of Achilles tendon was performed. Patients showed an increased prevalence of diabetes (42 vs. 13.1 %, p = 0.004), and practice of sport (60.5 vs. 28.9 %, p = 0.0001), and higher BMI values (26.8 ± 3 vs. 24.8 ± 2.3, p = 0.001). Sonographic abnormalities, being diagnostic criteria, were present in all the patients with Achilles tendinopathy, but signs of degeneration were also found in 36.8 % of asymptomatic controls. Symptomatic subjects with diabetes, compared to those without, showed a higher prevalence of severe degeneration (75 vs. 36.3 %, p = 0.01). HbA1c values were significantly lower in sport practitioners, both diabetics and non-diabetics. Moreover, patients practicing sport showed a trend towards lower BMI values, compared to the sedentary counterpart. Sport practice in elderly diabetics provides relevant metabolic advantages, reducing HbA1c and BMI. However, some sport activities (e.g., speed walking, jogging or tennis) can expose to the risk of Achilles tendinopathy. So, sport practice should be encouraged, but practitioners should follow individual training programs and be submitted to periodic sonographic controls.
van Linschoten, R; den Hoed, P T; de Jongh, A C
--Chronic Achilles tendinopathy in sports often leads to various therapeutic strategies, medical shopping and frequently to inability to perform at the desired level. --Although it is clear that this chronic tendinopathy is not an inflammatory disease of the tendon, the cause of the degeneration of the tendon fibres is not understood. --The main therapeutic measure--based on scientific evidence--is eccentric calf-muscle training for at least 3 months. --Recent therapies such as sclerotherapy ofneovascularizations in and around the Achilles tendon appear to be promising, but more studies are required. --About 20% of the patients tend to be refractive to conservative measures. --In selected cases surgery can be undertaken, with percutaneous longitudinal tenotomy proving effective in 75-80% of the cases.
Background Abnormal lower limb biomechanics is speculated to be a risk factor for Achilles tendinopathy. This study systematically reviewed the existing literature to identify, critique and summarise lower limb biomechanical factors associated with Achilles tendinopathy. Methods We searched electronic bibliographic databases (Medline, EMBASE, Current contents, CINAHL and SPORTDiscus) in November 2010. All prospective cohort and case-control studies that evaluated biomechanical factors (temporospatial parameters, lower limb kinematics, dynamic plantar pressures, kinetics [ground reaction forces and joint moments] and muscle activity) associated with mid-portion Achilles tendinopathy were included. Quality of included studies was evaluated using the Quality Index. The magnitude of differences (effect sizes) between cases and controls was calculated using Cohen's d (with 95% CIs). Results Nine studies were identified; two were prospective and the remaining seven case-control study designs. The quality of 9 identified studies was varied, with Quality Index scores ranging from 4 to 15 out of 17. All studies analysed running biomechanics. Cases displayed increased eversion range of motion of the rearfoot (d = 0.92 and 0.67 in two studies), reduced maximum lower leg abduction (d = -1.16), reduced ankle joint dorsiflexion velocity (d = -0.62) and reduced knee flexion during gait (d = -0.90). Cases also demonstrated a number of differences in dynamic plantar pressures (primarily the distribution of the centre of force), ground reaction forces (large effects for timing variables) and also showed reduced peak tibial external rotation moment (d = -1.29). Cases also displayed differences in the timing and amplitude of a number of lower limb muscles but many differences were equivocal. Conclusions There are differences in lower limb biomechanics between those with and without Achilles tendinopathy that may have implications for the prevention and management of the condition
Robinson, J; Cook, J; Purdam, C; Visentini, P; Ross, J; Maffulli, N; Taunton, J; Khan, K
Background—There is no disease specific, reliable, and valid clinical measure of Achilles tendinopathy. Objective—To develop and test a questionnaire based instrument that would serve as an index of severity of Achilles tendinopathy. Methods—Item generation, item reduction, item scaling, and pretesting were used to develop a questionnaire to assess the severity of Achilles tendinopathy. The final version consisted of eight questions that measured the domains of pain, function in daily living, and sporting activity. Results range from 0 to 100, where 100 represents the perfect score. Its validity and reliability were then tested in a population of non-surgical patients with Achilles tendinopathy (n = 45), presurgical patients with Achilles tendinopathy (n = 14), and two normal control populations (total n = 87). Results—The VISA-A questionnaire had good test-retest (r = 0.93), intrarater (three tests, r = 0.90), and interrater (r = 0.90) reliability as well as good stability when compared one week apart (r = 0.81). The mean (95% confidence interval) VISA-A score in the non-surgical patients was 64 (59–69), in presurgical patients 44 (28–60), and in control subjects it exceeded 96 (94–99). Thus the VISA-A score was higher in non-surgical than presurgical patients (p = 0.02) and higher in control subjects than in both patient populations (p<0.001). Conclusions—The VISA-A questionnaire is reliable and displayed construct validity when means were compared in patients with a range of severity of Achilles tendinopathy and control subjects. The continuous numerical result of the VISA-A questionnaire has the potential to provide utility in both the clinical setting and research. The test is not designed to be diagnostic. Further studies are needed to determine whether the VISA-A score predicts prognosis. Key Words: Achilles; tendinopathy; tendinitis; outcome; questionnaire PMID:11579069
Maffulli, Nicola; Papalia, Rocco; D'Adamio, Stefano; Diaz Balzani, Lorenzo; Denaro, Vincenzo
Several pharmacological interventions have been proposed for the management of Achilles tendinopathy, with no agreement on which is the overall best option available. This systematic review investigates the efficacy and safety of different local pharmacological treatments for Achilles tendinopathy. We included only randomized controlled studies (RCTs) focusing on clinical and functional outcomes of therapies consisting in injection of a substance or local application. Assessment of the methodological quality was performed using a modified version of the Coleman methodology score (CMS) to determine possible risks of bias. Thirteen RCTs were included with a total of 528 studied patients. Eleven studies reported the outcomes of injection therapies. Two studies examined the outcomes of patients who applied glyceryl trinitrate patch. The mean modified CMS was 70.6 out of 90. There was no significant evidence of remarkable benefits provided by any of the therapies studied. There is not univocal evidence to advise any particular pharmacological treatment as the best advisable non-operative option for Achilles tendinopathy as equivalent alternative to the most commonly used eccentric loading rehabilitation program. However, potential was shown by the combination of different substances administered with physical therapy. There is a need for more long-term investigations, studying large enough cohort with standardized scores and evaluations shared by all the investigations to confirm the healing potential, and provide a stronger statistical comparison of the available treatments. © The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: email@example.com.
Miao, Xu-Dong; Jiang, Hongfei; Wu, Yong-Ping; Tao, Hui-Min; Yang, Di-Sheng; Hu, Hang
The present study investigated the clinical outcomes of the posterior midline approach in the treatment of 34 patients with significantly calcified insertional Achilles tendinopathy. The posterior midline approach was applied for the surgical treatment of 34 patients with chronic significantly calcified insertional Achilles tendinopathy after failed conservative treatment. Gastrocnemius recession was performed simultaneously for patients with gastrocnemius contracture. The Fowler-Philip angle and parallel pitch lines were measured before surgery, and the visual analog scale, Tegner score, and Victorian Institute of Sport tendon study group score were recorded before and after surgery. The mean follow-up period was 45.2 ± 17.7 (range 24 to 84) months. After surgery, the visual analog scale score had decreased notably, and the Tegner score and Victorian Institute of Sport tendon study group score had increased significantly. The posterior midline approach can achieve satisfactory outcomes in the treatment of significantly calcified insertional Achilles tendinopathy, and gastrocnemius recession (Strayer procedure) should be performed for patients with gastrocnemius contracture to improve the surgical outcome. Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Jayaseelan, Dhinu J; Post, Andrew A; Mischke, John J; Sault, Josiah D
Insertional Achilles tendinopathy (IAT) can be a challenging condition to manage conservatively. Eccentric exercise is commonly used in the management of chronic tendinopathy; however, it may not be as helpful for insertional tendon problems as compared to mid-portion dysfunction. While current evidence describing the physical therapy management of IAT is developing, gaps still exist in descriptions of best practice. The purpose of this case report is to describe the management of a patient with persistent IAT utilizing impairment-based joint mobilization, self-mobilization, and exercise. A 51-year-old male was seen in physical therapy for complaints of posterior heel pain and reduced running capacity. He was seen by multiple physical therapists previously, but reported continued impairment, and functional restriction. Joint-based non-thrust mobilization and self-mobilization exercise were performed to enhance his ability to run and reduce symptoms. The subject was seen for four visits over the course of two months. He made clinically significant improvements on the Foot and Ankle Activity Measure and Victorian Institute of Sport Assessment-Achilles tendon outcomes, was asymptomatic, and participated in numerous marathons. Improvements were maintained at one-year follow-up. Mobility deficits can contribute to the development of tendinopathy, and without addressing movement restrictions, symptoms and functional decline related to tendinopathy may persist. Joint-directed manual therapy may be a beneficial intervention in a comprehensive plan of care in allowing patients with chronic tendon changes to optimize function. Therapy, Level 4.
Kim, SungJoong; Yu, JaeHo
This study aimed to clarify the mechanical gait changes caused by achilles tendinopathy by comparing gait parameters and changes in hip, knee, and ankle moments between an experimental group (EG) and a control group (CG). Twenty runners with achilles tendinopathy were included in the EG (male/female: 10/10, age: 27.00 ± 4.63), and 20 CG (male/female: 10/10, age: 27.25 ± 4.33) participants were recruited. Subjects walked a 13-m distance at their normal walking speed 5 times to obtain motion analysis and joint moment data. Gait parameter analysis showed significant differences in double-limb support (EG: 22.65 ± 4.26%, CG: 20.37 ± 4.46%), step length (EG: 0.58 ± 0.0 7m, CG: 0.64 ± 0.08 m), step width (EG: 0.16 ± 0.04 m, CG: 0.14 ± 0.05 m), stride time (EG: 1.09 ± 0.10 second, CG: 1.05 ± 0.08 second), and walking speed (EG: 1.09±0.18 m·s-1, CG: 1.23 ± 0.17 m·s-1) between the 2 groups (p < 0.05). Significant differences were found in hip joint moment for initial contact, mid-stance, terminal stance, and pre-swing phases; knee joint moment for initial contact and pre-swing phases; and ankle joint moment for pre-swing and terminal swing phases (p < 0.05). Gait parameters and hip, knee, and ankle moments were altered in runners with achilles tendinopathy. Thus, clinical features of gait changes should be understood for optimal treatment of achilles tendinopathy; further research is required in this field. Key points A reduction in gait parameters, namely, step length, stride length, and walking speed, and an increase in double-limb support occurs in runners with achilles tendinopathy. A reduction in the hip extension moment occurs during the initial contact, as well as a reduction in the knee flexion moment from the mid-stance to pre-swing phases, a continuous decrease in the knee flexion moment from the early stance phase, and a reduction in the extension moment during the terminal stance phase. A reduction in the ankle plantar flexion moment occurs from
Spang, C; Harandi, V M; Alfredson, H; Forsgren, S
The plantaris tendon is increasingly recognised as an important factor in midportion Achilles tendinopathy. Its innervation pattern is completely unknown. Plantaris tendons (n=56) and associated peritendinous tissue from 46 patients with midportion Achilles tendinopathy and where the plantaris tendon was closely related to the Achilles tendon were evaluated. Morphological evaluations and stainings for nerve markers [general (PGP9.5), sensory (CGRP), sympathetic (TH)], glutamate NMDA receptor and Schwann cells (S-100β) were made. A marked innervation, as evidenced by evaluation for PGP9.5 reactions, occurred in the peritendinous tissue located between the plantaris and Achilles tendons. It contained sensory and to some extent sympathetic and NMDAR1-positive axons. There was also an innervation in the zones of connective tissue within the plantaris tendons. Interestingly, some of the nerve fascicles showed a partial lack of axonal reactions. New information on the innervation patterns for the plantaris tendon in situations with midportion Achilles tendinopathy has here been obtained. The peritendinous tissue was found to be markedly innervated and there was also innervation within the plantaris tendon. Furthermore, axonal degeneration is likely to occur. Both features should be further taken into account when considering the relationship between the nervous system and tendinopathy.
Spang, C.; Harandi, V.M.; Alfredson, H.; Forsgren, S.
Objectives: The plantaris tendon is increasingly recognised as an important factor in midportion Achilles tendinopathy. Its innervation pattern is completely unknown. Methods: Plantaris tendons (n=56) and associated peritendinous tissue from 46 patients with midportion Achilles tendinopathy and where the plantaris tendon was closely related to the Achilles tendon were evaluated. Morphological evaluations and stainings for nerve markers [general (PGP9.5), sensory (CGRP), sympathetic (TH)], glutamate NMDA receptor and Schwann cells (S-100β) were made. Results: A marked innervation, as evidenced by evaluation for PGP9.5 reactions, occurred in the peritendinous tissue located between the plantaris and Achilles tendons. It contained sensory and to some extent sympathetic and NMDAR1-positive axons. There was also an innervation in the zones of connective tissue within the plantaris tendons. Interestingly, some of the nerve fascicles showed a partial lack of axonal reactions. Conclusion: New information on the innervation patterns for the plantaris tendon in situations with midportion Achilles tendinopathy has here been obtained. The peritendinous tissue was found to be markedly innervated and there was also innervation within the plantaris tendon. Furthermore, axonal degeneration is likely to occur. Both features should be further taken into account when considering the relationship between the nervous system and tendinopathy. PMID:26032213
Munteanu, Shannon E; Scott, Lisa A; Bonanno, Daniel R; Landorf, Karl B; Pizzari, Tania; Cook, Jill L; Menz, Hylton B
To evaluate the effectiveness of customised foot orthoses in chronic mid-portion Achilles tendinopathy. This was a participant-blinded, parallel-group randomised controlled trial at a single centre (La Trobe University, Melbourne, Australia). One hundred and forty participants aged 18-55 years with mid-portion Achilles tendinopathy were randomised to receive eccentric calf muscle exercises with either customised foot orthoses (intervention group) or sham foot orthoses (control group). Allocation to intervention was concealed. The Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire was completed at baseline, then at 1, 3, 6 and 12 months, with 3 months being the primary end point. Differences between groups were analysed using intention to treat with analysis of covariance. After randomisation into the customised foot orthoses group (n=67) or sham foot orthoses group (n=73), there was 70.7% follow-up of participants at 3 months. There were no significant differences between groups at any time point. At 3 months, the mean (SD) VISA-A score was 82.1 (16.3) and 79.2 (20.0) points for the customised and sham foot orthosis groups, respectively (adjusted mean difference (95% CI)=2.6 (-2.9 to 8.0), p=0.353). There were no clinically meaningful differences between groups in any of the secondary outcome measures. Customised foot orthoses, prescribed according to the protocol in this study, are no more effective than sham foot orthoses for reducing symptoms and improving function in people with mid-portion Achilles tendinopathy undergoing an eccentric calf muscle exercise programme. Australian New Zealand Clinical Trials Registry: number ACTRN12609000829213. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
Introduction. The aim of this study was to investigate the utility of ultrasonography (US) for predicting and assessing the effectiveness of extracorporeal shock wave therapy (ESWT) in insertional Achilles tendinopathy (IAT). Methods. A total of 42 patients with an established diagnosis of chronic IAT were examined by US before ESWT and at 4 weeks and 12 weeks after ESWT. The thickness and cross-sectional area (CSA) of the Achilles tendon, size of calcific plaques, tendon structure score, and neovascularization score were measured at each time point. Results. After therapy, Victorian Institute of Sport Assessment-Achilles (VISA-A) scores increased significantly, and the size of calcific plaques decreased (P < 0.05). Neovascularization scores increased at the 4th week and then decreased at the 12th week (P < 0.05). The thickness, CSA, and structure of the Achilles tendon did not change. Variables observed by US at baseline were not associated with changes in VISA-A scores at follow-up. However, the changes in calcific plaque size and neovascularization scores were related to the improvement of VISA-A scores between pre- and posttherapy (P < 0.01). Conclusion. Ultrasonography can reveal some changes in the insertion of the Achilles tendon after ESWT, but the outcome of ESWT in IAT cannot be predicted by the variables observed by US. PMID:28004000
Jafari, Leila; Vachon, Pascal; Beaudry, Francis; Langelier, Eve
Abstract Animal models of forced running are used to study overuse tendinopathy, a common health problem for which clear evidence for effective and accessible treatments is still lacking. In these models, pain evaluation is necessary to better understand the disease, help design and evaluate therapies, and ensure humane treatment of the animals. Therefore, the main objective of this study was to evaluate pain and pathologic findings in an animal model of moderate Achilles tendinopathy induced by treadmill running. Air puffs, instead of electrical shocks, were used to stimulate running so that pain associated with stimulation would be avoided. Pressure pain sensitivity was evaluated in vivo using a new instrumented plier, whereas spinal cord peptides were analyzed ex vivo with high‐performance liquid chromatography tandem mass spectrometry. Tendon histologic slides were semiquantitatively evaluated, using the Bonar score technique and biomechanical properties, using the traction test. After 8 weeks of treadmill running (2 weeks for adaptation and 6 weeks for the lesion protocol), the protocol was stopped because the air puffs became ineffective to stimulate running. We, nevertheless, observed some histologic changes characteristic of overuse tendinopathy as well as decreased mechanical properties, increased Substance P and dynorphin A peptides but without pressure pain sensitivity. These results suggest that air‐puffs stimulation is sufficient to induce an early stage tendinopathy to study new therapeutic drugs without inducing unnecessary pain. They also indicate that pain‐associated peptides could be related with movement evoked pain and with the sharp breakdown of the running performance. PMID:25602018
Post, Andrew A.; Mischke, John J.; Sault, Josiah D.
Background & Purpose Insertional Achilles tendinopathy (IAT) can be a challenging condition to manage conservatively. Eccentric exercise is commonly used in the management of chronic tendinopathy; however, it may not be as helpful for insertional tendon problems as compared to mid-portion dysfunction. While current evidence describing the physical therapy management of IAT is developing, gaps still exist in descriptions of best practice. The purpose of this case report is to describe the management of a patient with persistent IAT utilizing impairment-based joint mobilization, self-mobilization, and exercise. Case description A 51-year-old male was seen in physical therapy for complaints of posterior heel pain and reduced running capacity. He was seen by multiple physical therapists previously, but reported continued impairment, and functional restriction. Joint-based non-thrust mobilization and self-mobilization exercise were performed to enhance his ability to run and reduce symptoms. Outcomes The subject was seen for four visits over the course of two months. He made clinically significant improvements on the Foot and Ankle Activity Measure and Victorian Institute of Sport Assessment-Achilles tendon outcomes, was asymptomatic, and participated in numerous marathons. Improvements were maintained at one-year follow-up. Discussion Mobility deficits can contribute to the development of tendinopathy, and without addressing movement restrictions, symptoms and functional decline related to tendinopathy may persist. Joint-directed manual therapy may be a beneficial intervention in a comprehensive plan of care in allowing patients with chronic tendon changes to optimize function. Level of Evidence Therapy, Level 4 PMID:28217424
Filardo, Giuseppe; Kon, Elizaveta; Di Matteo, Berardo; Di Martino, Alessandro; Tesei, Giulia; Pelotti, Patrizia; Cenacchi, Annarita; Marcacci, Maurilio
Background Chronic Achilles tendinopathy is responsible for a severe reduction in physical performance and persistent pain. There is currently a number of therapeutic options and the local administration of growth factors is an emerging treatment strategy. In particular, platelet-rich plasma (PRP) is a widely used way to provide a local regenerative stimulus for tendon healing. The aim of this study was to document the mid-term results obtained after treating recalcitrant Achilles tendinopathy with injections of high concentrate, leucocyte-rich PRP. Materials and methods Twenty-seven patients (mean age: 44.6 years; 22 men and 5 women) affected by chronic mid-portion Achilles tendinopathy (7 bilateral, for a total of 34 tendons), refractory to previous treatments, were enrolled. Patients were treated with three ultrasound-guided intra-tendinous injections of PRP at 2-week intervals. Patients were prospectively evaluated at baseline, and then at 2, 6, and up to a mean of 54.1 months of follow-up (minimum 30 months), using the following tools: Blanzina, VISA-A, EQ-VAS for general health, and Tegner scores. Results The VISA-A score showed a significant improvement: the baseline score of 49.9±18.1 increased to 62.9±19.8 at 2 months (p=0.002), with a further improvement at 6 months (84.3±17.1, p<0.0005), and stable results at 4.5 years (90.0±13.9). The EQ-VAS score also showed a similar positive trend. An evaluation of the activity level confirmed these findings, showing a significant improvement in the Tegner score over time (p=0.017 for the final evaluation). The longer duration of symptoms before treatment was associated with a slower return to sport (p=0.041). Discussion PRP injections produced good overall results for the treatment of chronic recalcitrant Achilles tendinopathy with a stable outcome up to a medium-term follow-up. Longer symptom duration was related with a more difficult return to sporting activity. PMID:24960641
Gillis, Craig T; Lin, Jason S
After 3 to 6 months of conservative management for insertional calcific Achilles tendinopathy, operative intervention might be warranted. Despite a success rate of 75% to 100% with surgery, no consensus has been reached on the amount of acceptable detachment of the Achilles tendon. The present case series reports on the results of a central splitting approach with 80% to 90% detachment of the Achilles insertion repaired with a double-row bridging suture device. A total of 14 patients (16 heels) for whom nonoperative management for insertional calcific Achilles tendinopathy had previously failed were enrolled in the present study they had undergone surgical management. The patients were followed up for a mean of 18 (range 11 to 25) months postoperatively and were evaluated using the American Orthopaedic Foot and Ankle Society Hind Foot scoring system, 36-item Short Form Health Survey questionnaire, and pre- and postoperative visual analog pain scale. The mean visual analog pain scale core had decreased 5.84 (range 1 to 9) points postoperatively (p < .001). The mean postoperative American Orthopaedic Foot and Ankle Society Hind Foot score was 87 ± 19.7 (range 52 to 105) points. One patient reported moderate pain with no limitation of activities. The mean 36-item Short-Form Health Survey score for physical functioning was 77.7 (range 30 to 100) points postoperatively in 11 patients. No patient reported incisional discomfort. All 14 patients (16 heels) reported being satisfied and had returned to their previous functional status. Thus, the central splitting Achilles approach with anchoring of the Achilles insertion using the double-row suture device is a safe and reasonable option in the operative treatment of insertional calcific Achilles tendinopathy.
Saunders, Colleen J; Van Der Merwe, Lize; Cook, Jill; Handley, Christopher J; Collins, Malcolm; September, Alison V
Cartilage oligomeric matrix protein is a structural protein of the extracellular matrix, while thrombospondin-2 is a matricellular protein involved in cell-matrix interactions. Recent studies have shown that genetic variation is a significant risk factor for Achilles tendinopathy, and the genes encoding cartilage oligomeric matrix protein (COMP) and thrombospondin-2 (THBS2) were identified as good candidate genes for association with Achilles tendinopathy. This study aimed to test the association of sequence variants within these candidate genes with the risk of Achilles tendinopathy in participants from South Africa (SA) and Australia (AUS). Three-hundred and forty (133 SA; 207 AUS) control participants with no history of Achilles tendinopathy and 178 (94 SA; 84 AUS) participants clinically diagnosed with Achilles tendinopathy were genotyped for five single nucleotide polymorphisms within the COMP and THBS2 genes in this case-control study. There was no difference in genotype distributions between control and tendinopathy groups for either the THBS2 variants rs9505888, rs6422747 and rs9283850, or the COMP variants rs730079 and rs28494505 in the SA and AUS populations. As the selection of COMP and THBS2 as candidate genes was hypothesis driven, based on biological function, the possibility that other variants within these genes are associated with Achilles tendinopathy cannot be excluded.
Benazzo, Francesco; Zanon, Giacomo; Klersy, Catherine; Marullo, Matteo
The study aimed to compare two methods of open surgical treatment for midportion Achilles tendinopathy in sportsmen. A novel technique consisting in transferring some soleus fibres into the degenerated tendon to improve its vascularization and longitudinal tenotomies are evaluated and compared. From 2006 to 2011, fifty-two competitive and noncompetitive athletes affected by midportion Achilles tendinopathy were surgically treated and prospectively evaluated at 6 months and at a final 4-year mean follow-up. Twenty patients had longitudinal tenotomies, and thirty-two had soleus fibres transfer. Clinical outcome was evaluated by the American Orthopaedic Foot and Ankle Society (AOFAS) score and the Victorian Institute of Sports Assessment-Achilles (VISA-A) score. Time to return to walk and to run and tendon thickening were also recorded. Patients in the soleus transfer group had a higher increase in AOFAS and VISA-A score at 6 months and at the mean 4-year final follow-up (by 5.4 points, 95 % CI 2.9-7.9, p < 0.001 and by 5.7 points, 95 % CI 2.5-8.9, p = 0.001, for AOFAS and VISA, respectively). They also needed less time to return to run: 98.9 ± 17.4 days compared to 122.2 ± 26.3 days for the longitudinal tenotomies group (p = 0.0019). The soleus transfer group had a greater prevalence of tendon thickening (59.4 % compared to 30.0 % in the longitudinal tenotomies group, p = 0.037). Open surgery for midportion Achilles tendinopathy is safe and effective in medium term. Despite similar outcomes in postoperative functional scores, soleus transfer allows a faster recovery but has a higher incidence of tendon thickening. These results should suggest the use of the soleus graft technique in high-level athletes. Prospective comparative study, Level II.
McAuliffe, Seán; McCreesh, Karen; Culloty, Fiona; Purtill, Helen; O'Sullivan, Kieran
Ultrasound (US) imaging is commonly used to visualise tendon structure. It is not clear whether the presence of structural abnormalities in asymptomatic tendons predicts the development of future tendon symptoms in the Achilles or patellar tendon. To perform a systematic review and meta-analysis investigating the ability of US imaging to predict future symptoms of patellar or Achilles tendinopathy. Prospective studies that performed US imaging of Achilles OR patellar tendon structure among asymptomatic patients at baseline and a clinical measure of pain and/or function at follow-up were included. Study quality was assessed using the Critical Appraisal Skills Programme tool by two independent reviewers, and predictive ability of US was assessed using meta-analyses. The majority of participants in the review were from sporting populations. Meta-analysis revealed that tendon abnormalities on US are associated with future symptoms of both patellar and Achilles tendinopathy (RR=4.97, 95% CI 3.20 to 7.73). Subgroup analysis indicated that tendon abnormalities at baseline were associated with an increased risk of both Achilles (RR=7.33, 95% CI 2.95 to 18.24) and patellar (RR=4.35, 95% CI 2.62 to 7.23) tendinopathy. This systematic review and meta-analysis indicates that tendon abnormalities visualised using US in asymptomatic tendons are predictive of future tendinopathy and are associated with at least a fourfold increased risk. Identification of at-risk athletes using screening tools such as US may allow preventative programmes to be implemented. However, it is clear that other factors beyond tissue structure are involved in the development of lower limb tendinopathy. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.
Munteanu, Shannon E; Landorf, Karl B; Menz, Hylton B; Cook, Jill L; Pizzari, Tania; Scott, Lisa A
Background Achilles tendinopathy is a common condition that can cause marked pain and disability. Numerous non-surgical treatments have been proposed for the treatment of this condition, but many of these treatments have a poor or non-existent evidence base. The exception to this is eccentric calf muscle exercises, which have become a standard non-surgical intervention for Achilles tendinopathy. Foot orthoses have also been advocated as a treatment for Achilles tendinopathy, but the long-term efficacy of foot orthoses for this condition is unknown. This manuscript describes the design of a randomised trial to evaluate the efficacy of customised foot orthoses to reduce pain and improve function in people with Achilles tendinopathy. Methods One hundred and forty community-dwelling men and women aged 18 to 55 years with Achilles tendinopathy (who satisfy inclusion and exclusion criteria) will be recruited. Participants will be randomised, using a computer-generated random number sequence, to either a control group (sham foot orthoses made from compressible ethylene vinyl acetate foam) or an experimental group (customised foot orthoses made from semi-rigid polypropylene). Both groups will be prescribed a calf muscle eccentric exercise program, however, the primary difference between the groups will be that the experimental group receive customised foot orthoses, while the control group receive sham foot orthoses. The participants will be instructed to perform eccentric exercises 2 times per day, 7 days per week, for 12 weeks. The primary outcome measure will be the total score of the Victorian Institute of Sport Assessment - Achilles (VISA-A) questionnaire. The secondary outcome measures will be participant perception of treatment effect, comfort of the foot orthoses, use of co-interventions, frequency and severity of adverse events, level of physical activity and health-related quality of life (assessed using the Short-Form-36 questionnaire - Version two). Data will
Hahn, Frederik; Meyer, Patrick; Maiwald, Christian; Zanetti, Marco; Vienne, Patrick
In patients with chronic Achilles tendinopathy, augmentation with flexor hallucis longus (FHL) tendon transfer can be performed to improve pain and functional limitations. There are no reports of postoperative imaging for evaluating tendon integration, inflammatory alterations or degeneration of the FHL muscle. The purpose of this study was to evaluate postoperative MR imaging based on clinical outcome and isokinetic strength. 13 patients with chronic Achilles tendinopathy (10 ruptures) underwent augmentation with FHL transfer. Clinical parameters, isokinetic strength and outcome measurements (AOFAS, SF-36) were evaluated at an average followup of 46.5 months. Qualitative and quantitative analyses of postoperative MRI were conducted using the non-operated side for comparison. All patients had a significant reduction of pain. The operated side had a torque deficit of 35% for plantar flexion. Ten patients returned to their former level of activity. MRI showed a complete integration of the FHL tendon in six patients. Fatty atrophy in the triceps surae was found in ten patients. The FHL was free of degeneration in all patients. Hypertrophy of the FHL of more than 15% was observed in eight patients. Augmentation with FHL transfer is a valuable option in the treatment of chronic Achilles tendinopathy with and without rupture. Our results demonstrate high patient satisfaction without donor site morbidity. The FHL tendon is well integrated into the Achilles tendon. Hypertrophy of the FHL muscle suggests functional incorporation into plantar flexion. The primary benefit of the operation is pain relief and increased muscle strength.
Roos, Thomas R.; Roos, Andrew K.; Kleimeyer, John P.; Ahmed, Marwa A.; Goodlin, Gabrielle T.; Fredericson, Michael; Ioannidis, John P. A.; Avins, Andrew L.; Dragoo, Jason L.
Achilles tendinopathy or rupture and anterior cruciate ligament (ACL) rupture are substantial injuries affecting athletes, associated with delayed recovery or inability to return to competition. To identify genetic markers that might be used to predict risk for these injuries, we performed genome-wide association screens for these injuries using data from the Genetic Epidemiology Research on Adult Health and Aging (GERA) cohort consisting of 102,979 individuals. We did not find any single nucleotide polymorphisms (SNPs) associated with either of these injuries with a p-value that was genome-wide significant (p<5x10-8). We found, however, four and three polymorphisms with p-values that were borderline significant (p<10−6) for Achilles tendon injury and ACL rupture, respectively. We then tested SNPs previously reported to be associated with either Achilles tendon injury or ACL rupture. None showed an association in our cohort with a false discovery rate of less than 5%. We obtained, however, moderate to weak evidence for replication in one case; specifically, rs4919510 in MIR608 had a p-value of 5.1x10-3 for association with Achilles tendon injury, corresponding to a 7% chance of false replication. Finally, we tested 2855 SNPs in 90 candidate genes for musculoskeletal injury, but did not find any that showed a significant association below a false discovery rate of 5%. We provide data containing summary statistics for the entire genome, which will be useful for future genetic studies on these injuries. PMID:28358823
Yeo, Andrea; Kendall, Namita; Jayaraman, Sunderarajan
Chronic Achilles tendinopathy is a common overuse injury. There are several modalities of treatment, reflecting difficulties in management. In particular, due to the well-recognised surgical morbidity, treatment has steered towards less invasive routes. Previous studies have targeted pathology either inside or outside the tendon in isolation with varying results. This study aimed to target both pathological sites by combining dry needling with percutaneous hydrostatic decompression as a novel treatment. Twenty-one patients with 26 chronic, non-insertional Achilles tendinopathy were prospectively enrolled. Ultrasound-guided dry needling of neovascular areas and small-volume hydrostatic paratenon decompression was performed 6-weekly. Sonographic assessment of tendon thickness and neovascularity was undertaken. Following treatment, a standardised physiotherapy regime was adopted. Visual analogue scores (VAS) were used as the primary outcome measure. Telephonic interviews were carried out 12 and 24 months post-treatment. Twenty-four tendons (in 19 patients) were successfully treated. The mean treatment session was 2. There was no significant change in neovascularity or tendon thickness. Therapeutic intervention led to a significant improvement in VAS at rest (42.4 ± 24.4 vs. 18.4 ± 26.0, p = 0.0005) and during activity (72.8 ± 16.0 vs. 33.7 ± 23.2, p < 0.0001). At 12 and 24 months, >75 % of patients were highly satisfied with their outcome with nearly half reporting complete resolution of their symptoms. >85 % were also able to return to their sporting interests. Combined therapy of dry needling with percutaneous hydrostatic paratenon decompression under ultrasound guidance is a well-tolerated procedure with good short- and long-term pain and functional outcomes. Prospective case series, Level IV.
Hunt, Kenneth J; Cohen, Bruce E; Davis, W Hodges; Anderson, Robert B; Jones, Carroll P
Chronic insertional Achilles tendinopathy is a common pathology that can be difficult to manage. Some experts have advocated augmentation with the flexor hallucis longus (FHL) tendon in patients over age 50 and those with more severe tendon disease. We hypothesized that FHL augmentation would be associated with superior clinical outcome scores and greater ankle plantar flexion strength compared with Achilles debridement alone. Consecutive patients older than 50 years who had failed nonoperative treatment for chronic insertional Achilles tendinopathy were randomly assigned to Achilles decompression and debridement alone (control group) or Achilles decompression and debridement augmented with FHL transfer (FHL group). Outcome measures included American Orthopaedic Foot & Ankle Society (AOFAS) ankle/hindfoot score, visual analog scale (VAS) for pain, ankle and hallux plantar flexion strength, and a patient satisfaction survey. A total of 39 enrolled patients had a minimum 1-year follow-up, 18 in the control group and 21 in the FHL transfer group. The average patient age was 60.5 years. AOFAS and VAS scores improved in both groups at 6 months and 1 year with no difference between groups. There was greater ankle plantar flexion strength in the FHL group at 6 months and at 1 year compared with the control group (P < .05). There was no difference between the 2 groups in hallux plantar flexion strength preoperatively and at 1 year after surgery. Some 87% of patients were satisfied with the outcome of their procedure. There was no significant increase in wound complications in the FHL group (P < .05). We found no differences in pain, functional outcome (as measured by the AOFAS ankle/hindfoot scale), and patient satisfaction when comparing patients treated with Achilles debridement alone versus FHL augmentation for chronic Achilles tendinopathy. Ankle plantar flexion strength appeared to be improved with FHL transfer, with no loss of hallux plantar flexion strength
Chimenti, Ruth L; Flemister, A Samuel; Tome, Joshua; McMahon, James M; Houck, Jeff R
Study Design Controlled laboratory study; cross-sectional. Background Little is known about ankle range of motion (ROM) and strength among patients with insertional Achilles tendinopathy (IAT) and whether limited ankle ROM and plantar flexor weakness impact IAT symptom severity. Objectives The purposes of the study were (1) to examine whether participants with IAT exhibit limited non-weight-bearing dorsiflexion ROM, reduced plantar flexor strength, and/or altered ankle biomechanics during stair ascent; and (2) to determine which impairments are associated with symptom severity. Methods Participants included 20 patients with unilateral IAT (mean ± SD age, 59 ± 8 years; 55% female) and 20 individuals without tendinopathy (age, 58.2 ± 8.5 years; 55% female). A dynamometer was used to measure non-weight-bearing ROM and isometric plantar flexor strength. Three-dimensional motion analysis was used to quantify ankle biomechanics during stair ascent. End-range dorsiflexion was quantified as the percentage of non-weight-bearing dorsiflexion used during stair ascent. Group differences were compared using 2-way and 1-way analyses of variance. Pearson correlations were used to test for associations among dependent variables and symptom severity. Results Groups differed in ankle biomechanics, but not non-weight-bearing ROM or strength. During stair ascent, the IAT group used greater end-range dorsiflexion (P = .03), less plantar flexion (P = .02), and lower peak ankle plantar flexor power (P = .01) than the control group. Higher end-range dorsiflexion and lower ankle power during stair ascent were associated with greater symptom severity (P<.05). Conclusion Patients with IAT do not experience restrictions in non-weight-bearing dorsiflexion ROM or isometric plantar flexor strength. However, altered ankle biomechanics during stair ascent were linked with greater symptom severity and likely contribute to decreased function. J Orthop Sports Phys Ther 2016;46(12):1051-1060. Epub
Reid, Duncan; McNair, Peter J; Johnson, Shelley; Potts, Geoff; Witvrouw, Erik; Mahieu, Nele
To compare surface electromyographic (EMG) activity of the gastrocnemius and soleus muscles between persons with and without Achilles tendinopathy (AT) during an eccentric muscle exercise in different knee joint positions. Repeated measures design. Research laboratory. Participants (n = 18) diagnosed with AT and 18 control subjects were recruited. Gastrocnemius and soleus muscle activity was examined by surface (EMG) during extended and flexed knee joint conditions while performing the eccentric training technique. The EMG data were expressed as a percentage of a maximum voluntary contraction (MVC). EMG activity was notably higher (mean difference: 10%, effect size: 0.59) in those subjects with AT. Irrespective of the presence of AT, there was a significant interaction effect between muscle and joint position. The gastrocnemius muscle was significantly more active in the extended knee condition and soleus muscle activity was unchanged across joint positions. The results indicated that the presence of AT influenced calf muscle activity levels during performance of the eccentric exercise. There were differences in muscle activity during the extended and flexed knee conditions. This result does support performing Alfredson, Pietila, Jonsson, and Lorentzon (1998) eccentric exercise in an extended knee position but the specific effects of the knee flexed position on the Achilles tendon during eccentric exercise have yet to be determined, particularly in those with AT. Copyright © 2011 Elsevier Ltd. All rights reserved.
Lohrer, Heinz; Nauck, Tanja
Background Achilles tendinopathy is the predominant overuse injury in runners. To further investigate this overload injury in transverse and longitudinal studies a valid, responsive and reliable outcome measure is demanded. Most questionnaires have been developed for English-speaking populations. This is also true for the VISA-A score, so far representing the only valid, reliable, and disease specific questionnaire for Achilles tendinopathy. To internationally compare research results, to perform multinational studies or to exclude bias originating from subpopulations speaking different languages within one country an equivalent instrument is demanded in different languages. The aim of this study was therefore to cross-cultural adapt and validate the VISA-A questionnaire for German-speaking Achilles tendinopathy patients. Methods According to the "guidelines for the process of cross-cultural adaptation of self-report measures" the VISA-A score was cross-culturally adapted into German (VISA-A-G) using six steps: Translation, synthesis, back translation, expert committee review, pretesting (n = 77), and appraisal of the adaptation process by an advisory committee determining the adequacy of the cross-cultural adaptation. The resulting VISA-A-G was then subjected to an analysis of reliability, validity, and internal consistency in 30 Achilles tendinopathy patients and 79 asymptomatic people. Concurrent validity was tested against a generic tendon grading system (Percy and Conochie) and against a classification system for the effect of pain on athletic performance (Curwin and Stanish). Results The "advisory committee" determined the VISA-A-G questionnaire as been translated "acceptable". The VISA-A-G questionnaire showed moderate to excellent test-retest reliability (ICC = 0.60 to 0.97). Concurrent validity showed good coherence when correlated with the grading system of Curwin and Stanish (rho = -0.95) and for the Percy and Conochie grade of severity (rho 0
Imai, Kan; Ikoma, Kazuya; Chen, Qingshan; Zhao, Chunfeng; An, Kai-Nan; Gay, Ralph E
Augmented soft tissue mobilization (ASTM) has been used to treat Achilles tendinopathy and is thought to promote collagen fiber realignment and hasten tendon regeneration. The objective of this study was to evaluate the biomechanical and histological effects of ASTM therapy on rabbit Achilles tendons after enzymatically induced injury. This study was a non-human bench controlled research study using a rabbit model. Both Achilles tendons of 12 rabbits were injected with collagenase to produce tendon injury simulating Achilles tendinopathy. One side was then randomly allocated to receive ASTM, while the other received no treatment (control). ASTM was performed on the Achilles tendon on postoperative days 21, 24, 28, 31, 35, and 38. Tendons were harvested 10 days after treatment and examined with dynamic viscoelasticity and light microscopy. Cross-sectional area in the treated tendons was significantly greater than in controls. Storage modulus tended to be lower in the treated tendons but elasticity was not significantly increased. Loss modulus was significantly lower in the treated tendons. There was no significant difference found in tangent delta (loss modulus/storage modulus). Microscopy of control tendons showed that the tendon fibers were wavy and type III collagen was well stained. The tendon fibers of the augmented soft tissue mobilization treated tendons were not wavy and type III collagen was not prevalent. Biomechanical and histological findings showed that the Achilles tendons treated with ASTM had better recovery of biomechanical function than did control tendons. Copyright © 2015 National University of Health Sciences. Published by Elsevier Inc. All rights reserved.
Ooi, Chin Chin; Schneider, Michal Elisabeth; Malliaras, Peter; Chadwick, Martine; Connell, David Alister
This primary aim of this study was to evaluate the diagnostic performance of axial-strain sonoelastography (ASE), B-mode ultrasound (US) and color Doppler US in confirming clinically symptomatic Achilles tendinopathy. The secondary aim was to establish the relationship between the strain ratio during sonoelastography and Victorian Institute of Sport Assessment-Achilles (VISA-A) scores. The VISA-A questionnaire is a validated clinical rating scale that evaluates the symptoms and dysfunction of the Achilles tendon. One hundred twenty Achilles tendons of 120 consecutively registered patients with clinical symptoms of Achilles tendinopathy and another 120 gender- and age-matched, asymptomatic Achilles tendons of 120 healthy volunteers were assessed with B-mode US, ASE and color Doppler US. Symptomatic patients had significantly higher strain ratio scores and softer Achilles tendon properties compared with controls (p < 0.001). The strain ratio was moderately correlated with VISA-A scores (r = -0.62, p < 0.001). The diagnostic accuracy of B-mode US, ASE and color Doppler US in confirming clinically symptomatic Achilles tendinopathy was 94.7%, 97.8% and 82.5% respectively. There was excellent correlation between the clinical reference standard and the grade of tendon quality on ASE (κ = 0.91, p < 0.05), compared with B-mode US (κ = 0.74, p < 0.05) and color Doppler imaging (κ = 0.49, p < 0.05). ASE is an accurate clinical tool in the evaluation of Achilles tendinopathy, with results comparable to those of B-mode US and excellent correlation with clinical findings. The strain ratio may offer promise as a supplementary tool for the objective evaluation of Achilles tendon properties.
Background Achilles tendinopathy (AT) is a common condition, causing considerable morbidity in athletes and non-athletes alike. Conservative or physical therapies are accepted as first-line management of AT; however, despite a growing volume of research, there remains a lack of high quality studies evaluating their efficacy. Previous systematic reviews provide preliminary evidence for non-surgical interventions for AT, but lack key quality components as outlined in the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Statement. The aim of this study was to conduct a systematic review and meta-analysis (where possible) of the evidence for physical therapies for AT management. Methods A comprehensive strategy was used to search 11 electronic databases from inception to September 2011. Search terms included Achilles, tendinopathy, pain, physical therapies, electrotherapy and exercise (English language full-text publications, human studies). Reference lists of eligible papers were hand-searched. Randomised controlled trials (RCTs) were included if they evaluated at least one non-pharmacological, non-surgical intervention for AT using at least one outcome of pain and/or function. Two independent reviewers screened 2852 search results, identifying 23 suitable studies, and assessed methodological quality and risk of bias using a modified PEDro scale. Effect size calculation and meta-analyses were based on fixed and random effects models respectively. Results Methodological quality ranged from 2 to 12 (/14). Four studies were excluded due to high risk of bias, leaving 19 studies, the majority of which evaluated midportion AT. Effect sizes from individual RCTs support the use of eccentric exercise. Meta-analyses identified significant effects favouring the addition of laser therapy to eccentric exercise at 12 weeks (pain VAS: standardised mean difference −0.59, 95% confidence interval −1.11 to −0.07), as well as no differences in effect
Scott, Lisa A; Munteanu, Shannon E; Menz, Hylton B
Orthotic devices such as foot orthoses, splints, taping and bracing are recommended for Achilles tendinopathy (AT). This systematic review was conducted to review the current evidence for the effectiveness of orthotic devices for the treatment of mid-portion or insertional AT. Electronic bibliographic databases (MEDLINE, EMBASE, Current Contents, CINAHL and SPORTDiscus) were searched in May 2014. The methodological quality of included studies was evaluated using the Quality Index. Where possible, effects were determined using standardised mean differences. The strength of evidence for each intervention was determined according to the quality and number of studies. Twelve studies satisfied the inclusion criteria; nine studies investigated mid-portion AT, whilst three studies did not distinguish between mid-portion and insertional pathology. Weak evidence showed that foot orthoses were equivalent to physical therapy, and equivalent to no treatment. Very weak evidence supported the use of adhesive taping alone or when combined with foot orthoses. Moderate evidence showed that the AirHeel™ brace was as effective as a calf muscle eccentric exercise programme, and weak evidence showed that this intervention was not beneficial when added to a calf muscle eccentric exercise programme. Weak evidence showed that an ankle joint dorsiflexion night splint was equally effective to a calf muscle eccentric exercise programme, and strong evidence showed that this intervention was not beneficial when added to a calf muscle eccentric exercise programme. These findings may aid clinical decision making in the context of AT, however further high-quality studies are required.
Verrall, G M; Dolman, B K; Best, T M
Mid-substance Achilles tendinopathy is common in the active population. Eccentric (lengthening) exercises are known to be effective in alleviating the clinical condition. To better understand mid-substance Achilles tendinopathy and the response to lengthening exercises physical science principles of elasticity are applied. We apply elastic motion laws to the spring-like tendon as well as the normal and pathological adaptation seen with this common injury. We will validate important assumptions of the spring-like behavior of the tendon and then apply these findings to the injured and rehabilitating states. Our analysis considers that the tendon can be viewed as being spring-like with elasticity principles being applicable and the force exerted on the tendon during lengthening is primarily in a uniaxial direction. This applied lengthening force results in tendon mechanical and structural adaptation. Injury, and ultimately the clinical condition, occurs when the applied force exceeds the ability of the tendon to normally adapt. Morphological changes of the injured tendon are an attempt by the body to make the tendon more compliant. Lengthening exercises can be assessed as achieving this task with an improvement of tendon compliance. Physical science analysis proposes that the preferred rehabilitation tendon pathway is to try and decrease tendon stiffness to allow for more tendon lengthening. The body's morphological alterations of the pathological tendon are also consistent with this approach. For mid-substance Achilles tendinopathy, this adaptation of decreased stiffness ultimately increases the tendons ability to withstand applied force during lengthening. © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
Yao, Wei; Chen, Shiyi
Purpose. To compare the results of extracorporeal shock wave therapy (ESWT) for insertional Achilles tendinopathy (IAT) with or without Haglund's deformity. Methods. Between September 2014 and May 2015, all patients who underwent ESWT were retrospectively enrolled in this study. A total of 67 patients were available for follow-up and assigned into nondeformtiy group (n = 37) and deformtiy group (n = 30). Clinical outcomes were evaluated by VISA-A Score and 6-point Likert scale. Results. The VISA-A score increased in both groups, from 49.57 ± 9.98 at baseline to 83.86 ± 8.59 at 14.5 ± 7.2 months after treatment in nondeformity group (P < 0.001) and from 48.70 ± 9.38 at baseline to 67.78 ± 11.35 at 15.3 ± 6.7 months after treatment in deformity group (P < 0.001). However, there was a greater improvement in VISA-A Score for the nondeformity group compared with deformity group (P = 0.005). For the 6-point Likert scale, there were decreases from 3.92 ± 0.80 at baseline to 1.57 ± 0.73 at the follow-up time point in nondeformity group (P < 0.001) and from 4.0 ± 0.76 at baseline to 2.37 ± 1.03 at the follow-up time point in deformity group (P < 0.001). There was no significant difference in improvement of the 6-point Likert scale between both groups (P = 0.062). Conclusions. ESWT resulted in greater clinical outcomes in patients without Haglund's deformity compared with patients with Haglund's deformity. PMID:28042570
Scheer, Nicole A.; Alstat, Lucas R.; Van Zant, Robert S.
PURPOSE The purpose of this case report was to describe the use of Astym therapy to improve hamstring flexibility and Achilles tendinopathy in a child with cerebral palsy. CASE DESCRIPTION An eight-year-old female with cerebral palsy was referred to physical therapy for the treatment of bilateral hamstring inflexibility and Achilles tendinopathy. Treatment focused on an Astym therapy protocol of eccentric exercise, stretching, active and passive range of motion, gait training, and a home exercise program. The patient underwent a total of 11 physical therapy treatment sessions. OUTCOMES At the conclusion of treatment, the patient demonstrated improved resting muscle tone in bilateral lower extremities with active 90/90 hamstring flexibility measured at 165° and ankle dorsiflexion active range of motion of 5° without pain at 0° and 90° knee flexion. The patient exhibited an improved gait pattern with even stride length and diminished genu recurvatum, decreased pain with standing and walking, discontinued use of ankle–foot orthoses, and improved activity tolerance and overall function for daily activities. DISCUSSION The results of this case report indicate that physical therapy rehabilitation utilizing an Astym therapy protocol can successfully achieve gains in flexibility and strength and allow for improved function of bilateral lower extremities in a patient with cerebral palsy. CONCLUSION Based on the findings of this case report, clinicians should consider the use of Astym therapy in treating musculoskeletal soft tissue dysfunction in pediatric patients with cerebral palsy. PMID:27790051
Scheer, Nicole A; Alstat, Lucas R; Van Zant, Robert S
The purpose of this case report was to describe the use of Astym therapy to improve hamstring flexibility and Achilles tendinopathy in a child with cerebral palsy. An eight-year-old female with cerebral palsy was referred to physical therapy for the treatment of bilateral hamstring inflexibility and Achilles tendinopathy. Treatment focused on an Astym therapy protocol of eccentric exercise, stretching, active and passive range of motion, gait training, and a home exercise program. The patient underwent a total of 11 physical therapy treatment sessions. At the conclusion of treatment, the patient demonstrated improved resting muscle tone in bilateral lower extremities with active 90/90 hamstring flexibility measured at 165° and ankle dorsiflexion active range of motion of 5° without pain at 0° and 90° knee flexion. The patient exhibited an improved gait pattern with even stride length and diminished genu recurvatum, decreased pain with standing and walking, discontinued use of ankle-foot orthoses, and improved activity tolerance and overall function for daily activities. The results of this case report indicate that physical therapy rehabilitation utilizing an Astym therapy protocol can successfully achieve gains in flexibility and strength and allow for improved function of bilateral lower extremities in a patient with cerebral palsy. Based on the findings of this case report, clinicians should consider the use of Astym therapy in treating musculoskeletal soft tissue dysfunction in pediatric patients with cerebral palsy.
Pavone, Vito; Di Stefano, Antonio; Testa, Gianluca; Costarella, Luciano; Sessa, Giuseppe
Introduction. We report the results of a series of 40 patients with chronic insertional Achilles tendinopathy treated with low-energy ESWT after the failure of a 3-month program of eccentric exercises alone. Methods and Materials. 40 patients, 28 (70%) males and 12 (30%) females, were treated between January and December 2014. All patients were previously treated with only eccentric exercises for a 3-month period. The treatment protocol included 4 sessions of ESWT with a 2-week interval, from 800 shots in each one (4 Hz, 14 KeV), together with eccentric exercises. Visual Analogue Scale (VAS) and American Orthopedic Foot and Ankle Society (AOFAS) Hindfoot score were recorded. Results. At the 12-month follow-up, 26 (65.0%) patients did not complain about pain (VAS < 2), 11 (27.5%) patients got back to normal activities despite residual pain (VAS 2–4), and 3 (7.5%) of the patients still complained about pain (VAS > 4). There was no significative improvement in both scores after eccentric exercises alone. Mean VAS improvement was 5.8 ± 1.3 SD points (P < 0.001). Mean AOFAS Hindfoot score improvement was 19.8 ± 5.0 SD points (P < 0.001). Conclusions. ESWT is recommended, in combination with an eccentric exercise program, in patients with chronic Achilles tendinopathy being both insertional and not. PMID:27843949
Erroi, Davide; Sigona, Matilde; Suarez, Tania; Trischitta, Donatella; Pavan, Antonio; Vulpiani, Maria Chiara; Vetrano, Mario
Summary Background: Insertional Achilles tendinopathy (IAT) represents a serious challenge for both physiatrists and surgeons. Here we analyse the results obtained by two conservative treatments [platelet-rich plasma (PRP) injections and focused extracorporeal shock-wave therapy (ESWT)] in physically active patients with IAT. Methods: During two consecutive periods, 45 consecutive patients with IAT were treated with 3 sessions of ESWT (2400 impulses at 0.17–0.25 mJ/mm2 per session) (24 cases between September 2011 and July 2013) or with 2 autologous PRP injections over two weeks (21 cases between September 2013 and July 2015). All patients were evaluated at 0, 2-, 4-, 6-month follow-up after therapy. The outcome measures were VISA-A, VAS, Patient Satisfaction. Results: Intra-group analysis showed a significant improvement of VISA-A and VAS scores in both groups at all time-points. No differences between groups were observed for VAS and VISA-A scores at all time-points, excepted for VISA-A at 4-months in favour of ESWT group (P=0.049). Patient satisfaction increased progressively (>70% at 6 months) and with no differences between two groups. Conclusion: Both ESWT and PRP therapy are effective and safe. Our study confirms the success of these conservative treatments in Achilles tendinopathy, even in the insertional one. Level of evidence: IIIa. PMID:28717617
Retrospective Analysis of the Effectiveness of Platelet-Rich Plasma in the Treatment of Achilles Tendinopathy: Pretreatment and Posttreatment Correlation of Magnetic Resonance Imaging and Clinical Assessment.
Oloff, Lawrence; Elmi, Eman; Nelson, Joseph; Crain, Jana
Platelet-rich plasma (PRP) has been presented as a means of treating Achilles tendinopathy. Over the past dozen years, a plethora of medical articles have advocated this treatment, yet little evidentiary-based research exists in support of this approach. Treatment protocols with PRP have been performed in 2 ways during this time: administered adjunctively during tendon surgery and as a stand-alone injection. The senior author has utilized PRP by both methods to treat Achilles tendinopathy over the past 7 years; 26 patients so treated were able to be recalled, half having undergone Achilles tendon surgery in combination with PRP administration and the other half PRP alone. In this retrospective study, qualified patients had pretreatment and posttreatment magnetic imaging studies and completed a Victorian Institute of Sports Assessment-Achilles questionnaire. In this limited study, PRP showed promise in the treatment of Achilles tendinopathy. Both the stand-alone injection group and surgical/injection groups had statistically significant degrees of improvement in pre-MRI and post-MRI imaging studies. There was no statistically significant difference between the 2 treatment groups. Of interest, it appears that the difference between the MRI scoring correlates with the survey score. Therapeutic, Level, IV: Case series. © 2015 The Author(s).
Silbernagel, Karin Grävare; Thomeé, Roland; Eriksson, Bengt I; Karlsson, Jon
Objective To assess the relationship between muscle‐tendon function and symptoms in patients with Achilles tendinopathy using a validated test battery. Design A prospective non‐randomised trial. Setting Orthopaedic Department, Sahlgrenska University Hospital, Sweden. Patients 37 patients with a clinical diagnosis of Achilles tendinopathy in the midportion of the tendon, with symptoms for >2 months, were evaluated at the initiation of the study and after 1 year. Intervention The patients were treated using a rehabilitation programme, under the supervision of a physical therapist, for 6 months. Main outcome measurements The patients were evaluated using the Swedish version of the Victorian Institute of Sports Assessment—Achilles questionnaire (VISA‐A‐S) for symptoms, and a test battery for evaluation of the lower leg muscle‐tendon function. Results There were significant improvements in the VISA‐A‐S score (p<0.00, n = 37) and the test battery (p<0.02, n = 19) at the 1‐year follow‐up. The VISA‐A‐S questionnaire had an effect size of 2.1 and the test battery had an effect size of 0.73. A low correlation (r = 0.178, p>0.05) was found between the VISA‐A‐S score and the test battery. A high correlation (r = 0.611, p<0.05) was found between the drop counter movement jump and the VISA‐A‐S score. All other tests in the test battery had low correlations (r = −0.305 to 0.155, p>0.05) with the VISA‐A‐S score. Only 25% (4/16) of the patients who had full symptomatic recovery had achieved full recovery of muscle–tendon function as measured by the test battery. Conclusion Full symptomatic recovery in patients with Achilles tendinopathy does not ensure full recovery of muscle–tendon function. The VISA‐A‐S questionnaire and the test battery are sensitive to clinically relevant changes with treatment and can be recommended for use in both the clinic and research. PMID:17261555
de Vos, R J; Weir, A; Visser, R J A; de Winter, ThC; Tol, J L
Aim To assess whether the use of a night splint is of added benefit on functional outcome in treating chronic midportion Achilles tendinopathy. Methods This was a single‐blind, prospective, single centre, randomised controlled trial set in the Sports Medical Department, The Hague Medical Centre, The Netherlands. Inclusion criteria were: age 18–70 years, active participation in sports, and tendon pain localised at 2–7 cm from distal insertion. Exclusion criteria were: insertional disorders, partial or complete ruptures, or systemic illness. 70 tendons were included and randomised into one of two treatment groups: eccentric exercises with a night splint (night splint group, n = 36) or eccentric exercises only (eccentric group, n = 34). Interventions Both groups completed a 12‐week heavy‐load eccentric training programme. One group received a night splint in addition to eccentric exercises. At baseline and follow‐up at 12 weeks, patient satisfaction, Victorian Institute of Sport Assessment–Achilles questionnaire (VISA‐A) score and reported compliance were recorded by a single‐blind trained researcher who was blinded to the treatment. Results After 12 weeks, patient satisfaction in the eccentric group was 63% compared with 48% in the night splint group. The VISA‐A score significantly improved in both groups; in the eccentric group from 50.1 to 68.8 (p = 0.001) and in the night splint group from 49.4 to 67.0 (p<0.001). There was no significant difference between the two groups in VISA‐A score (p = 0.815) and patient satisfaction (p = 0.261). Conclusion A night splint is not beneficial in addition to eccentric exercises in the treatment of chronic midportion Achilles tendinopathy. PMID:17178774
The short-term effect after a single injection of high-molecular-weight hyaluronic acid in patients with enthesopathies (lateral epicondylitis, patellar tendinopathy, insertional Achilles tendinopathy, and plantar fasciitis): a preliminary study.
Kumai, Tsukasa; Muneta, Takeshi; Tsuchiya, Akihiro; Shiraishi, Masaharu; Ishizaki, Yoshitaka; Sugimoto, Kazuya; Samoto, Norihiro; Isomoto, Shinji; Tanaka, Yasuhito; Takakura, Yoshinori
Hyaluronic acid (HA) with a high molecular weight of 2700 kDa is approved in Japan to treat osteoarthritis of the knee, periarthritis scapulohumeralis, and knee pain associated with rheumatoid arthritis. The purpose of this preliminary study was to investigate the short-term efficacy, safety, and injectable volume of HA in the treatment of enthesopathies. A total of 61 patients (16 with lateral epicondylitis, 14 with patellar tendinopathy, 15 with insertional Achilles tendinopathy, and 16 with plantar fasciitis) were each administered a single injection of HA (up to 2.5 ml). Efficacy and safety were assessed by comparing the visual analog scale (VAS) for pain and local symptoms before injection (baseline) and at 1 week after injection. We also investigated the injectable volume by means of the difference in syringe weight before and after injection and by the judgment of the administering investigator. The injection of HA resulted in a change in VAS (mean ± SD) of -2.20 ± 2.26 cm for the four sites overall and -2.55 ± 2.43 cm for lateral epicondylitis, -2.01 ± 2.16 cm for patellar tendinopathy, -1.80 ± 1.91 cm for insertional Achilles tendinopathy, and -2.38 ± 2.61 cm for plantar fasciitis. The injection of HA also improved local symptoms in each site. It was also determined that 2.5 ml of HA can be injected in each of the four sites. A single injection of HA resulted in similar improvements of pain in each of the four enthesopathies (lateral epicondylitis, patellar tendinopathy, insertional Achilles tendinopathy, and plantar fasciitis). These results suggest that HA could be clinically effective in the treatment of enthesopathies.
Lynen, Nils; De Vroey, Thierry; Spiegel, Imke; Van Ongeval, Frederik; Hendrickx, Niels-Jan; Stassijns, Gaëtane
To compare the safety and efficacy of hyaluronan (HA) injections with standard extracorporeal shock wave therapy (ESWT) in the treatment of painful midportion Achilles' tendinopathy. Multinational, prospective, randomized controlled, blinded-observer trial. Ambulatory care. Adults (N=62) with Achilles' midportion tendinopathy for ≥6 weeks and a pain score of at least 40mm (Huskisson visual analog scale [VAS], 100mm) were randomized, and 59 were analyzed in the intention-to-treat data set. There were no withdrawals because of adverse effects. Two peritendinous HA injections versus 3 ESWT applications at weekly intervals. Primary efficacy criterion was changed from the Victorian Institute of Sports Assessment-Achilles' questionnaire (VISA-A) score to the percent change in pain (VAS) at 3 months posttreatment, compared with baseline values. Main secondary parameters were VISA-A, Clinical Global Impression (CGI), and clinical parameters. HA treatment provided a clinically relevant improvement in Achilles' midportion tendinopathy. A large superiority of the HA group, compared with ESWT application, was observed for percent change in pain (VAS), and this superiority was proven to be statistically significant (Mann-Whitney statistic [MW]=.7507 with P=.0030 lower than required α=.025 significance level 1-sided; Mann-Whitney U test) at 3 months posttreatment. Similar findings for HA were also observed at 4 weeks (MW=.6425, P=.0304) and 6 months (MW=.7172, P=.0018). Advantage of HA treatment was confirmed by VISA-A questionnaire, CGI, and clinical parameters. Ten adverse events, 4 in the HA group and 6 in the ESWT group, were reported, but none were classified as serious. Two peritendinous HA injections showed greater treatment success in Achilles' midportion tendinopathy compared with standard ESWT. Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
van Sterkenburg, Maayke N; Kerkhoffs, Gino M M J; Kleipool, Roeland P; Niek van Dijk, C
The source of pain and the background to the pain mechanisms associated with mid-portion Achilles tendinopathy have not yet been clarified. Intratendinous degenerative changes are most often addressed when present. However, it is questionable if degeneration of the tendon itself is the main cause of pain. Pain is often most prominent on the medial side, 2–7 cm from the insertion onto the calcaneus. The medial location of the pain has been explained to be caused by enhanced stress on the calcaneal tendon due to hyperpronation. However, on this medial side the plantaris tendon is also located. It has been postulated that the plantaris tendon might play a role in these medially located symptoms. To our knowledge, the exact anatomy and relationship between the plantaris- and calcaneal tendon at the level of complaints have not been anatomically assessed. This was the purpose of our study. One-hundred and seven lower extremities were dissected. After opening the superficial fascia and paratendon, the plantaris tendon was bluntly released from the calcaneal tendon moving distally. The incidence of the plantaris tendon, its course, site of insertion and possible connections were documented. When with manual force the plantaris tendon could not be released, it was defined as a ‘connection’ with the calcaneal tendon. In all specimens a plantaris tendon was identified. Nine different sites of insertion were found, mostly medial and fan-shaped onto the calcaneus. In 11 specimens (10%) firm connections were found at the level of the calcaneal tendon mid-portion. Clinical and histological studies are needed to confirm the role of the plantaris tendon in mid-portion Achilles tendinopathy. PMID:21323916
... DeLee & Drez's Orthopaedic Sports Medicine: Principles and Practice. 4th ed. Philadelphia, Pa.: Saunders Elsevier; 2015. http://www.clinicalkey.com. Accessed July 9, 2015. Ham P, et al. Achilles tendinopathy ...
A 3-Arm Randomized Trial for Achilles Tendinopathy: Eccentric Training, Eccentric Training Plus a Dietary Supplement Containing Mucopolysaccharides, or Passive Stretching Plus a Dietary Supplement Containing Mucopolysaccharides.
Balius, Ramon; Álvarez, Guillermo; Baró, Fernando; Jiménez, Fernando; Pedret, Carles; Costa, Ester; Martínez-Puig, Daniel
Tendinopathy is an overuse tendon injury that occurs in loaded tendons and results in pain and functional impairment. Although many treatments for painful tendons are described, the scientific evidence for most of the conservative and surgical treatments is not always conclusive. This study was designed to evaluate the efficacy of 3 different interventions in patients with Achilles tendinopathy. The interventions include the combination of 2 physical therapy programs (eccentric training [EC] or passive stretching [PS]) with a supplement containing mucopolisaccharides. The efficacy of the interventions was evaluated depending on the stage of the disease. Fifty-nine patients were randomly assigned to 1 of 3 treatment groups, and classified according to the disease stage: reactive versus degenerative tendinopathy. Treatment groups were EC; EC + a dietary supplement containing mucopolisaccharides, type I collagen, and vitamin C (MCVC); and a passive stretching program + MCVC. Patients were evaluated at baseline, 6 weeks, and 12 weeks with the Victorian Institute of Sports Assessment-Achilles questionnaire for function, a visual analog scale for pain, and ultrasound characterization for the evolution of tendon structure. A significant improvement in Victorian Institute of Sports Assessment-Achilles questionnaire score, pain at rest, and pain during activity were detected in all 3 treatment groups at 6 and 12 weeks' follow-up when compared with baseline. In patients with reactive tendinopathy, the reduction in pain at rest was greater in the groups who took the supplemental MCVC than in the EC alone group (P < 0.05). MCVC seems to be therapeutically useful for management of tendinopathies, providing some additional benefit to physical therapy. This is especially evident in early stages of the disease, when the tendon does not present severe matrix and vascular changes. NCT01691716.
Borda, Jennifer; Selhorst, Mitchell
Achilles tendinopathy is an overuse injury that often affects individuals engaged in recreational or competitive level activity. Although most patients experience satisfactory results with therapy, a substantial portion fail to respond to traditional treatment. The purpose of this case study is to describe the successful use of compression tack and flossing (CTF) with lacrosse ball massage (LBM) in the treatment of an adolescent athlete with Achilles tendinopathy who had failed to respond to traditional treatment. The patient was a 14-year old female diagnosed with chronic Achilles tendinopathy. She presented with 8/10 left posterior ankle pain during activity and scored 66/80 on the Lower Extremity Functional Scale (LEFS). After six weeks of PT consisting of eccentric exercise, proprioceptive training, and iontophoresis, the patient continued to report pain during sport and no significant improvements on the LEFS. With traditional PT failing to resolve symptoms, the patient was treated with CTF and LBM. The outcomes of interest were the LEFS and the ability to participate in sport without pain. After only two sessions focusing on CTF and LBM, she had 0/10 pain during sport and scored a 79/80 on the LEFS. Patient was discharged to continue with a home exercise program consisting of CTF and LBM, and eccentric exercise. The patient's outcomes significantly improved after CTF and LBM was added to eccentric exercise. These results suggest that this intervention may be a viable adjunct treatment for Achilles tendinopathy; however further research, including controlled clinical trials and long-term outcome data, are warranted.
The chronic painful Achilles tendon mid-portion was for many years, and still is in many countries, treated with intratendinous revision surgery. However, by coincidence, painful eccentric calf muscle training was tried, and it showed very good clinical results. This finding was unexpected and led to research into the pain mechanisms involved in this condition. Today we know that there are very few nerves inside, but multiple nerves outside, the ventral side of the chronic painful Achilles tendon mid-portion. These research findings have resulted in new treatment methods targeting the regions with nerves outside the tendon, methods that allow for a rapid rehabilitation and fast return to sports. PMID:26537813
McCormack, Joshua R; Underwood, Frank B; Slaven, Emily J; Cappaert, Thomas A
Eccentric exercise is commonly used in the management of Achilles tendinopathy (AT) but its effectiveness for insertional AT has been questioned. Soft tissue treatment (Astym) combined with eccentric exercise could result in better outcomes than eccentric exercise alone. Soft tissue treatment (Astym) plus eccentric exercise will be more effective than eccentric exercise alone for subjects with insertional AT. Prospective randomized controlled trial. Level 2. Sixteen subjects were randomly assigned to either a soft tissue treatment (Astym) and eccentric exercise group or an eccentric exercise-only group. Intervention was completed over a 12-week period, with outcomes assessed at baseline, 4, 8, 12, 26, and 52 weeks. Outcomes included the Victorian Institute of Sport Assessment Achilles-Specific Questionnaire (VISA-A), the numeric pain rating scale (NPRS), and the global rating of change (GROC). Significantly greater improvements on the VISA-A were noted in the soft tissue treatment (Astym) group over the 12-week intervention period, and these differences were maintained at the 26- and 52-week follow-ups. Both groups experienced a similar statistically significant improvement in pain over the short and long term. A significantly greater number of subjects in the soft tissue treatment (Astym) group achieved a successful outcome at 12 weeks. Soft tissue treatment (Astym) plus eccentric exercise was more effective than eccentric exercise only at improving function during both short- and long-term follow-up periods. Soft tissue treatment (Astym) plus eccentric exercise appears to be a beneficial treatment program that clinicians should consider incorporating into the management of their patients with insertional AT.
Backman, L J; Andersson, G; Wennstig, G; Forsgren, S; Danielson, P
To quantify the intratendinous levels of substance P (SP) at different stages of overload in an established model for Achilles tendinopathy (rabbit). Also, to study the distribution of the SP-receptor, the NK-1R, and the source of SP, in the tendon. Animals were subjected to the overuse protocol for 1, 3 or 6 weeks. One additional group served as unexercised controls. Immunoassay (EIA), immunohistochemistry (IHC), and in situ hybridisation (ISH) were performed. EIA revealed increased SP-levels in the Achilles tendon of the exercised limb in all the experimental groups as compared to in the controls (statistically significant; p=0.01). A similar trend in the unexercised Achilles tendon was observed but was not statistically significant (p=0.14). IHC and in ISH illustrated reactions of both SP and NK-1R mainly in blood vessel walls, but the receptor was also found on tenocytes. Achilles tendon SP-levels are elevated already after 1 week of loading. This shows that increased SP-production precedes tendinosis, as tendinosis-like changes occur only after a minimum of 3 weeks of exercise, as shown in a recent study using this model. We propose that central neuronal mechanism may be involved as similar trends were observed in the contralateral Achilles tendon.
González, Juan C; López, Catalina; Álvarez, María E; Pérez, Jorge E; Carmona, Jorge U
Leukocyte-reduced platelet-rich plasma (LR-PRP) is a therapy for tendinopathy of the Achilles tendon (TAT); however, there is scarce information regarding LR-PRP effects in rabbit models of TAT. We compared, at 4 and 12 weeks (w), the LR-PRP and placebo (PBS) effects on ultrasonography, histology and relative gene expression of collagen types I (COL1A1) and III (COL3A1) and vascular endothelial growth factor (VEGF) in 24 rabbits with TAT induced by collagenase. The rabbits (treated with both treatments) were euthanatised after either 4 or 12 w. A healthy group (HG (n = 6)) was included. At 4 and 12 w, the LR-PRP group had a no statistically different histology score to the HG. At w 4, the COL1A1 expression was significantly higher in the LR-PRP group when compared to HG, and the expression of COL3A1 from both LR-PRP and PBS-treated tendons was significantly higher when compared to the HG. At w 12, the expression of COL3A1 remained significantly higher in the PBS group in comparison to the LR-PRP group and the HG. At w 4, the LR-PRP group presented a significantly higher expression of VEGF when compared to the PBS group and the HG. In conclusion, LR-PRP treatment showed regenerative properties in rabbits with TAT.
González, Juan C.; López, Catalina; Álvarez, María E.; Pérez, Jorge E.; Carmona, Jorge U.
Leukocyte-reduced platelet-rich plasma (LR-PRP) is a therapy for tendinopathy of the Achilles tendon (TAT); however, there is scarce information regarding LR-PRP effects in rabbit models of TAT. We compared, at 4 and 12 weeks (w), the LR-PRP and placebo (PBS) effects on ultrasonography, histology and relative gene expression of collagen types I (COL1A1) and III (COL3A1) and vascular endothelial growth factor (VEGF) in 24 rabbits with TAT induced by collagenase. The rabbits (treated with both treatments) were euthanatised after either 4 or 12 w. A healthy group (HG (n = 6)) was included. At 4 and 12 w, the LR-PRP group had a no statistically different histology score to the HG. At w 4, the COL1A1 expression was significantly higher in the LR-PRP group when compared to HG, and the expression of COL3A1from both LR-PRP and PBS-treated tendons was significantly higher when compared to the HG. At w 12, the expression of COL3A1 remained significantly higher in the PBS group in comparison to the LR-PRP group and the HG. At w 4, the LR-PRP group presented a significantly higher expression of VEGF when compared to the PBS group and the HG. In conclusion, LR-PRP treatment showed regenerative properties in rabbits with TAT. PMID:26781753
Kragsnaes, Maja Skov; Fredberg, Ulrich; Stribolt, Katrine; Kjaer, Soren Geill; Bendix, Knud; Ellingsen, Torkell
Limited data exist on the presence and function of immune-competent cells in chronic tendinopathic tendons and their potential role in inflammation and tissue healing as well as in predicting long-term outcome. To quantify subtypes of immune-competent cells in biopsy specimens from nonruptured chronic tendinopathic Achilles tendons and healthy control tendons. In addition, to examine whether findings in baseline cell biopsy specimens can predict the long-term presence of Achilles tendon symptoms. Cross-sectional and case-control study; Level of evidence, 3. Fifty patients with nonruptured chronic Achilles tendinopathy and 15 healthy participants were included. At time of inclusion, an ultrasound examination was performed immediately before an ultrasound-guided Achilles tendon biopsy specimen was obtained. Tissue samples were evaluated immunohistochemically by quantifying the presence of macrophages (CD68-PGM1(+), CD68-KP1(+)), hemosiderophages (Perls blue), T lymphocytes (CD2(+), CD3(+), CD4(+), CD7(+), CD8(+)), B lymphocytes (CD20(+)), natural killer cells (CD56(+)), mast cells (NaSDCl(+)), Schwann cells (S100(+)), and endothelial cells (CD34(+)) using a stereological technique. A follow-up examination was conducted more than 4 years (range, 4-9 years) after the biopsy procedure to evaluate the long-term presence of Achilles tendon symptoms. Macrophages, T lymphocytes, mast cells, and natural killer cells were observed in the majority (range, 52%-96%) of biopsy specimens from nonruptured chronic tendinopathic Achilles tendons. CD68-KP1(+) macrophages (0.29% vs 0; P = .005) and CD34(+) endothelial cells (3% vs 0.97%; P = .04) were significantly more numerous in tendinopathic tendons compared with healthy tendons. The presence of iron(+) hemosiderophages was more frequently observed in biopsy specimens obtained from the group who was asymptomatic at follow-up compared with the symptomatic group (42% vs 5%; P = .02). This study provides evidence for the presence of
Clementson, Martin; Lorén, Ingemar; Dahlberg, Leif; Aström, Mats
Sclerosing injections under ultrasonographic guidance is a new method of treatment for persistent pain in Achilles tendinosis. Good results, even superior to those of surgery, have been described. We report the outcome of 25 patients with midportion tendinosis receiving sclerosing treatment. Twenty-eight consecutive patients (29 tendons) with ultrasonographical findings of midportion tendinosis examined during the period November 2004 to November 2005 were identified in the database of the Department of Radiology, Malmö University Hospital. Twenty-five patients (26 tendons) were found suitable for treatment. Follow-up consisted of self-assessment questionnaire or phone interview. In 19 patients (20 tendons), results were good or excellent. Complications were few and mild. We conclude that sclerosing injections is a promising alternative to surgery in chronic Achilles midportion tendinosis. Our results are comparable to those obtained with surgery, but the procedure is less invasive. However, a few cases of tendinosis lack detectable neovessels and may still be candidates for surgery.
Shock wave therapy associated with eccentric strengthening versus isolated eccentric strengthening for Achilles insertional tendinopathy treatment: a double-blinded randomised clinical trial protocol.
Mansur, Nacime Salomão Barbachan; Faloppa, Flávio; Belloti, João Carlos; Ingham, Sheila J McNeill; Matsunaga, Fabio Teruo; Santos, Paulo Roberto Dias Dos; Santos, Bruno Schiefer Dos; Carrazzone, Oreste Lemos; Peixoto, Gabriel; Aoyama, Bruno Takeshi; Tamaoki, Marcel Jun Sugawara
There is no consensus regarding the treatment of Achilles insertional tendinopathies. Eccentric training remains the main choice in the conservative treatment of this illness; however, the good results in the management of non-insertional Achilles tendinopathy were not replicated in the insertional condition. Low energy shock wave therapy has been described as an alternative to these patients, but has yet to be empirically tested. Shock wave therapy, adjunctive to the eccentric strengthening protocol, will improve measures of pain and function. Double blind, placebo-controlled, parallel groups, randomised clinical trial. 93 patients with a diagnosis of chronic insertional tendinopathy, referred from primary or secondary healthcare services, will be assessed and enrolled in this study. They will be divided into two groups (randomised by sequentially numbered identical envelopes, which will be administered serially to participants), one containing the combination of low energy shock wave and eccentric exercises, as treatment and the other comprehending the exercises and the placebo treatment (an apparatus placed in the therapeutic head). The assessments will occur in 2, 4, 6, 12 and 24 weeks. Patients will be evaluated primarily by the Victorian Institute of Sport Assessment-Achilles questionnaire and secondarily by the visual analogue scale, Algometry, the American Orthopedic Foot and Ankle Society scale, the Foot and Ankle Outcome Score and the 12-item Short Form Health Survey. We will use comparison of two proportions via relative frequency analysis, the Pearson Correlation the χ(2) test and the analysis of variance for statistical analyses. This study intends to demonstrate if the association of the eccentric exercise programme with the shock wave therapy can produce good results regarding the treatment of the Achilles insertional tendinopathy. In an attempt to prevent the high costs and complications associated with the surgical intervention, we will try to
Mansur, Nacime Salomão Barbachan; Faloppa, Flávio; Belloti, João Carlos; Ingham, Sheila J McNeill; Matsunaga, Fabio Teruo; dos Santos, Paulo Roberto Dias; dos Santos, Bruno Schiefer; Carrazzone, Oreste Lemos; Peixoto, Gabriel; Aoyama, Bruno Takeshi; Tamaoki, Marcel Jun Sugawara
Background There is no consensus regarding the treatment of Achilles insertional tendinopathies. Eccentric training remains the main choice in the conservative treatment of this illness; however, the good results in the management of non-insertional Achilles tendinopathy were not replicated in the insertional condition. Low energy shock wave therapy has been described as an alternative to these patients, but has yet to be empirically tested. Hypothesis Shock wave therapy, adjunctive to the eccentric strengthening protocol, will improve measures of pain and function. Design Double blind, placebo-controlled, parallel groups, randomised clinical trial. Materials and methods 93 patients with a diagnosis of chronic insertional tendinopathy, referred from primary or secondary healthcare services, will be assessed and enrolled in this study. They will be divided into two groups (randomised by sequentially numbered identical envelopes, which will be administered serially to participants), one containing the combination of low energy shock wave and eccentric exercises, as treatment and the other comprehending the exercises and the placebo treatment (an apparatus placed in the therapeutic head). The assessments will occur in 2, 4, 6, 12 and 24 weeks. Patients will be evaluated primarily by the Victorian Institute of Sport Assessment-Achilles questionnaire and secondarily by the visual analogue scale, Algometry, the American Orthopedic Foot and Ankle Society scale, the Foot and Ankle Outcome Score and the 12-item Short Form Health Survey. We will use comparison of two proportions via relative frequency analysis, the Pearson Correlation the χ2 test and the analysis of variance for statistical analyses. Discussion This study intends to demonstrate if the association of the eccentric exercise programme with the shock wave therapy can produce good results regarding the treatment of the Achilles insertional tendinopathy. In an attempt to prevent the high costs and complications
Wheeler, Patrick C; Mahadevan, Dev; Bhatt, Raj; Bhatia, Maneesh
We undertook a comparison evaluation of outcomes after 2 different high-volume image-guided injection (HVIGI) procedures performed under direct ultrasound guidance in patients with chronic noninsertional Achilles tendinopathy. In group A, the HVIGI involved high-volume (10 mL of 1% lidocaine combined with 40 mL of saline) and no dry needling. In group B, the HVIGI involved a smaller volume (10 mL of 1% lidocaine combined with 20 mL of saline) and dry needling of the Achilles tendon. A total of 34 patients were identified from the clinical records, with a mean overall age of 50.6 (range 26 to 83) years and an overall mean follow-up duration of 277 (range 49 to 596) days. The change between the preinjection and postinjection Victorian Institute of Sports Assessment-Achilles scores of 33.4 ± 22.5 points in group A and 6.94 ± 22.2 points in group B, was statistically significant (p = .002). In group A, 3 patients (16.7%) required surgical treatment compared with 6 patients (37.5%) in group B requiring surgical treatment (p = .180). Our results indicated that a higher volume without dry needling compared with a lower volume with dry needling resulted in greater improvement in noninsertional Achilles tendinopathy. However, confounding factors mean it is not possible to categorically state that this difference was solely due to different injection techniques. Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Objective To investigate the factors affecting prognosis of extracorporeal shockwave therapy (ESWT) for chronic refractory Achilles tendinopathy (AT). Methods Thirty-six patients (48 consecutive feet) with chronic AT (>6 months) and who underwent ESWT for ‘poor’ or ‘fair’ grade in Roles-Maudsley Score (RMS) after unsuccessful conservative treatment were included in the present study. A maximum of 12 sessions of ESWT were conducted until treatment success: RMS reached ‘good’ or ‘excellent’. Termination of ESWT for no response, or ‘poor’ or ‘fair’ grade was regarded as treatment failure. Immediate outcome, long-term outcome (telephone interview after mean 26 months), and factors affecting treatment success were analyzed. Results Numeric Rating Scale was significantly decreased at immediate and long-term follow-up. Success rate was 71.1% and 90.3%, respectively. Univariate logistic regression identified that immediate treatment success was associated with retrocalcaneal enthesophyte on X-ray (odds ratio [OR], 0.06; 95% confidence interval [CI], 0.01–0.28), pretreatment abnormal ultrasonography echogenicity within Achilles tendon (OR, 18.89; 95% CI, 2.08–171.96), mean duration of ‘post-treatment soreness’ (OR, 0.55; 95% CI, 0.33–0.94), and duration of ‘post-treatment soreness after first ESWT’ (OR, 0.06; 95% CI, 0.01–0.34). The duration of ‘post-treatment soreness after first ESWT’ was found to be the only factor associated with long-term success (OR, 0.32; 95% CI, 0.10–0.99). Conclusion ESWT appears to be effective in achieving long-term success in chronic refractory AT. Immediate success was associated with absence of retrocalcaneal enthesophyte on X-ray, presence of pretreatment abnormal ultrasonography echogenicity, shorter mean duration of ‘post-treatment soreness’, and shorter duration of ‘post-treatment soreness after first ESWT’. The shorter duration of ‘post-treatment soreness after first ESWT’ was
Morath, O; Kubosch, E J; Taeymans, J; Zwingmann, J; Konstantinidis, L; Südkamp, N P; Hirschmüller, A
Chronic painful Achilles tendinopathy (AT) is a common disorder among athletes. Sclerotherapy (ST) and prolotherapy (PT) are two promising options among the numerous other conservative therapies. As their efficacy and potential adverse effects (AE) are still unclear, we systematically searched, analyzed, and synthesized the available literature on ST and PT for treating AT. Electronic databases, Google Scholar and articles' reference lists were searched according to PRISMA guidelines. Eligibility criteria were set up according to the PICOS-scheme including human and animal studies. Three authors independently reviewed the results and evaluated methodological quality (Coleman Methodology Score and Cochrane Risk of Bias Assessment). The initial search yielded 1104 entries. After screening, 18 articles were available for qualitative synthesis, six of which were subjected to meta-analysis. The mean Coleman Score of the 13 human studies was 50. Four RCTs were ranked as having a low risk of selection bias. Three of those reported a statistically significant drop in the visual analog scale (VAS) score, one a significant increase in the VISA-A Score. 12 of 13 human studies reported positive results in achieving pain relief and patient satisfaction, whereas only one study's finding differed. Meta-analysis revealed an unambiguous result in favor of the intervention (weighted mean difference D=-4.67 cm, 95% CI -5.56 to -3.76 cm [P<.001]). Only one serious AE and two minor AEs were reported in the entire literature. This systematic review suggests that ST and PT may be effective treatment options for AT and that they can be considered safe. Long-term studies and RCTs are still needed to support their recommendation. © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
Salini, Vincenzo; Vanni, Daniele; Pantalone, Andrea; Abate, Michele
Background: Platelet Rich Plasma (PRP) has shown positive and long-lasting effects in patients with tendinopathies. However, information about age-related differences in the clinical outcome is limited. Aim of this retrospective study was to compare the efficacy of PRP therapy in young and elderly subjects suffering for Achilles tendinopathy. Materials and method: Patients with recalcitrant non-insertional Achilles tendinopathy were enrolled. Clinical (VISA-A) and instrumental (ultrasonography) data were collected at baseline and after 1, 3, 6, and 12 months. PRP injections (once a week for 3 weeks) were performed in sterile conditions and under ultrasound (US) control. Results: Forty-four subjects (29 young: mean age 39.5 ± 6.9; 15 elderly: mean age 61.5 ± 5.3) were retrospectively evaluated. At baseline, no significant differences were observed in the clinical and US parameters. Throughout the whole length of the study, a significant increase of VISA-A score was seen in both groups (from 50.3 ± 8.8 to 76.1 ± 6.6 in the young group, and from 48.7 ± 7.6 to 61.1 ± 9.4 in the elderly group); however, the infra-groups comparison showed better results in young patients, compared to the aged counterpart. Conclusion: Our results show that PRP is less effective in aged people. This finding can be ascribed to several biochemical and biomechanical differences documented in tendons of young and elderly subjects (reduced number and functionality of tenocytes and tenoblasts), which becomes more evident in the long-term tissue healing. However, prospective trials, using different PRP preparations and enrolling a larger number of subjects, are needed to draw more sound and definitive conclusions. PMID:26696880
Andersson, Gustav; Backman, Ludvig J; Scott, Alexander; Lorentzon, Ronny; Forsgren, Sture; Danielson, Patrik
Tenocytes produce substance P (SP), and its receptor (neurokinin-1 receptor (NK-1R)) is expressed throughout the tendon tissue, especially in patients with tendinopathy and tissue changes (tendinosis) including hypercellularity and vascular proliferation. Considering the known effects of SP, one might ask whether SP contributes to these changes. To test whether development of tendinosis-like changes (hypercellularity and angiogenesis) is accelerated during a 1-week course of exercise with local administration of SP in an established Achilles tendinopathy model. Rabbits were subjected to a protocol of Achilles tendon overuse for 1 week, in conjunction with SP injections in the paratenon. Exercised control animals received NaCl injections or no injections, and unexercised, uninjected controls were also used. Tenocyte number and vascular density, as well as paratendinous inflammation, were evaluated. Immunohistochemistry and in situ hybridisation to detect NK-1R were conducted. Results There was a significant increase in tenocyte number in the SP-injected and NaCl-injected groups compared with both unexercised and exercised, uninjected controls. Tendon blood vessels increased in number in the SP-injected group compared with unexercised controls, a finding not seen in NaCl-injected controls or in uninjected, exercised animals. Paratendinous inflammation was more pronounced in the SP-injected group than in the NaCl controls. NK-1R was detected in blood vessel walls, nerves, inflammatory cells and tenocytes. SP accelerated the development of tendinosis-like changes in the rabbit Achilles tendon, which supports theories of a potential role of SP in tendinosis development; a fact of clinical interest since SP effects can be effectively blocked. The angiogenic response to SP injections seems related to paratendinitis.
Mahieu, N; Van Tiggelen, D; De Muynck, M; Dumalin, M; Witvrouw, E
The purpose of this study was to evaluate the vascular response of the Achilles tendon as indicated by power Doppler activity during a military training program of 6 weeks. 49 male military recruits (98 tendons) volunteered for this study. Before and during the military training program, the Achilles tendons were screened with gray-scale ultrasonography and power Doppler US. Reactive tendinopathies of the Achilles tendons were registered by means of a clinical examination, VAS-scores and VISA-A scores. The US examination, the clinical examination, VAS-scores and VISA-A scores showed that 13/98 tendons developed a reactive tendinopathy. 3 of these 13 symptomatic tendons showed intratendinous Doppler activity. In these tendons, pain was always present before the vascular response of the Achilles tendon. Both pain and hypervascularisation remained visible till the end of the basic military training. In 5 asymptomatic tendons with no structural changes of the tendon, a vascular response was seen during one single measurement. It can be hypothesized that there is no relationship between the vascular response of the Achilles tendon and the pain in a reactive tendinopathy. In a reactive tendinopathy, other pain mechanisms must be investigated in future research. © Georg Thieme Verlag KG Stuttgart · New York.
Habets, B; Smits, H W; Backx, F J G; van Cingel, R E H; Huisstede, B M A
Investigating differences in hip muscle strength between athletes with Achilles tendinopathy (AT) and asymptomatic controls. Cross-sectional case-control study. Sports medical center. Twelve recreational male athletes with mid-portion AT and twelve matched asymptomatic controls. Isometric strength of the hip abductors, external rotators, and extensors was measured using a handheld dynamometer. Functional hip muscle performance was evaluated with the single-leg squat. The Victorian Institute of Sport Assessment-Achilles (VISA-A) questionnaire was completed to determine clinical severity of symptoms. Compared to controls, participants with AT demonstrated 28.9% less isometric hip abduction strength (p = 0.012), 34.2% less hip external rotation strength (p = 0.010), and 28.3% less hip extension strength (p = 0.034) in the injured limb. Similar differences were found for the non-injured limb (26.7-41.8%; p < 0.03). No significant differences were found in functional hip muscle performance between the injured and non-injured limb or between the groups, and no significant correlation was found between hip muscle strength and VISA-A scores. Recreational male athletes with chronic mid-portion AT demonstrated bilateral weakness of hip abductors, external rotators, and extensors compared to their asymptomatic counterparts. These findings suggest that hip muscle strength may be important in the assessment and rehabilitation of those with AT. Copyright © 2016 Elsevier Ltd. All rights reserved.
Masood, Tahir; Kalliokoski, Kari; Bojsen-Møller, Jens; Finni, Taija
Achilles tendon rupture (ATR) is the most common tendon rupture injury. The consequences of ATR on metabolic activity of the Achilles tendon and ankle plantarflexors are unknown. Furthermore, the effects of eccentric rehabilitation on metabolic activity patterns of Achilles tendon and ankle plantarflexors in ATR patients have not been reported thus far. We present a case study demonstrating glucose uptake (GU) in the Achilles tendon, the triceps surae, and the flexor hallucis longus of a post-surgical ATR patient before and after a 5-month eccentric rehabilitation. At baseline, three months post-surgery, all muscles and Achilles tendon displayed much higher GU in the ATR patient compared to a healthy individual despite lower plantarflexion force. After the rehabilitation, plantarflexion force increased in the operated leg while muscle GU was considerably reduced. The triceps surae muscles showed similar values to the healthy control. When compared to the healthy or a matched patient with Achilles tendon pain after 12 weeks of rehabilitation, Achilles tendon GU levels of ATR patient remained greater after the rehabilitation. Past studies have shown a shift in the metabolic fuel utilization towards glycolysis due to immobilization. Further research, combined with immuno-histological investigation, is needed to fully understand the mechanism behind excessive glucose uptake in ATR cases. Copyright © 2015 Elsevier Ltd. All rights reserved.
DeCarbo, William T; Bullock, Mark J
Noninsertional Achilles tendinopathy often responds to nonoperative treatment. When nonoperative treatment fails, the clinician must distinguish between paratendinopathy and noninsertional tendinopathy. In paratendinopathy, myofibroblasts synthesize collagen, causing adhesions, and the paratenon may be released or excised. If a core area of tendinopathy is identified on MRI, the area is excised longitudinally and repaired with a side-to-side suture. If greater than 50% of the tendon diameter is excised, the authors recommend a short flexor hallucis longus tendon transfer with an interference screw. A turndown flap of the gastrocnemius aponeurosis is also described with good results.
Tsehaie, J; Poot, D H J; Oei, E H G; Verhaar, J A N; de Vos, R J
To evaluate whether baseline MRI parameters provide prognostic value for clinical outcome, and to study correlation between MRI parameters and clinical outcome. Observational prospective cohort study. Patients with chronic midportion Achilles tendinopathy were included and performed a 16-week eccentric calf-muscle exercise program. Outcome measurements were the validated Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire and MRI parameters at baseline and after 24 weeks. The following MRI parameters were assessed: tendon volume (Volume), tendon maximum cross-sectional area (CSA), tendon maximum anterior-posterior diameter (AP), and signal intensity (SI). Intra-class correlation coefficients (ICCs) and minimum detectable changes (MDCs) for each parameter were established in a reliability analysis. Twenty-five patients were included and complete follow-up was achieved in 20 patients. The average VISA-A scores increased significantly with 12.3 points (27.6%). The reliability was fair-good for all MRI-parameters with ICCs>0.50. Average tendon volume and CSA decreased significantly with 0.28cm(3) (5.2%) and 4.52mm(2) (4.6%) respectively. Other MRI parameters did not change significantly. None of the baseline MRI parameters were univariately associated with VISA-A change after 24 weeks. MRI SI increase over 24 weeks was positively correlated with the VISA-A score improvement (B=0.7, R(2)=0.490, p=0.02). Tendon volume and CSA decreased significantly after 24 weeks of conservative treatment. As these differences were within the MDC limits, they could be a result of a measurement error. Furthermore, MRI parameters at baseline did not predict the change in symptoms, and therefore have no added value in providing a prognosis in daily clinical practice. Copyright © 2017 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
McCreesh, Karen M; Riley, Sara J; Crotty, James M
This report describes the case of an amateur soccer player with chronic patellar tendinopathy who underwent ultrasound imaging before and after engaging in an 8-week programme of eccentric exercise. On initial assessment, greyscale ultrasound imaging demonstrated tendon thickening and reduced echogenicity, while Power Doppler imaging demonstrated a large amount of neovascularity. After 8 weeks of an eccentric loading programme, the patient reported significantly improved symptoms and functional scores, while follow-up imaging demonstrated improvement in the echo appearance of the tendon and complete resolution of the neovascularity. The association between neovascularity and symptoms in tendinopathy research is conflicting, with a paucity of research in the area of patellar tendinopathy. While further research is needed to clarify the significance of greyscale and Power Doppler ultrasound changes in relation to symptoms in patellar tendinopathy, ultrasound imaging was shown to be a useful adjunct to diagnosis and outcome assessment in this case.
Woodley, Brett L; Newsham‐West, Richard J; Baxter, G David
Objectives: To determine the effectiveness of eccentric exercise (EE) programmes in the treatment of common tendinopathies. Data sources: Relevant randomised controlled trials (RCTs) were sourced using the OVID website databases: MEDLINE (1966–Jan 2006), CINAHL (1982–Jan 2006), AMED (1985–Jan 2006), EMBASE (1988–Jan 2006), and all EBM reviews – Cochrane DSR, ACP Journal Club, DARE, and CCTR (Jan 2006). The Physiotherapy Evidence Database (PEDro) was also searched using the keyword: eccentric. Review methods: The PEDro and van Tulder scales were employed to assess methodological quality. Levels of evidence were then obtained according to predefined thresholds: Strong–consistent findings among multiple high‐quality RCTs. Moderate–consistent findings among multiple low‐quality RCTs and/or clinically controlled trials (CCTs) and/or one high‐quality RCT. Limited–one low‐quality RCT and/or CCT. Conflicting–inconsistent findings among multiple trials (RCTs and/or CCTs). No evidence–no RCTs or CCTs. Results: Twenty relevant studies were sourced, 11 of which met the inclusion criteria. These included studies of Achilles tendinopathy (AT), patella tendinopathy (PT) and tendinopathy of the common wrist extensor tendon of the lateral elbow (LET). Limited levels of evidence exist to suggest that EE has a positive effect on clinical outcomes such as pain, function and patient satisfaction/return to work when compared to various control interventions such as concentric exercise (CE), stretching, splinting, frictions and ultrasound. Levels of evidence were found to be variable across the tendinopathies investigated. Conclusions: This review demonstrates the dearth of high‐quality research in support of the clinical effectiveness of EE over other treatments in the management of tendinopathies. Further adequately powered studies that include appropriate randomisation procedures, standardised outcome measures and long‐term follow‐up are required
Haslerud, Sturla; Lopes-Martins, Rodrigo Alvaro Brandão; Frigo, Lúcio; Bjordal, Jan Magnus; Marcos, Rodrigo Labat; Naterstad, Ingvill Fjell; Magnussen, Liv Heide; Joensen, Jon
Low-level laser therapy (LLLT) and cryotherapy are widely used treatments in the acute phase of tendon injury. The aim of this study was to investigate the interaction of these two treatments on tendon inflammation and mechanical properties. Six groups of six Wistar rats were used in this study. The Achilles tendons of the healthy control group were not subjected to injury or treatment. The tendons of the injured nontreated group (ING) were injured, but not treated. The remaining four groups were injured and subjected to LLLT, cryotherapy, LLLT first/cryotherapy, or cryotherapy first/LLLT. All treatments were performed at 1 h post-trauma. Inflammatory mediators, tendon histology, and biomechanical properties were assessed at 24 h post-trauma by comparing the treatment groups with the ING. In all treatment groups, the inflammatory process shifted in an anti-inflammatory direction compared with the ING. Significant alterations in cytokine expression were found in only the LLLT group (↓IL-1β) and the combined intervention groups (↓IL-1β, ↓TNF-α, ↑IL-6). It was also found that cryotherapy followed by LLLT was the only treatment that significantly (p < 0.05) improved the biomechanical parameters of force (N) and displacement (mm) at the tendon rupture and corresponded with the best histological scores of all of the treatment groups. Our results demonstrate that cryotherapy in combination with LLLT can produce an anti-inflammatory "add-on" effect. The order of therapy administration seems essential, as superior histology and biomechanical results were found in the cryotherapy first/LLLT group.
Boesen, Anders Ploug; Hansen, Rudi; Boesen, Morten Ilum; Malliaras, Peter; Langberg, Henning
Injection therapies are often considered alongside exercise for chronic midportion Achilles tendinopathy (AT), although evidence of their efficacy is sparse. To determine whether eccentric training in combination with high-volume injection (HVI) or platelet-rich plasma (PRP) injections improves outcomes in AT. Randomized controlled trial; Level of evidence, 1. A total of 60 men (age, 18-59 years) with chronic (>3 months) AT were included and followed for 6 months (n = 57). All participants performed eccentric training combined with either (1) one HVI (steroid, saline, and local anesthetic), (2) four PRP injections each 14 days apart, or (3) placebo (a few drops of saline under the skin). Randomization was stratified for age, function, and symptom severity (Victorian Institute of Sports Assessment-Achilles [VISA-A]). Outcomes included function and symptoms (VISA-A), self-reported tendon pain during activity (visual analog pain scale [VAS]), tendon thickness and intratendinous vascularity (ultrasonographic imaging and Doppler signal), and muscle function (heel-rise test). Outcomes were assessed at baseline and at 6, 12, and 24 weeks of follow-up. VISA-A scores improved in all groups at all time points ( P < .05), with greater improvement in the HVI group (mean ± SEM, 6 weeks = 27 ± 3 points; 12 weeks = 29 ± 4 points) versus PRP (6 weeks = 14 ± 4; 12 weeks = 15 ± 3) and placebo (6 weeks = 10 ± 3; 12 weeks = 11 ± 3) at 6 and 12 weeks ( P < .01) and in the HVI (22 ± 5) and PRP (20 ± 5) groups versus placebo (9 ± 3) at 24 weeks ( P < .01). VAS scores improved in all groups at all time points ( P < .05), with greater decrease in HVI (6 weeks = 49 ± 4 mm; 12 weeks = 45 ± 6 mm; 24 weeks = 34 ± 6 mm) and PRP (6 weeks = 37 ± 7 mm; 12 weeks = 41 ± 7 mm; 24 weeks = 37 ± 6 mm) versus placebo (6 weeks = 23 ± 6 mm; 12 weeks = 30 ± 5 mm; 24 weeks = 18 ± 6 mm) at all time points ( P < .05) and in HVI versus PRP at 6 weeks ( P < .05). Tendon thickness showed a
Zappia, Marcello; Cuomo, Giovanna; Martino, Maria Teresa; Reginelli, Alfonso; Brunese, Luca
The aim of this study was to determine whether foot position could modify power Doppler grading in evaluation of the Achilles enthesis. Eighteen patients with clinical Achilles enthesitis were studied with power Doppler ultrasound (PDUS) in five different positions of the foot: active and passive dorsiflexion, neutral position, active and passive plantar flexion. The Doppler signal was graded in any position and compared with the others. The Doppler signal was higher with the foot in plantar flexion and decreased gradually, sometimes till to disappear, while increasing dorsiflexion. The Doppler signal was always less during the active keeping of the position of the joint, than during the passive. The PDUS examination of the Achilles enthesis should be performed also with the foot in passive plantar flexion, in order not to underestimate the degree of vascularization.
Tsai, Wen-Chung; Yang, Yun-Ming
The fluoroquinolones (FQs) are used to treat a wide range of infections because of their excellent gastrointestinal absorption, superior tissue penetration and broad-spectrum activity. Recently, FQ-associated tendinopathy and tendon rupture have been reported, especially in the elderly and patients with diabetes and renal failure. However, these adverse effects do not appear to be widely known among physicians. Because of the frequent use of FQs in clinical practice, physicians should be aware of their potential for severe disability from tendon rupture. Achilles tendinopathy or rupture is among the most serious side effects associated with FQ use, with reports markedly increasing, especially with the use of ciprofloxacin. The histopathologic findings include degenerative lesions, fissures, interstitial edema without cellular infiltration, necrosis and neovascularization. There are possible molecular mechanisms accounting for FQ-associated tendinopathy. First, ciprofloxacin mediates inhibition of cell proliferation and G2/M cell cycle arrest in tendon cells by down-regulation of cyclin B and cyclin-dependent kinase 1. Second, ciprofloxacin inhibits the spead and migration of tenocytes by down-regulation of focal adhesion kinase phosphorylation. Third, ciprofloxacin enhances the enzymatic activity of matrix metalloproteinase-2 with degradation of type I collagen. Management of FQ-associated tendinopathy includes immediate discontinuation of FQs, rest, non-steroidal anti-inflammatory drugs, physical modalities and eccentric strengthening exercise. Tendon rupture may require surgical intervention.
Malvankar, S; Khan, W S
The Achilles tendon is believed to have first developed two million years ago enabling humans to run twice as fast. However if the Achilles tendon is so important in terms of evolution, then why is this tendon so prone to injury - especially for those more active like athletes. The Achilles tendon had an integral role in evolving apes from a herbivorous diet to early humans who started hunting for food over longer distances, resulting in bipedal locomotion. Evolutionary advantages of the Achilles tendon includes it being the strongest tendon in the body, having an energy-saving mechanism for fast locomotion, allows humans to jump and run, and additionally is a spring and shock absorber during gait. Considering these benefits it is therefore not surprising that studies have shown athletes have thicker Achilles tendons than subjects who are less active. However, contradictory to these findings that show the importance of the Achilles tendon for athletes, it is well known that obtaining an Achilles tendon injury for an athlete can be career-altering. A disadvantage of the Achilles tendon is that the aetiology of its pathology is complicated. Achilles tendon ruptures are believed to be caused by overloading the tensed tendon, like during sports. However studies have also shown athlete Achilles tendon ruptures to have degenerative changes in the tendon. Other flaws of the Achilles tendon are its non-uniform vascularity and incomplete repair system which may suggest the Achilles tendon is on the edge of evolution. Research has shown that there is a genetic influence on the predisposition a person has towards Achilles tendon injuries. So if this tendon is here to stay in our anatomy, and it probably is due to the slow rate of evolution in humans, research in genetic modification could be used to decrease athletes' predisposition to Achilles tendinopathy.
Two-thirds of Achilles tendon injuries in competitive athletes are paratenonitis and one-fifth are insertional complaints (bursitis and insertion tendinitis). The remaining afflictions consist of pain syndromes of the myotendineal junction and tendinopathies. The majority of Achilles tendon injuries from sport occur in males, mainly because of their higher rates of participation in sport, but also with tendinopathies a gender difference is probably indicated. Athletes in running sports have a high incidence of Achilles tendon overuse injuries. About 75% of total and the majority of partial tendon ruptures are related to sports activities usually involving abrupt repetitive jumping and sprinting movements. Mechanical factors and a sedentary lifestyle play a role in the pathology of these injuries. Achilles tendon overuse injuries occur at a higher rate in older athletes than most other typical overuse injuries. Recreational athletes with a complete Achilles tendon rupture are about 15 years younger than those with other spontaneous tendon ruptures. Following surgery, about 70 to 90% of athletes have a successful comeback after Achilles tendon injury. Surgery is required in about 25% of athletes with Achilles tendon overuse injuries and the frequency of surgery increases with patient age and duration of symptoms as well as occurrence of tendinopathic changes. However, about 20% of injured athletes require a re-operation for Achilles tendon overuse injuries, and about 3 to 5% are compelled to abandon their sports career because of these injuries. Myotendineal junction pain should be treated conservatively. Partial Achilles tendon ruptures are primarily treated conservatively, although the best treatment method of chronic partial rupture seems to be surgery. Complete Achilles tendon ruptures of athletes are treated surgically, because this increases the likelihood of athletes reaching preinjury activity levels and minimises the risk of re-ruptures. Marked forefoot
Simpson, Michael R; Howard, Thomas M
Because our understanding of tendinopathy has evolved in recent years, the condition is now considered a degenerative process; this affects the approach to treatment. Initial therapy should always involve relative rest and modification of physical activity, use of rehabilitative exercises, and evaluation of intrinsic and extrinsic causes of injury. The posterior tibial tendon is a dynamic arch stabilizer; injury to this tendon can cause a painful flat-footed deformity with hindfoot valgus and midfoot abduction (characterized by the too many toes sign). Treatment of posterior tibial tendinopathy is determined by its severity and can include immobilization, orthotics, physical therapy, or subspecialty referral. Because peroneal tendinopathy is often misdiagnosed, it can lead to chronic lateral ankle pain and instability and should be suspected in a patient with either of these symptoms. Treatment involves physical therapy and close monitoring for surgical indications. Achilles tendinopathy is often caused by overtraining, use of inappropriate training surfaces, and poor flexibility. It is characterized by pain in the Achilles tendon 4 to 6 cm above the point of insertion into the calcaneus. Evidence from clinical trials shows that eccentric strengthening of the calf muscle can help patients with Achilles tendinopathy. Flexor hallucis longus tendinopathy is most common among ballet dancers. Patients may complain of an insidious onset of pain in the posteromedial aspect of the ankle; treatment involves correcting physical training errors, focusing on body mechanics, and strengthening the body's core. Anterior tibial tendinopathy is rare, but is typically seen in patients older than 45 years. It causes weakness in dorsiflexion of the ankle; treatment involves short-term immobilization and physical therapy.
Uquillas, Carlos A; Guss, Michael S; Ryan, Devon J; Jazrawi, Laith M; Strauss, Eric J
Achilles tendon pathology is common and affects athletes and nonathletes alike. The cause is multifactorial and controversial, involving biological, anatomical, and mechanical factors. A variety of conditions characterized by Achilles tendon inflammation and/or degeneration can be clinically and histologically differentiated. These include insertional Achilles tendinopathy, retrocalcaneal bursitis, Achilles paratenonitis, Achilles tendinosis, and Achilles paratenonitis with tendinosis. The mainstay of treatment for all of these diagnoses is nonoperative. There is a large body of evidence addressing treatment of acute and chronic Achilles tendon ruptures; however, controversy remains.
Lui, Tun Hing
Pain in the posterosuperior portion of the calcaneus can be caused by a retrocalcaneal bursitis, enlargement of the superior bursal prominence of the calcaneus, insertional Achilles tendinopathy, stress fracture of the calcaneus, or inflammation of an adventitious bursa between the Achilles tendon and the skin. Hypertrophied tendon impinging on the posterosuperior calcaneal tuberosity can be a cause of retrocalcaneal pain after repair of acute rupture of the Achilles tendon. This can be effectively treated by endoscopic calcaneoplasty. Therapeutic, Level IV, Case Report.
Tam, P K; Ho, Carmen T K
We report a case of Achilles tendinitis after intake of ciprofloxacin for treatment of respiratory tract infection. Fluoroquinolone-induced tendinopathy is an uncommon but increasingly recognised adverse effect of this antibiotic class. Most of the cases occur in the Achilles tendon and may lead to tendon rupture. Possible predisposing risk factors include use of steroid, patients with renal impairment or renal transplant, old age, and being an athlete. The drug should be stopped once this condition is suspected. Symptomatic treatment should be given and orthopaedic referral is desirable if tendon rupture occurs.
Ferrero, G.; Fabbro, E.; Orlandi, D.; Martini, C.; Lacelli, F.; Serafini, G.; Silvestri, E.; Sconfienza, L.M.
Purpose The efficacy of platelet-rich plasma (PRP) in the treatment and healing of chronic tendinopathy through stimulation of cell proliferation and total collagen production has been demonstrated by both in vitro and in vivo studies. The aim of this study is to evaluate the effectiveness of ultrasound (US)-guided autologous PRP injections in patellar and Achilles tendinopathy. Materials and methods Autologous PRP was injected under US-guidance into the Achilles and patellar tendons (30 Achilles tendons, 28 patellar tendons) in 48 prospectively selected patients (30 males, 18 females, mean age 38 ± 16 years, range 20–61 years). All patients were previously evaluated according to the Victoria Institute of Sport Assessment (VISA) scale, which assessed pain and activity level, and they all underwent US of the tendon before treatment and at follow-up after 20 days and 6 months. Statistical analysis was performed with Chi-square and Wilcoxon tests. Results 20 days after PRP injection the patients presented a non-significant improvement of clinical symptoms. At the 6-month follow-up VISA score increased from a mean value of 57–75.5 (p < .01). US evaluation revealed a reduction of hypoechoic areas in 26 tendons (p < .01) associated with a widespread improvement of fibrillar echotexture of the tendon and reduced hypervascularity at power Doppler. Conclusion PRP injection in patellar and Achilles tendinopathy results in a significant and lasting improvement of clinical symptoms and leads to recovery of the tendon matrix potentially helping to prevent degenerative lesions. US-guidance allows PRP injection into the tendon with great accuracy. PMID:23730392
Owens, Brett D.; Wolf, Jennifer Moriatis; Seelig, Amber D.; Jacobson, Isabel G.; Boyko, Edward J.; Smith, Besa; Ryan, Margaret A.K.; Gackstetter, Gary D.; Smith, Tyler C.; Bagnell, Melissa
Background: Overuse injuries have a significant impact on United States military service members, but research to date has been limited in its ability to assess occupational and behavioral risk factors. Hypothesis/Purpose: To prospectively identify risk factors for the development of lower extremity tendinopathy and plantar fasciitis in United States military personnel. Study Design: Descriptive epidemiology study. Methods: Baseline data from the Millennium Cohort Study, a long-term observational cohort of military personnel, were utilized. Service members were enrolled in the cohort in 2001, 2004, and 2007. A total of 80,106 active-duty personnel were followed over 1 year for the development of patellar tendinopathy, Achilles tendinopathy, and plantar fasciitis. Regression analyses were used to estimate significant associations between each tendinopathy, plantar fasciitis, and demographic, behavioral, and occupational characteristics. Results: Using medical records, 450 cases of Achilles tendinitis, 584 cases of patellar tendinopathy, and 1228 cases of plantar fasciitis were identified. Recent deployment was associated with an increased risk for developing plantar fasciitis (adjusted odds ratio [AOR], 1.27; 95% confidence interval [CI], 1.04-1.56). Moderate weekly alcohol consumption was marginally associated with an increased risk for Achilles tendinopathy (AOR, 1.33; 95% CI, 1.00-1.76). Overweight or obese individuals were more likely to develop Achilles tendinopathy and plantar fasciitis. Conclusion: Lower extremity tendinopathies and plantar fasciitis are common among military service members, and this study identified several modifiable risk factors for their occurrence. These potential risk factors could serve as the focus for future preventive and intervention studies. PMID:26535232
Fernández-Palazzi, F; Rivas, S; Mujica, P
Overuse injuries of tendons are known to occur in persons whose activities submit the tendon to excessive stress. Classical ballet dancers performing en pointe, demie point, or plié exert forces that, although normal in magnitude, are increased in frequency, thus overusing the Achilles tendon. In the present study all cases of Achilles tendinopathy seen in a period of three years in three ballet companies were reviewed by a special orthopedic clinic. The cause, whether by abnormal tension or incorrect use, development, and progression to chronic tendinopathy, as well as measures to prevent it, were analyzed in 19 cases. The methods of treatment, including conservative treatment with rest and refraining from dancing, local treatment such as ice and adhesive strapping, antiinflammatory drugs, local injections, thermotherapy, and laser therapy, were compared, and the time of recovery and ability to resume dancing were evaluated. Two cases required surgical treatment to subside, and the patients had to retire from professional dancing. The roentgenographic diagnosis of stage and progression of the tendinopathy is emphasized as a valuable accessory sign. The similarity in lesions between Achilles and patellar tendon problems was observed and confirmed.
Wiell, Charlotte; Szkudlarek, Marcin; Hasselquist, Maria; Møller, Jakob M; Nørregaard, Jesper; Terslev, Lene; Ostergaard, Mikkel
The objective of this study was to describe ultrasonography (US) and magnetic resonance imaging (MRI) findings at painful Achilles tendons and entheses in patients with and without spondyloarthropathy (SpA and non-SpA) and healthy control persons (CTRLs). Particularly, we aimed to investigate if any changes differentiate SpA from non-SpA. Finally, we investigated the reliability of US compared to clinical examination of Achilles tendinopathy, using MRI as gold standard reference. Twelve SpA patients and 15 non-SpA patients with pain and tenderness at at least one Achilles tendon and/or enthesis due to sports-related causes and 10 CTRLs were examined at the Achilles tendons and entheses with US, MRI and clinical assessment. Intratendinous changes, entheseal changes, bursitis and peritendonitis were assessed. An US interobserver substudy was performed in nine persons. US findings showed high agreement between observers (median 89 %, κ = 0.64) and with MRI (median 89 %, κ = 0.74). All inflammatory intratendinous changes were less frequent in SpA than non-SpA patients (p < 0.05). Entheseal changes and bursitis were found equally frequent in both patient groups except for enthesophytes, which were most common in the SpA group (p < 0.01). No findings were exclusively found in SpA. When MRI was considered gold standard, US showed higher sensitivity for intratendinous and entheseal changes than clinical examination (median sensitivity 0.83 versus 0.66). Especially, entheseal changes had higher sensitivity than clinical examination without loss of specificity. In conclusion, US performed by a trained operator can be a useful adjunct to clinical examination for improved assessment of Achilles tendons and entheses.
Peters, Janne A; Zwerver, Johannes; Diercks, Ronald L; Elferink-Gemser, Marije T; van den Akker-Scheek, Inge
Tendinopathy, the most prevalent tendon disorder which is considered as the clinical diagnosis of pain and dysfunction, is common in sports and its prevalence is ever-increasing. Despite the lack of clarity about risk factors, various preventive interventions for tendinopathy have been investigated. The main objective of this study is to review current preventive interventions for tendinopathy in the major regions: ankle, knee, hip, groin, shoulder and elbow. A systematic literature search was conducted. The PubMed and Embase databases were explored to identify articles that met the inclusion criteria. The included studies were assessed on methodological quality and data was summarized. Ten articles were included that describe a wide variety of preventive interventions. These were divided into three categories: stretch and exercise interventions, shoe adaptations and other interventions. The methodological quality of the studies was moderate to high. Three out of ten studies showed a significant beneficial result. There is limited evidence that a long-term intervention including balance training is effective in the prevention of patellar and Achilles tendinopathy. Shoe adaptations in the form of shock absorbing insoles could have a preventive effect on Achilles tendinopathy. Hormone replacement therapy seems to reduce the risk for structural Achilles tendon changes in active post-menopausal women. No evidence was found for a positive effect of stretching exercises. Prophylactic eccentric training and stretching can increase the risk of injury in asymptomatic players with patellar tendon abnormalities. A limited amount of studies was available and more research is needed on (multifactorial) etiology, risk factors and preventive interventions. Copyright © 2015 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
Kim, Bom Soo; Joo, Young Chae; Choi, Byung Hyune; Kim, Kil Hwan; Kang, Joon Soon; Park, So Ra
Achilles tendinopathy is a common degenerative condition without a definitive treatment. An adequate chronic animal model of Achilles tendinopathy has not yet been developed. The purpose of this study was to evaluate the individual and combined effects of dry needling and treadmill running on the Achilles tendon of rats. Percutaneous dry needling, designed to physically replicate microrupture of collagen fibers in overloaded tendons, was performed on the right Achilles tendon of 80 Sprague-Dawley rats. The rats were randomly divided into two groups: a treadmill group, which included rats that underwent daily uphill treadmill running (n = 40), and a cage group, which included rats that could move freely within their cages (n = 40). At the end of weeks 1 and 4, 20 rats from each group were sacrificed, and bilateral Achilles tendons were collected. The harvested tendons were subjected to mechanical testing and histological analysis. Dry needling induced histological and mechanical changes in the Achilles tendons at week 1, and the changes persisted at week 4. The needled Achilles tendons of the treadmill group tended to show more severe histological and mechanical changes than those of the cage group, although these differences were not statistically significant. Dry needling combined with free cage activity or treadmill running produced tendinopathy-like changes in rat Achilles tendons up to 4 weeks after injury. Dry needling is an easy procedure with a short induction period and a high success rate, suggesting it may have relevance in the design of an Achilles tendinopathy model.
Crescibene, Antonio; Napolitano, Marcello; Sbano, Raffaella; Costabile, Enrico; Almolla, Hesham
Achilles tendinopathy and patellar tendinopathy are among the most frequent diagnoses in sports medicine. Therapeutic treatment of the disease is difficult, particularly in chronic cases. In literature, several studies suggest the employment of Platelet-Rich Plasma as a therapeutic alternative in tendinopathies. The choice of employing this method is based on the activity of growth factors contained in platelets which activate, amplify, and optimize the healing process. We selected 14 patients affected by Achilles tendinopathy and 7 patients affected by patellar tendinopathy, with a two-year final follow-up. These patients underwent a cycle of three tendinous infiltrations, after clinical and instrumental evaluation carried out by means of specific questionnaires and repeated ultrasound scans. Ultrasound scans of 18 patients showed signs of reduction in insertional irregularities. The result is confirmed by complete functional recovery of the patients, with painful symptomatology disappearing. The patients showed a clear pain reduction, along with an enhanced VISA score after the 24-month follow-up, equal to 84.2 points on a scale of 0 to 100. In conclusion, the present study provides evidence to suggest that PRP infiltration is a valid option to patients with chronic tendinopathy who did not benefit from other treatments. PMID:26171277
Macdermid, Joy C; Silbernagel, Karin Grävare
Synopsis Clinical measurement studies that address outcome evaluation for patients with tendinopathy should consider conceptual, clinical, practical, and measurement issues to guide the selection of valid measures. Clinical outcomes reported in research studies can provide benchmarks that assist with interpretation of scores during clinical decision making. Given the pathophysiology and functional impacts of tendinopathy, there is a need for outcome measures that assess physical impairments, activity performance, and patient-reported symptoms and function. Tendinopathy-specific patient-reported outcome measures have been shown to be superior to more generic tools for some conditions, such as lateral epicondyle tendinopathy (Patient-Rated Tennis Elbow Evaluation) and Achilles tendinopathy (Victorian Institute of Sport Assessment-Achilles), whereas both generic shoulder outcome measures and disease-specific measures perform similarly in individuals with rotator cuff tendinopathy. A patient-reported outcome measure that captures pain and limitation in function should be fundamental to outcome evaluation in patients with tendinopathy. The current measurement literature does not yet provide comprehensive empirical data to define optimal outcome measures for all types of tendinopathy. This article reviews concepts, instruments, and measurement properties that should provide clinicians with a foundation for assessment of condition severity and treatment outcomes in patients with tendinopathy. J Orthop Sports Phys Ther 2015;45(11):950-964. Epub 15 Oct 2015. doi:10.2519/jospt.2015.6054.
Lewis, Trevor G
Fluoroquinolone antibiotics have been widely used for over 25 years. Their key adverse effect is tendinopathy. A 76-year-old woman developed bilateral Achilles tendinopathy on the fourth day of fluoroquinolone use. Her doctor advised her to complete the course; however, she went on to sustain bilateral tendoachilles rupture. The patient undertook self-referral to a Primary Care Musculoskeletal Assessment Service, where bilateral Achilles tendon rupture was confirmed by ultrasonography. Surgical repair of both tendons was undertaken. Several months postoperatively the patient was discharged. Fluoroquinolone-related tendinopathy can occur within hours of commencing the medication or up to 6 months post cessation. The incidence of Achilles tendon disorders significantly outweighs pathology in other tendons. Men are up to four times more susceptible than women, hence bilateral rupture in a 76-year-old woman is rare. Patients prescribed fluoroquinolones presenting with tendinopathy require consideration of dose reduction or cessation of fluoroquinolone therapy.
Eickler, Richard; Pomeranz, Stephen J
Achilles tendinitis is a common etiology of heel pain, which is a common patient complaint. Achilles tendinitis can be classified into noninsertional tendinosis and insertional tendinitis on the basis of clinical features, radiologic signs, and pathologic findings. Magnetic resonance imaging (MRI) allows classification and reveals associated findings, including retrocalcaneal bursitis, paratendinitis, and paratenonitis. Furthermore, MRI may not only confirm findings of Achilles tendinitis but also diagnose other etiologies of heel pain. This article reviews the MRI findings and terminology of Achilles tendinitis often found in radiology reports.
Schwartz, Aaron; Watson, Jonathan N; Hutchinson, Mark R
Patellar tendinopathy is a common condition. There are a wide variety of treatment options available, the majority of which are nonoperative. No consensus exists on the optimal method of treatment. PubMed spanning 1962-2014. Clinical review. Level 4. The majority of cases resolve with nonoperative therapy: rest, physical therapy with eccentric exercises, cryotherapy, anti-inflammatories, corticosteroid injections, extracorporeal shockwave therapy, glyceryl trinitrate, platelet-rich plasma injections, and ultrasound-guided sclerosis. Refractory cases may require either open or arthroscopic debridement of the patellar tendon. Corticosteroid injections provide short-term pain relief but increase risk of tendon rupture. Anti-inflammatories and injectable agents have shown mixed results. Surgical treatment is effective in many refractory cases unresponsive to nonoperative modalities. Physical therapy with an eccentric exercise program is the mainstay of treatment for patellar tendinopathy. Platelet-rich plasma has demonstrated mixed results; evidence-based recommendations on its efficacy cannot be made. In the event that nonoperative treatment fails, surgical intervention has produced good to excellent outcomes in the majority of patients. © 2015 The Author(s).
Schwartz, Aaron; Watson, Jonathan N.; Hutchinson, Mark R.
Context: Patellar tendinopathy is a common condition. There are a wide variety of treatment options available, the majority of which are nonoperative. No consensus exists on the optimal method of treatment. Evidence Acquisition: PubMed spanning 1962-2014. Study Design: Clinical review. Level of Evidence: Level 4. Results: The majority of cases resolve with nonoperative therapy: rest, physical therapy with eccentric exercises, cryotherapy, anti-inflammatories, corticosteroid injections, extracorporeal shockwave therapy, glyceryl trinitrate, platelet-rich plasma injections, and ultrasound-guided sclerosis. Refractory cases may require either open or arthroscopic debridement of the patellar tendon. Corticosteroid injections provide short-term pain relief but increase risk of tendon rupture. Anti-inflammatories and injectable agents have shown mixed results. Surgical treatment is effective in many refractory cases unresponsive to nonoperative modalities. Conclusion: Physical therapy with an eccentric exercise program is the mainstay of treatment for patellar tendinopathy. Platelet-rich plasma has demonstrated mixed results; evidence-based recommendations on its efficacy cannot be made. In the event that nonoperative treatment fails, surgical intervention has produced good to excellent outcomes in the majority of patients. PMID:26502416
Knobloch, K; Thermann, H; Hüfner, T
Achilles tendon ruptures are one end of a continuum starting with the healthy Achilles tendon via the thickened and painful tendinopathic Achilles tendon with neovascularisation to the complete tendon rupture. Often times chinolone antibiotics, cortisone therapy and valgus foot axis are associated risk factors. Incidence of Achilles tendon ruptures is estimated to be 10/100 000 per year with a mean age of 35-40 years. Physical activity is encountered in 75 % cases of Achilles tendon ruptures. Running is associated with Achilles tendinopathy as the predominant overuse injury in an analysis among 291 athletes with 10 million kilometers exposure. The Achilles tendinopathic rate was 0.016/1000 km differentiated in 0.008/1000 km mid-portion tendinopathy and 0.005/1000 km insertional tendinopathy. Achilles tendinopathy in running overuse injuries is followed by runner's knee (0.013/1000 km), shin splint (0.0104/1000 km) and plantar fasciitis (0.0054/1000 km). Dynamic ultrasound in 20 degrees plantar flexion is of utmost importance for therapeutic decision making. With an adaptation rate of 75 % or more of the ruptured tendon in 20 degrees plantar flexion and a high patient's compliance we perform an early functional conservative treatment regimen in Achilles tendon ruptures. In almost all other cases the percutaneous Achilles tendon repair is indicated, where nervus suralis lesions have to be appreciated. The vulnerable zone is 10-12 cm proximal to the calcaneus at the lateral border of the Achilles tendon with the sural nerve in close proximity with the tendon. Early functional rehabilitation is not associated with a higher risk of rerupture but with improved subjective assessments and should therefore be advocated.
... You Prevent Achilles Tendonitis? Take these steps to reduce your risk of Achilles tendonitis: Stay in good shape year-round and try to keep your muscles as strong as they can be. Strong, flexible muscles work more efficiently and put less stress on your tendon. Increase the intensity and length ...
Connors, G. Patrick
Five ailments which can cause pain in the achilles tendon area are: (1) muscular strain, involving the stretching or tearing of muscle or tendon fibers; (2) a contusion, inflammation or infection called tenosynovitis; (3) tendonitis, the inflammation of the tendon; (4) calcaneal bursitis, the inflammation of the bursa between the achilles tendon…
Connors, G. Patrick
Five ailments which can cause pain in the achilles tendon area are: (1) muscular strain, involving the stretching or tearing of muscle or tendon fibers; (2) a contusion, inflammation or infection called tenosynovitis; (3) tendonitis, the inflammation of the tendon; (4) calcaneal bursitis, the inflammation of the bursa between the achilles tendon…
Mårdh, Anders; Lund, Iréne
Introduction: Pain in the Achilles tendon during loading is a very common condition. Conservative treatments, such as low level laser therapy (LLLT) have been reported to give varying results. Recently, a new laser treatment technique, high power laser treatment (HPLT) (Swiss DynaLaser®), was introduced in Scandinavia, but has not, to our knowledge, been systematically tested before. The objective of this study was to evaluate the effects of HPLT compared to placebo HPLT in rated pain and assessed pain threshold in patients with chronic Achilles tendinosis. Methods: The study was a randomized, single blind, placebo controlled trial. Patients were randomized to receive 6 treatments of either HPLT or placebo HPLT during a period of 3-4 weeks with a follow up period of 8-12 weeks. Outcome measures were rated pain according to questions of the Foot and Ankle Outcome Score (FAOS, Swedish version LK1.0) and assessment of electro-cutaneous stimulated pain threshold and matched pain (PainMatcher). Results: The results of the study demonstrated significant changes of assessments within groups, that were more pronounced towards lower levels of rated pain in the HPLT group than in the placebo HPLT group. The between group difference were significant in four of nine questions regarding loading activities of the FAOS subscale. Assessed pain thresholds were found increased in the HPLT group, as compared to the placebo HPLT group. At individual level, the results varied. Conclusion: The results indicate that HPLT may provide a future option for treatment of Achilles tendinosis related pain, but further studies are warranted. PMID:27330704
Rupture of the Achilles tendon is a significant injury, and the likelihood of a good recovery is directly associated with early diagnosis and appropriate referral. Such injuries are commonly assessed and identified by practitioners working in 'minors' areas of emergency departments or urgent care settings. The literature frequently describes rupture of the Achilles tendon as 'typically sport-related' affecting 'middle-aged weekend warriors', but this aetiology accounts for only about 70% of such injuries. Factors such as the natural ageing process, obesity and use of some commonly prescribed medications, can increase the risk of developing a tendinopathy and subsequent rupture, often from a seemingly insignificant incident. However, research suggests that injuries in this patient population are more likely be missed on first examination. This article describes risk factors that should alert clinicians to the possibility of Achilles tendon rupture in 'atypical' patient populations.
Tendinitis of the heel ... foot. Rarely, it is caused by an injury. Tendinitis due to overuse is most common in younger ... occur in walkers, runners, or other athletes. Achilles tendinitis may be more likely to occur if: There ...
... make the pain worse. If you regularly do high-impact exercises (such as running), switching to low-impact activities will put less stress on the Achilles tendon. Cross- training activities such as biking, elliptical exercise, and swimming ...
Shimatsu, Kaumakaokalani; Subramaniam, Somasundaram; Sim, Helen; Aronowitz, Paul
Fluoroquinolone-induced tendinopathy most commonly affects the Achilles tendon; however, involvement of several other tendons has been described. This is a case report of ciprofloxacin-induced tendinopathy of the gluteal tendons with MRI findings. An obese 25-year-old woman with no significant past medical history was diagnosed with acute pyelonephritis and was treated with intravenous ciprofloxacin. Shortly after her first dose of ciprofloxacin, she developed severe left hip pain and decreased range of motion. MRI of the hips showed bilateral tendinopathy of the gluteal muscle insertion. A diagnosis of ciprofloxacin-induced tendinopathy was made based on her MRI and a Naranjo score of 7. Ciprofloxacin was stopped and her pain quickly resolved. Fluoroquinolones cause tendinopathy in 0.14 % to 0.4 % of patients using these agents. Fluoroquinolone-associated tendinopathy is a serious adverse reaction that can affect many tendons and should be considered in any patient presenting with new musculoskeletal complaints and in whom there is a history of fluoroquinolone use within the preceding 6 months.
Presence of a non-neuronal cholinergic system and occurrence of up- and down-regulation in expression of M2 muscarinic acetylcholine receptors: new aspects of importance regarding Achilles tendon tendinosis (tendinopathy).
Bjur, Dennis; Danielson, Patrik; Alfredson, Håkan; Forsgren, Sture
Limited information is available concerning the existence of a cholinergic system in the human Achilles tendon. We have studied pain-free normal Achilles tendons and chronically painful Achilles tendinosis tendons with regard to immunohistochemical expression patterns of the M(2) muscarinic acetylcholine receptor (M(2)R), choline acetyltransferase (ChAT), and vesicular acetylcholine transporter (VAChT). M(2)R immunoreactivity was detected in the walls of blood vessels. As evidenced via parallel staining for CD31 and alpha-smooth muscle actin, most M(2)R immunoreactivity was present in the endothelium. M(2)R immunoreactivity also occured in tenocytes, which regularly immunoreact for vimentin. The degree of M(2)R immunoreactivity was highly variable, tendinosis tendons that exhibit hypercellularity and hypervascularity showing the highest levels of immunostaining. Immunoreaction for ChAT and VAChT was detected in tenocytes in tendinosis specimens, particularly in aberrant cells. In situ hybridization revealed that mRNA for ChAT is present in tenocytes in tendinosis specimens. Our results suggest that autocrine/paracrine effects occur concerning the tenocytes in tendinosis. Up-regulation/down-regulation in the levels of M(2)R immunoreactivity possibly take place in tenocytes and blood vessel cells during the various stages of tendinosis. The presumed local production of acetylcholine (ACh), as evidenced by immunoreactivity for ChAT and VAChT and the detection of ChAT mRNA, appears to evolve in response to tendinosis. These observations are of importance because of the well-known vasoactive, trophic, and pain-modulating effects that ACh is known to have and do unexpectedly establish the presence of a non-neuronal cholinergic system in the Achilles tendon.
Goom, Thomas S H; Malliaras, Peter; Reiman, Michael P; Purdam, Craig R
Synopsis Proximal hamstring tendinopathy (PHT) typically manifests as deep buttock pain at the hamstring common origin. Both athletic and nonathletic populations are affected by PHT. Pain and dysfunction are often long-standing and limit sporting and daily functions. There is limited evidence regarding diagnosis, assessment, and management; for example, there are no randomized controlled trials investigating rehabilitation of PHT. Some of the principles of management established in, for example, Achilles and patellar tendinopathy would appear to apply to PHT but are not as well documented. This narrative review and commentary will highlight clinical aspects of assessment and management of PHT, drawing on the available evidence and current principles of managing painful tendinopathy. The management outline presented aims to guide clinicians as well as future research. J Orthop Sports Phys Ther 2016;46(6):483-493. Epub 15 Apr 2016. doi:10.2519/jospt.2016.5986.
Loppini, Mattia; Maffulli, Nicola
Summary Tendinopathy is one of the most frequent overuse injuries associated with sport. It is a failure of a chronic healing response associated with both chronic overloaded and unloaded states. Although several conservative therapeutic options have been proposed, very few of them are supported by randomized controlled trials. Eccentric exercises provide excellent clinical results both in athletic and sedentary patients, with no reported adverse effects. Combining eccentric loading and low-energy shock wave therapy produces higher success rates compared with eccentric training alone or shock wave therapy alone. High-volume injection of normal saline solution, corticosteroids, or anesthetics can reduce pain and improve long-term function in patients with Achilles or patellar tendinopathy. The use of injectable substances such as platelet-rich plasma, autologous blood, polidocanol, and corticosteroids in and around tendons is not support by strong clinical evidence. Further randomized controlled trials are necessary to define the best conservative management of tendinopathy. PMID:23738261
Krey, David; Borchers, James; McCamey, Kendra
To summarize the best available evidence to determine if tendon needling is an effective treatment for tendinopathy. Data source. Medline and Cochrane Databases through November 2013. Utilizing the search terms tendinopathy, needle, needling, tenotomy, dry needling, needling tendon, needle fenestration, and tendon fenestration, 17 articles were identified through our systematic literature search. Of these, 4 studies met the inclusion criteria. Four independent reviewers reviewed the articles. The study results and generated conclusions were agreed upon. The studies that were included in this review suggest that tendon needling improves patient reported outcomes in patients with tendinopathy. In 2 studies evaluating tendon needling in lateral epicondylosis, one showed an improvement in a subjective visual analogue scale score of 34% (significant change > 25%) from baseline at 6 months. The other showed an improvement of 56.1% in a visual analogue scale score from baseline. In 1 study evaluating tendon needling in addition to eccentric therapy for Achilles tendinosis, the subjective Victorian Institute of Sport Assessment-Achilles (VISA-A) score improved by 19.9 (significant change > 10) (95% CI, 13.6-26.2) from baseline. In 1 study evaluating tendon needling in rotator cuff tendinosis, the subjective shoulder pain and disability index showed statistical significant improvement from baseline at 6 months (P < 0.05). The evidence suggests that tendon needling improves patient-reported outcome measures in patients with tendinopathy. There is a trend that shows that the addition of autologous blood products may further improve theses outcomes.
Tendinopathies are one of the most common sports/musculoskeletal injury in modern western societies. Many physiotherapy approaches have been recommended in the literature for the management of tendinopathy. The most effective treatment in the management of tendinopathy is the eccentric training. Load, speed and frequency of contractions are the three principles of eccentric exercises, discussed in this report. However, eccentric training is not effective for all patients with tendinopathy and the effectiveness of this approach when applied as monotherapy is lower than it is applied as part of the rehabilitation process. For this reason, clinicians combine eccentric training with other physiotherapy techniques such as stretching, isometric and lumbar stability exercises, electrotherapy, manual therapy, soft tissue manipulation techniques, taping and acupuncture in the management of tendinopathies. Further research is needed to find out which treatment strategy combined with eccentric training will provide the best results in the rehabilitation of tendinopathy. PMID:26140271
Sun, Yu-Long; Wei, Zhuang; Zhao, Chunfeng; Jay, Gregory D; Schmid, Thomas M; Amadio, Peter C; An, Kai-Nan
Achilles tendon is one of the most commonly injured tendons. Mechanical force is regarded as a major causative factor. However, the biomechanics of Achilles tendon and mechanical mechanism of the injuries are unclear. Lubricin expresses at regions exposed to sliding motion and shear force in a number of tissues. This study investigated the distribution and concentration of lubricin in human Achilles tendons for better understanding the biomechanics of Achilles tendon. Achilles tendons were harvested from nine cadavers. Lubricin was extracted from various locations proximal to the calcaneal insertion and quantified with ELISA. The distribution of lubricin was investigated with immunohistochemistry. Lubricin was mainly identified at the interfaces of tendon fascicles, especially in the mid-portion of the tendon. The concentration of lubricin in Achilles tendons varied by individual and the distance from its calcaneal insertion. The distal portion of the tendon had a higher concentration of lubricin than the proximal regions of the tendon. This study suggests the presence of intratendinous sliding motion of fascicles and shear force at interfaces of fascicles in human Achilles tendon. Shear force could be an important mechanical factor for the development of Achilles tendinopathy and rupture. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.
Achilles tendon rupture Overview By Mayo Clinic Staff Achilles (uh-KILL-eez) tendon rupture is an injury that affects the back ... but it can happen to anyone. The Achilles tendon is a strong fibrous cord that connects the ...
Achilles tendon rupture-surgery; Percutaneous Achilles tendon rupture repair ... To fix your torn Achilles tendon, the surgeon will: Make a cut down the back of your heel Make several small cuts rather than one large cut ...
... your primary doctor. Treatments of the Ankle Achilles Tendinosis Surgery Achilles Tendon Rupture Surgery Ankle Arthrodesis Ankle ... for Osteochondral Lesions of the Talus Insertional Achilles Tendinosis Surgery Lateral Ankle Ligament Reconstruction Lateral Ankle Stabilization ...
... up. Tight calf muscles or muscles that lack flexibility decrease a person's range of motion and put an extra strain on the tendon. Running or exercising on a hard or uneven surface or doing lunges or plyometrics without adequate training. A traumatic injury to the Achilles tendon. How ...
Bullock, Mark J; DeCarbo, William T; Hofbauer, Mark H; Thun, Joshua D
Background Despite the low incidence of deep vein thrombosis (DVT) in foot and ankle surgery, some authors report a high incidence of symptomatic DVT following Achilles tendon rupture. The purpose of this study was to identify DVT risk factors inherent to Achilles tendon repair to determine which patients may benefit from prophylaxis. Methods One hundred and thirteen patient charts were reviewed following elective and nonelective Achilles tendon repair. For elective repair of insertional or noninsertional Achilles tendinopathy, parameters examined included lateral versus prone positioning and the presence versus absence of a flexor hallucis longus transfer. For nonelective repair, acute Achilles tendon ruptures were compared to chronic Achilles tendon ruptures. Results Of 113 Achilles tendon repairs, 3 venous thromboembolism (VTE) events (2.65%) occurred including 2 pulmonary emboli (1.77%). Seventeen of these repairs were chronic Achilles tendon ruptures, and all 3 VTE events (17.6%) occurred within this subgroup. Elevated body mass index was associated with VTE in patients with chronic Achilles ruptures although this did not reach significance (P = .064). No VTE events were reported after repair of 28 acute tendon ruptures or after 68 elective repairs of tendinopathy. Two patients with misdiagnosed partial Achilles tendon tears were excluded because they experienced a VTE event 3 weeks and 5 weeks after injury, prior to surgery. Conclusion In our retrospective review, chronic Achilles ruptures had a statistically significant higher incidence of VTE compared with acute Achilles ruptures (P = .048) or elective repair (P = .0069). Pharmaceutical anticoagulation may be considered for repair of chronic ruptures. Repair of acute ruptures and elective repair may not warrant routine prophylaxis due to a lower incidence of VTE.
Bhabra, Gev; Wang, Allan; Ebert, Jay R.; Edwards, Peter; Zheng, Monica; Zheng, Ming H.
Lateral elbow tendinopathy, commonly known as tennis elbow, is a condition that can cause significant functional impairment in working-age patients. The term tendinopathy is used to describe chronic overuse tendon disorders encompassing a group of pathologies, a spectrum of disease. This review details the pathophysiology of tendinopathy and tendon healing as an introduction for a system grading the severity of tendinopathy, with each of the 4 grades displaying distinct histopathological features. Currently, there are a large number of nonoperative treatments available for lateral elbow tendinopathy, with little guidance as to when and how to use them. In fact, an appraisal of the clinical trials, systematic reviews, and meta-analyses studying these treatment modalities reveals that no single treatment reliably achieves outstanding results. This may be due in part to the majority of clinical studies to date including all patients with chronic tendinopathy rather than attempting to categorize patients according to the severity of disease. We relate the pathophysiology of the different grades of tendinopathy to the basic science principles that underpin the mechanisms of action of the nonoperative treatments available to propose a treatment algorithm guiding the management of lateral elbow tendinopathy depending on severity. We believe that this system will be useful both in clinical practice and for the future investigation of the efficacy of treatments. PMID:27833925
Chan, Otto; Morton, Sarah; Pritchard, Mel; Parkes, Tina; Malliaras, Peter; Crisp, Tom; Padhiar, Nat; Maffulli, Nicola; King, John; Morrissey, Dylan
Summary Background: Achillodynia is common and includes Achilles tendinopathy, partial Achilles tears and Achilles tendon ruptures. However, we believe an additional pathology should be considered for Achillodynia differentials – the intratendinous tear (ITT). Methods: Examinations of 740 achillodynic patients in one specialist centre were reviewed. ITTs were defined as a clearly visualised echopoor area situated centrally and extending to, but not through the tendon periphery, with pain on palpation and no clinical findings consistent with Achilles rupture. Descriptive statistics were used to analyse differences between pathological sub-groups, and images described qualitatively. Results: 5% (29 males, 8 females) of 740 patients had an ITT. Patients typically presented with a history of sudden onset localised pain and the ability to train but not reach maximal loading. Average age was 36.3 years (range 20–64), significantly lower than mid-tendon tendinopathy (8.48 years; p<0.01). 92% had concurrent Achilles tendinopathy. Elite sportspeople were more highly represented in the ITT than mid-tendon tendi nopathy groups (86.2% ITT group vs 13.8% mid-tendon AT group; p<0.01). Conclusions: ITTs should be actively searched for in patients with Achilles pathology, especially in elite male athletes with a history of high-impact pain. Prospective research is warranted concerning diagnosis and management. Level of evidence: IV. PMID:28717612
Marques, Anna Cristina de Farias; Albertini, Regiane; Serra, Andrey Jorge; da Silva, Evela Aparecida Pereira; de Oliveira, Vanessa Lima Cavalcante; Silva, Luciana Miatto; Leal-Junior, Ernesto Cesar Pinto; de Carvalho, Paulo de Tarso Camillo
This study investigates the effect of photobiomodulation therapy (PBMT) on collagen type I and III, matrix metalloproteinase (MMP), and vascular endothelial growth factor (VEGF) in experimentally induced tendinopathy in female aged rats. Tendinopathy was induced by the Achilles tendoncollagenase peritendinous. Forty-two Wistar rats (Norvegicus albinus) were used; groups consisted of 36 aged animals (18 months old; mean body weight, 517.7 ± 27.54 g) and 6 adult animals (12 weeks old; mean body weight, 266± 19.30 g). The animals were divided into three groups: control, aged tendinopathy, and aged tendinopathy PBMT; the aged groups were subdivided based on time to euthanasia: 7, 14, and 21 days. PBMT involved a gallium-arsenide-aluminum laser (Theralaser, DMC®) with active medium operating at wavelength 830 ± 10 nm, 50 mW power, 0.028 cm(2) laser beam, 107 J/cm(2) energy density, 1.8 W/cm(2) power density, and an energy of 3 J per point. The laser was applied by direct contact with the left Achilles tendon during 60 s per point at a frequency of three times per week, until the euthanasia date (7, 14, and 21 days). VEGF, MMP-3, and MMP-9 were analyzed by immunohistochemistry, and collagen type I and III by Sirius red. PBMT increased the deposition of collagen type I and III in a gradual manner, with significant differences relative to the group aged tendonitis (p < 0.001), and in relation to VEGF (p < 0.001); decreased expression of MMP-3 and 9 were observed in group aged tendinopathy (p < 0.001). PBMT, therefore, increased the production of collagen type I and III, downregulated the expression of MMP-3 and MMP-9, and upregulated that of VEGF, with age and age-induced hormonal deficiency.
Witt, Bryan L; Hyer, Christopher F
Achilles tendinopathy is a clinical diagnosis characterized as a triad of symptoms including pain, swelling, and impaired performance of the diseased tendon. Achilles tendinopathy is divided into Achilles tendonitis and tendinosis based on histopathological examination. Achilles tendinosis is viewed microscopically as disorganized collagen, abnormal neovascularization, necrosis, and mucoid degeneration. Insertional Achilles tendinosis is a degenerative process of the tendon at the junction of the tendon and calcaneus. This disease is initially treated conservatively with activity modification, custom orthotic devices, heel lifts, and immobilization. After 3 to 6 months of conservative therapy has failed to alleviate symptoms, surgical management is indicated. Surgical management of insertional Achilles tendinosis includes Achilles tendon debridement, calcaneal exostosis ostectomy, and retrocalcaneal bursa excision. In this case series, we present 4 patients who underwent surgical management of insertional Achilles tendinosis with complete tendon detachment. All patients underwent reattachment of the Achilles tendon with the suture bridge technique. The Arthrex SutureBridge(®) (Arthrex, Inc., Naples, FL) device uses a series of 4 suture anchors and FiberWire(®) (Arthrex Inc.) to reattach the Achilles tendon to its calcaneal insertion. This hourglass pattern of FiberWire(®) provides a greater area of tendon compression, consequently allowing greater stability and possible earlier return to weightbearing activities. The patients were followed up for approximately 2 years' duration. There were no intraoperative or postoperative complications. At final follow-up there was no evidence of Achilles tendon ruptures or device failures. All patients were able to return to their activities of daily living without the use of assistive devices. The patients' average visual analog pain scale was 1 (range 0 to 4), and their average foot functional index score was 3.41 (range 0
Maffulli, Nicola; Spiezia, Filippo; Testa, Vittorino; Capasso, Giovanni; Longo, Umile Giuseppe; Denaro, Vincenzo
Chronic tears of the Achilles tendon with a tendon gap exceeding 6 cm are a surgical challenge. The purpose of this study is to report the long-term results of reconstruction of such chronic Achilles tendon ruptures with use of a free autologous gracilis tendon graft. Twenty-one patients underwent reconstruction of a chronic rupture of the Achilles tendon. Fifteen patients were available for clinical and functional assessment on the basis of anthropometric measurements, isometric strength testing, and the Achilles Tendon Total Rupture Score after a mean duration of follow-up of 10.9 years (range, eight to twelve years). All fifteen patients were able to walk on the tiptoes, and no patient used a heel lift or walked with a visible limp. At an average of 10.9 years of follow-up, the maximum calf circumference of the operatively treated leg remained substantially decreased and the operatively treated limb was significantly weaker than the contralateral, normal limb. Two patients had developed tendinopathy of the contralateral Achilles tendon, one had developed tendinopathy of the reconstructed tendon, and one had ruptured the contralateral Achilles tendon eight years after the index tear. The long-term results of treatment of chronic tears of the Achilles tendon with free gracilis tendon grafting showed that patients retained good functional results despite permanently impaired ankle plantar flexion strength and decreased calf circumference.
Kaux, Jean-François; Forthomme, Bénédicte; Goff, Caroline Le; Crielaard, Jean-Michel; Croisier, Jean-Louis
Tendinopathy is characterized by pain in the tendon and impaired performance sometimes associated with swelling of the tendon. Its diagnosis is usually clinical but ultrasonography and magnetic resonance imaging can refine the diagnosis. Tendinopathy is highly prevalent and is one of the most frequently self reported musculoskeletal diseases in physical workers and sports people. Nevertheless, it is very difficult to carry out general epidemiologic studies on tendinopathy because of the varying sports cultures and sports habits in different countries. The aetiology of tendinopathy seems to be multi-factorial, involving intrinsic and extrinsic factors. The role of inflammation is still debated but the absence of inflammatory cells does not mean that inflammatory mediators are not implicated. Different theories have been advanced to explain pain and chronicity mechanisms, but these mechanisms remain largely unknown. “Conventional ”treatments are generally employed empirically to fight pain and inflammation but they do not modify the histological structure of the tendon. However, these treatments are not completely satisfactory and the recurrence of symptoms is common. Currently, eccentric training remains the treatment of choice for tendinopathy, even though some studies are contradictory. Moreover, many interesting new treatments are now being developed to treat tendinopathy, but there is little evidence to support their use in clinical practice. Key points The word “tendinopathy ”is the correct term for the clinical diagnosis of pain accompanied by impaired performance, and sometimes swelling in the tendon. The aetiology of tendinopathy seems to be a multi-factorial process, involving promoting factors that are intrinsic or extrinsic, working either alone or in combination. US (with color Doppler) and MRI are usually prescribed when tendinopathy is unresponsive to treatment and entails lingering symptoms. Eccentric training is currently considered to be the
Best, Thomas M; Moore, Bob; Jarit, Paddy; Moorman, Claude T; Lewis, George K
The effectiveness of sustained acoustic medicine to alleviate pain and improve function in subjects with elbow or Achilles tendinopathy was evaluated through a level IV case series study. Subjects were trained to self-apply the wearable, long-duration, low-intensity ultrasonic device on their affected body part at home for 4 hours a day, at least 5 times per week over 6 weeks. Twenty-five subjects with clinician-diagnosed tendinopathy of the elbow (medial or lateral epicondyle) or Achilles tendon were enrolled. Pain measurements were recorded before, during, and after daily intervention using an 11-point numeric rating scale (NRS). Function of the injured limb was assessed biweekly using dynamometry. Repeated measures ANOVAs and paired-samples t-tests were used to examine the effect of treatment over time. Among subjects with elbow tendinopathy (n = 20), a 3.94 ± 2.15 point reduction in pain (p = 0.002) was observed over the 6-week study and a 2.83 ± 5.52 kg improvement in grip strength (p = 0.04) was observed over the first two weeks. In addition, a significant reduction in pain was observed within the 4-h treatment sessions (p < 0.001). Among 5 subjects with Achilles tendinopathy, a reduction in pain and improvement in strength was also observed. Daily multi-hour ultrasonic therapy was associated with improved pain and increased function in subjects with chronic tendon injuries. This trial showed the safety and feasibility of self-administration of sustained acoustic medicine, and suggests that this therapy may be clinically beneficial in the treatment of tendinopathies of the elbow and Achilles tendon. A randomized controlled trial appears warranted to more definitively investigate the therapeutic potential of this treatment modality. Registered at www.ClinicalTrials.gov, NCT02466308.
Tumilty, Steve; Munn, Joanne; David Baxter, G.; McDonough, Suzanne; Hurley, Deirdre A.; Basford, Jeffrey R.
Background: Low Level Laser Therapy (LLLT) is used in the treatment of tendon injuries. However, the clinical effectiveness of this modality remains controversial with limited agreement on the most efficacious dosage and parameter choices. Purpose: To assess the clinical effectiveness of LLLT in the treatment of tendinopathy and the validity of current dosage recommendations for treatment. Method: Medical databases were searched from inception to 1st August 2008. Controlled clinical trials evaluating LLLT as a primary intervention for any tendinopathy were included in the review. Methodological quality was classified using the PEDro scale. Appropriateness of treatment parameters were assessed using established guidelines. Results: Twenty five trials met the inclusion criteria. There was conflicting findings from multiple trials: 12 showed positive effects and 13 were inconclusive or showed no effect. Dosages used in the 12 positive studies support the existence of an effective dosage window that closely resembled current guidelines. Where pooling of data was possible, LLLT showed a positive effect size; in high quality studies of lateral epicondylitis, participants' grip strength was 9.59 Kg higher than the control group; for participants with Achilles tendinopathy, the effect was 13.6 mm less pain on a 100 mm visual analogue scale. Conclusion: This study found conflicting evidence as to the effectiveness of LLLT in the treatment of tendinopathy. However, an effective dosage window emerged showing benefit in the treatment of tendinopathy. Strong evidence exists from the 12 positive studies that positive outcomes are associated with the use of current dosage recommendations for the treatment of tendinopathy.
Tumilty, Steve; Munn, Joanne; McDonough, Suzanne; Hurley, Deirdre A.; Basford, Jeffrey R.; David Baxter, G.
Background: Low Level Laser Therapy (LLLT) is used in the treatment of tendon injuries. However, the clinical effectiveness of this modality remains controversial with limited agreement on the most efficacious dosage and parameter choices. Purpose: To assess the clinical effectiveness of LLLT in the treatment of tendinopathy and the validity of current dosage recommendations for treatment. Method: Medical databases were searched from inception to 1st August 2008. Controlled clinical trials evaluating LLLT as a primary intervention for any tendinopathy were included in the review. Methodological quality was classified using the PEDro scale. Appropriateness of treatment parameters were assessed using established guidelines. Results: Twenty five trials met the inclusion criteria. There was conflicting findings from multiple trials: 12 showed positive effects and 13 were inconclusive or showed no effect. Dosages used in the 12 positive studies support the existence of an effective dosage window that closely resembled current guidelines. Where pooling of data was possible, LLLT showed a positive effect size; in high quality studies of lateral epicondylitis, participants' grip strength was 9.59 Kg higher than the control group; for participants with Achilles tendinopathy, the effect was 13.6 mm less pain on a 100 mm visual analogue scale. Conclusion: This study found conflicting evidence as to the effectiveness of LLLT in the treatment of tendinopathy. However, an effective dosage window emerged showing benefit in the treatment of tendinopathy. Strong evidence exists from the 12 positive studies that positive outcomes are associated with the use of current dosage recommendations for the treatment of tendinopathy.
Joseph, Michael F; Lillie, Kurtis R; Bergeron, Daniel J; Cota, Kevin C; Yoon, Joseph S; Kraemer, William J; Denegar, Craig R
Achilles tendinopathy is a common disorder and is more prevalent in men. Although differences in tendon mechanics between men and women have been reported, understanding of tendon mechanics in young active people is limited. Moreover, there is limited understanding of changes in tendon mechanics in response to acute exercise. Our purpose was to compare Achilles tendon mechanics in active young adult men and women at rest and after light and strenuous activity in the form of repeated jumping with an added load. Participants consisted of 17 men and 14 women (18-30 years) who were classified as being at least moderately physically active as defined by the International Physical Activity Questionnaire. Tendon force/elongation measures were obtained during an isometric plantarflexion contraction on an isokinetic dynamometer with simultaneous ultrasound imaging of the Achilles tendon approximate to the soleus myotendinous junction. Data were collected at rest, after a 10-minute treadmill walk, and after a fatigue protocol of 100 toe jumps performed in a Smith machine, with a load equaling 20% of body mass. We found greater tendon elongation, decreased stiffness, and lower Young's modulus only in women after the jumping exercise. Force and stress were not different between groups but decreased subsequent to the jumping exercise bout. In general, women had greater elongation and strain, less stiffness, and a lower Young's modulus during plantarflexor contraction. These data demonstrate differences in tendon mechanics between men and women and suggest a potential protective mechanism explaining the lower incidence of Achilles tendinopathy in women.
Lui, Tun Hing
Chronic tendinopathy is characterized by pain in the tendon, generally at the start and completion of exercise. However, tendinosis may lead to decreased blood flow, increased stiffness of the tendon and reduced tensile strength, and predispose to rupture. Operative treatment is indicated to restore the function of the Achilles tendon and alleviate the prerupture heel cord pain. A case of acute Achilles tendon rupture with extensive tendinosis that was successfully treated with minimally invasive flexor hallucis longus transfer is reported.
Kirchgesner, Thomas; Larbi, Ahmed; Omoumi, Patrick; Malghem, Jacques; Zamali, Nadia; Manelfe, Julien; Lecouvet, Frédéric; Vande Berg, Bruno; Djebbar, Sahlya; Dallaudière, Benjamin
Drug-induced tendon toxicity is rare but often underestimated. To date, four main drug classes have been incriminated in tendinopathies. Quinolones and long-term glucocorticoids are the most widely known, but statins and aromatase inhibitors can also induce tendon damage. The specific pathophysiological mechanisms responsible for drug-induced tendinopathies remain unknown. Proven risk factors have been identified, such as age older than 60 years, pre-existing tendinopathy, and potentiation of toxic effects when several drug classes are used in combination. Mean time to symptom onset varies from a few days with quinolones to several months with statins and several years for long-term glucocorticoid therapy. The most common sites of involvement are the lower limb tendons, most notably the body of the Achilles tendon. The first part of this review discusses tendon anatomy and the pathophysiology and radiological manifestations of tendinopathies. The second part provides details on the main characteristics of each of the drugs classes associated with tendon toxicity.
Albers, Iris Sophie; Zwerver, Johannes; Diercks, Ronald Leo; Dekker, Janny Hendrika; Van den Akker-Scheek, Inge
Lower extremity tendinopathy is a common sports injury, but it can also affect non-athletes. Because tendinopathy is difficult to treat and has negative effects on the ability to work and quality of life, development of preventive interventions is important. The first step in the Van Mechelen prevention model is to determine the extent of the problem. The primary aim of this study was to determine the incidence and prevalence of lower extremity tendinopathy in a Dutch general practice population. The secondary aim was to investigate possible associated factors. A cross-sectional study was performed in a Dutch general practice. Using International Classification of Primary Care codes, the electronic patient files were searched to identify cases of adductor tendinopathy, greater trochanteric pain syndrome, jumper's knee, Achilles tendinopathy, and plantar fasciopathy in 2012. The tendinopathy patients were compared to the general practice population regarding age, gender, use of medication, and comorbidity using 95% confidence intervals. The prevalence and incidence rates of lower extremity tendinopathy found in this study were 11.83 and 10.52 per 1000 person-years. Lower extremity tendinopathy was more prevalent among older patients. No differences between tendinopathy patients and the general practice population were found regarding gender, use of medication, or comorbidity. In this cross-sectional study in a Dutch general practice, the prevalence and incidence rates of lower extremity tendinopathy were 11.83 and 10.52 per 1000 person-years. Lower extremity tendinopathy deserves a higher place in locomotor system research to develop preventive interventions.
Strom, Adam C; Casillas, Mark M
The operative management of acute Achilles tendon rupture marks the beginning of a comprehensive rehabilitation program. The goals of the rehabilitation program start with the reduction of pain and swelling and the recovery of ankle motion and power. They conclude with the restoration of coordinated activity and safe return to athletic activity. The rehabilitation protocol is directed by the injury and the quality of the repair, along with the patient's age, medical and social history, and athletic inclination. The protocol is dynamic and responsive to changing clinical findings.
CASTRO, Adham do Amaral e; SKARE, Thelma Larocca; NASSIF, Paulo Afonso Nunes; SAKUMA, Alexandre Kaue; BARROS, Wagner Haese
ABSTRACT Introduction: Tendinopathies and tendon tears account for over 30% of all musculoskeletal consultations. Obesity, which is becoming one of the world´s most prevalent public health issues, may be associated with this condition. Objective: To review the literature about tendinopathies and obesity association. Methods: This is a descriptive exploratory study using the portal Medline. Literature in English language from 2006 to 2014 were reviewed. Results: The pathogenesis of tendinopathies includes inflammatory, regenerative and degenerative processes that happen simultaneously from early to late phases of the disease. Mechanical stress upon tendons seems to be one of the most important factors to initiate the inflammatory response, but it´s not the only one that can deflagrate it: there are other extrinsic, genetic and metabolic factors that may be involved. Therefore, tendinopathies in obese patients can be due to tendon overload because of the excess of weight, but also because of increased production of pro-inflammatory mediators related to fat tissue such as adipokines. This pro-inflammatory state that obese people can suffer is known as adiposopathy, or sick fat syndrome. Weight loss is associated with decrease in adipokines and improvement of musculoskeletal symptoms. Conclusion: The relation of obesity and tendinopathies is supported by evidences of recent studies, exemplified in this review of literature. PMID:27683789
A 72-year-old female dialysis patient with insulin-dependent diabetes mellitus who was under long-term medication with oral prednisolone due to chronic obstructive pulmonary disease was given levofloxacin for one week to treat an acute bronchitis (one 500 mg dose on the first day, 125 mg/day orally from second day onwards). One day after the end of levofloxacin treatment, the patient complained about a constant dragging pain above the right heel that receded under local application of diclofenac ointment and inactivity of the right foot. Twelve days after ending administration of levofloxacin, strong pains in the right calf were suddenly felt during normal walking, and active plantar flexion was lost. Palpation showed the right calf to be soft; a distinct gap was found in the middle third of the Achilles tendon. The Thompson test was positive, and the patient was unable to stand on her right toes. Ultrasonography showed a discontinuity of the right Achilles tendon. A spontaneous Achilles tendon rupture after taking fluoroquinolone was diagnosed. Conservative treatment was applied due to the reduced general condition. Initial treatment involved a below-knee plaster cast in equinus position; the cast was replaced on the fourth day by a pneumatic walker, which was also worn during mobilisation by physiotherapy. A typical feature of fluoroquinolone-induced tendinopathy (FIT) is a considerable latency period in some cases between the commencement of treatment with a fluoroquinolone and the onset of FIT symptoms. In addition to fluoroquinolone intake, there are three other predisposing risk factors for tendinopathy: age over 60 years, long-term treatment with systemic glucocorticoids, and chronic kidney disease. The patient showed a combination of all the aforementioned risk factors. In patients with these risk factors, especially among people with a combination of said risk factors - which is frequently the case with nephrologic and dialysis patients, especially
Revak, Andrew; Diers, Keith; Kernozek, Thomas W; Gheidi, Naghmeh; Olbrantz, Christina
Achilles tendinopathies are common injuries during sport participation, although men are more prone to Achilles tendon injuries than women. Heel-raising and -lowering exercises are typically suggested for Achilles tendon rehabilitation. To compare the estimated Achilles tendon loading variables and the ankle range of motion (ROM) using a musculoskeletal model during commonly performed heel-raising and -lowering exercises. Controlled laboratory study. University biomechanics laboratory. Twenty-one healthy men (age = 21.59 ± 1.92 years, height = 178.22 ± 8.02 cm, mass = 75.81 ± 11.24 kg). Each participant completed 4 exercises: seated heel raising and lowering, bilateral standing heel raising and lowering, bilateral heel raising and unilateral lowering, and unilateral heel raising and lowering. A repeated-measures multivariate analysis of variance (α = .05) was used to compare Achilles tendon stress, force, and strain and ankle ROM for each exercise. Kinematic data were recorded at 180 Hz with 15 motion-analysis cameras synchronized with kinetic data collected from a force platform sampled at 1800 Hz. These data were then entered in a musculoskeletal model to estimate force in the triceps surae. For each participant, we determined Achilles tendon stress by measuring cross-sectional images using ultrasound. Peak Achilles tendon loading was lowest when performing the seated heel-raising and -lowering exercise and highest when performing the unilateral heel-raising and -lowering exercise. Loading was greater for the unilateral exercise or portions of the exercise that were performed unilaterally. Bilateral and seated exercises with less weight-bearing force resulted in less Achilles tendon loading. These exercises may serve as progressions during the rehabilitation process before full-body weight-bearing, unilateral exercises are allowed. Ankle ROM did not follow the same order as loading and may need additional monitoring or instruction during rehabilitation.
Wu, Yen-Ting; Wu, Po-Ting; Jou, I-Ming
The purpose of this study was to investigate the role of elastase on tendinopathy, as well as to evaluate the potential for peritendinous injections of elastase into rats to cause tendinopathy. We first investigated the expression of elastase in the tendons of patients with tendinopathy, and then established the effects of elastase injection on the Achilles tendons of rats. Ultrasonographic and incapacitance testing was used to conduct tests for 8 weeks. Tendon tissues were collected for histological observation and protein levels of collagen type I and type III were detected using Western blotting. The percentage of elastase-positive cells increased in human specimens with grades II and III tendinopathy. The rat model demonstrated that the thickness of the tendon increased after elastase injection during Week 2-8. Hypercellularity and focal lesions were detected after Week 2. The expression of elastase was increased and elastin was decreased in Week 8. Collagen type I expression was decreased, but type III was increased in Week 4. These results suggested that elastase may be involved in the development of chronic tendinopathy, and that peritendinous injection of elastase may result in tendinopathy in rats. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.
Wearing, Scott C; Reed, Lloyd; Hooper, Sue L; Bartold, Simon; Smeathers, James E; Brauner, Torsten
Footwear remains a prime candidate for the prevention and rehabilitation of Achilles tendinopathy because it is thought to decrease tension in the tendon through elevation of the heel. However, evidence for this effect is equivocal. This study used an acoustic transmission technique to investigate the effect of running shoes on Achilles tendon loading during barefoot and shod walking. Acoustic velocity was measured in the Achilles tendon of 12 recreationally active males (age, 31 ± 9 yr; height, 1.78 ± 0.06 m; weight, 81.0 ± 16.9 kg) during barefoot and shod walking at matched self-selected speed (3.4 ± 0.7 km·h). Standard running shoes incorporating a 10-mm heel offset were used. Vertical ground reaction force and spatiotemporal parameters were determined with an instrumented treadmill. Axial acoustic velocity in the Achilles tendon was measured using a custom-built ultrasonic device. All data were acquired at a rate of 100 Hz during 10 s of steady-state walking. Statistical comparisons between barefoot and shod conditions were made using paired t-tests and repeated-measure ANOVA. Acoustic velocity in the Achilles tendon was highly reproducible and was typified by two maxima (P1, P2) and minima (M1, M2) during walking. Footwear resulted in a significant increase in step length, stance duration, and peak vertical ground reaction force compared with barefoot walking. Peak acoustic velocity in the Achilles tendon (P1, P2) was significantly higher with running shoes. Peak acoustic velocity in the Achilles tendon was higher with footwear, suggesting that standard running shoes with a 10-mm heel offset increase tensile load in the Achilles tendon. Although further research is required, these findings question the therapeutic role of standard running shoes in Achilles tendinopathy.
Lui, Tun Hing
The causes of heel cord pain after repair of acute rupture of the Achilles tendon are unclear. The proposed etiologies include nonabsorbable suture granuloma formation, alteration of the pain receptors threshold in the tendon, and distension of the paratenon by the hypertrophied tendon, underlying tendinopathy, postrepair neovascularization, and peritendinous fibrous adhesion. We present an endoscopic technique of adhesiolysis of the Achilles tendon to deal with the various possible causes of postrepair heel cord pain. Therapeutic, Level 4: Case report. © 2015 The Author(s).
Kaux, Jean-François; Drion, Pierre; Croisier, Jean-Louis; Crielaard, Jean-Michel
Objectives: The restorative properties of platelets, through the local release of growth factors, are used in various medical areas. This article reviews fundamental and clinical research relating to platelet-rich plasma applied to tendinous lesions. Materials and method: Articles in French and English, published between 1 January 2012 and 31 December 2014. dealing with PRP and tendons were searched for using the Medline and Scopus data bases. Results: Forty-seven articles were identified which addressed pre-clinical and clinical studies: 27 relating to in vitro and in vivo animal studies and 20 relating to human studies. Of these, five addressed lateral epicondylitis, two addressed rotator cuff tendinopathies, ten dealt with patellar tendinopathies and three looked at Achilles tendinopathies. Conclusions: The majority of pre-clinical studies show that PRP stimulates the tendon’s healing process. However, clinical series remain more controversial and level 1, controlled, randomised studies are still needed. PMID:26195890
Salles, José Inácio; Amaral, Marcus Vinícius; Aguiar, Diego Pinheiro; Lira, Daisy Anne; Quinelato, Valquiria; Bonato, Letícia Ladeira; Duarte, Maria Eugenia Leite; Vieira, Alexandre Rezende; Casado, Priscila Ladeira
To investigate whether genetic variants can be correlated with tendinopathy in elite male volleyball athletes. Case-control study. Fifteen single nucleotide polymorphisms within BMP4, FGF3, FGF10, FGFR1 genes were investigated in 138 elite volleyball athletes, aged between 18 and 35 years, who undergo 4-5h of training per day: 52 with tendinopathy and 86 with no history of pain suggestive of tendinopathy in patellar, Achilles, shoulder, and hip abductors tendons. The clinical diagnostic criterion was progressive pain during training, confirmed by magnetic resonance image. Genomic DNA was obtained from saliva samples. Genetic markers were genotyped using TaqMan real-time PCR. Chi-square test compared genotypes and haplotype differences between groups. Multivariate logistic regression analyzed the significance of covariates and incidence of tendinopathy. Statistical analysis revealed participant age (p=0.005) and years of practice (p=0.004) were risk factors for tendinopathy. A significant association between BMP4 rs2761884 (p=0.03) and tendinopathy was observed. Athletes with a polymorphic genotype have 2.4 times more susceptibility to tendinopathy (OR=2.39; 95%CI=1.10-5.19). Also, association between disease and haplotype TTGGA in BMP4 (p=0.01) was observed. The FGF3 TGGTA haplotype showed a tendency of association with tendinopathy (p=0.05), and so did FGF10 rs900379. FGFR1 showed no association with disease. These findings indicate that haplotypes in BMP4 and FGF3 genes may contribute to the tendon disease process in elite volleyball athletes. Copyright © 2014 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.
Mallows, Adrian; Debenham, James; Walker, Tom; Littlewood, Chris
Fear, anxiety, depression, distress and catastrophisation are all factors known to affect pain and disability levels. To date, the association of such psychological factors has yet to be established in tendinopathy. Therefore, the purpose of this paper was to determine if psychological variables are associated with tendinopathy and whether any such variables may be associated with pain and disability outcomes in conservative management of tendinopathy. A systematic review was undertaken and included studies were appraised for risk of bias using the Newcastle-Ottawa Scale. Owing to heterogeneity of studies, a qualitative synthesis was undertaken. An electronic search of MEDLINE, CiNAHL, SPORTDiscus, PsycINFO, EMBASE and PsycARTICLES was undertaken from their inception to April 2016. Any study design that incorporated psychological measures and clinical outcomes using participants with tendinopathy. Ten articles describing nine studies and 1108 participants were included. Conflicting evidence exists regarding the association of anxiety, depression and lateral epicondylalgia (LE). Strong evidence suggests LE is not associated with kinesiophobia. Moderate evidence links catastrophisation and distress with LE. Moderate evidence suggests distress is not associated with rotator cuff tendinopathy, but kinesiophobia and catastrophisation are. Limited evidence suggests patellar tendinopathy is not associated with anxiety or depression and kinesiophobia may be linked with suboptimal outcomes in Achilles tendinopathy. Tendinopathy requires an individualised approach to management. Clinicians should consider using validated screening tools for the presence of psychological variables as a part of their holistic management. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.
Bjordal, Jan M.; Iversen, Vegard; Lopes-Martins, Rodrigo Alvaro B.
Objective: Low level laser therapy (LLLT) has been forwarded as therapy for osteoarthritis and tendinopathy. Results in animal and cell studies suggest that LLLT may act through a biological mechanism of inflammatory modulation. The current study was designed to investigate if LLLT has an anti-inflammatory effect on activated tendinitis of the Achilles tendon. Methods: Seven patients with bilateral Achilles tendonitis (14 tendons) who had aggravated symptoms by pain-inducing activity immediately prior to the study. LLLT (1.8 Joules for each of three points along the Achilles tendon with 904nm infrared laser) and placebo LLLT were administered to either Achilles tendons in a random order to which patients and therapist were blinded. Inflammation was examined by 1) mini-invasive microdialysis for measuring the concentration of inflammatory marker PGE II in the peritendinous tissue, 2) ultrasound with Doppler measurement of peri- and intratendinous blood flow, 3) pressure pain algometry and 4) single hop test. Results: PGE 2- levels were significantly reduced at 75, 90 and 105 minutes after active LLLT compared both to pre-treatment levels (p=0.026) and to placebo LLLT (p=0.009). Changes in pressure pain threshold (PPT) were significantly different (P=0.012) between groups. PPT increased by a mean value of 0.19 kg/cm2 [95%CI:0.04 to 0.34] after treatment in the active LLLT group, while pressure pain threshold was reduced by -0.20 kg/cm2 [95%CI:-0.45 to 0.05] after placebo LLLT. Conclusion: LLLT can be used to reduce inflammatory musculskeletal pain as it reduces inflammation and increases pressure pain threshold levels in activity-induced pain episodes of Achilles tendinopathy.
Viganò, Marco; Stanco, Deborah; Bottagisio, Marta; Di Giancamillo, Alessia; Setti, Stefania; de Girolamo, Laura
Tendinopathy is a big burden in clinics and it represents 45% of musculoskeletal lesions. Despite the relevant social impact, both pathogenesis and development of the tendinopathy are still under-investigated, thus limiting the therapeutic advancement in this field. The purpose of this study was to evaluate the dose-dependent and time-related tissue-level changes occurring in a collagenase-induced tendinopathy in rat Achilles tendons, in order to establish a standardized model for future pre-clinical studies. With this purpose, 40 Sprague Dawley rats were randomly divided into two groups, treated by injecting collagenase type I within the Achilles tendon at 1 mg/mL (low dose) or 3 mg/mL (high dose). Tendon explants were histologically evaluated at 3, 7, 15, 30 and 45 days. Our results revealed that both the collagenase doses induced a disorganization of collagen fibers and increased the number of rounded resident cells. In particular, the high dose treatment determined a greater neovascularization and fatty degeneration with respect to the lower dose. These changes were found to be time-dependent and to resemble the features of human tendinopathy. Indeed, in our series, the acute phase occurred from day 3 to day 15, and then progressed towards the proliferative phase from day 30 to day 45 displaying a degenerative appearance associated with a very precocious and mild remodeling process. The model represents a good balance between similarity with histological features of human tendinopathy and feasibility, in terms of tendon size to create lesions and costs when compared to other animal models. Moreover, this model could contribute to improve the knowledge in this field, and it could be useful to properly design further pre-clinical studies to test innovative treatments for tendinopathy. PMID:27548063
Perucca Orfei, Carlotta; Lovati, Arianna B; Viganò, Marco; Stanco, Deborah; Bottagisio, Marta; Di Giancamillo, Alessia; Setti, Stefania; de Girolamo, Laura
Tendinopathy is a big burden in clinics and it represents 45% of musculoskeletal lesions. Despite the relevant social impact, both pathogenesis and development of the tendinopathy are still under-investigated, thus limiting the therapeutic advancement in this field. The purpose of this study was to evaluate the dose-dependent and time-related tissue-level changes occurring in a collagenase-induced tendinopathy in rat Achilles tendons, in order to establish a standardized model for future pre-clinical studies. With this purpose, 40 Sprague Dawley rats were randomly divided into two groups, treated by injecting collagenase type I within the Achilles tendon at 1 mg/mL (low dose) or 3 mg/mL (high dose). Tendon explants were histologically evaluated at 3, 7, 15, 30 and 45 days. Our results revealed that both the collagenase doses induced a disorganization of collagen fibers and increased the number of rounded resident cells. In particular, the high dose treatment determined a greater neovascularization and fatty degeneration with respect to the lower dose. These changes were found to be time-dependent and to resemble the features of human tendinopathy. Indeed, in our series, the acute phase occurred from day 3 to day 15, and then progressed towards the proliferative phase from day 30 to day 45 displaying a degenerative appearance associated with a very precocious and mild remodeling process. The model represents a good balance between similarity with histological features of human tendinopathy and feasibility, in terms of tendon size to create lesions and costs when compared to other animal models. Moreover, this model could contribute to improve the knowledge in this field, and it could be useful to properly design further pre-clinical studies to test innovative treatments for tendinopathy.
Ackermann, Paul W.; Renström, Per
Context: Tendinopathy is increasing in prevalence and accounts for a substantial part of all sports injuries and occupational disorders. Despite the magnitude of the disorder, high-quality scientific data on etiology and available treatments have been limited. Evidence Acquisition: The authors conducted a MEDLINE search on tendinopathy, or “tendonitis” or “tendinosis” or “epicondylitis” or “jumpers knee” from 1980 to 2011. The emphasis was placed on updates on epidemiology, etiology, and recent patient-oriented Level 1 literature. Results: Repetitive exposure in combination with recently discovered intrinsic factors, such as genetic variants of matrix proteins, and metabolic disorders is a risk factor for the development of tendinopathy. Recent findings demonstrate that tendinosis is characterized by a fibrotic, failed healing response associated with pathological vessel and sensory nerve ingrowth. This aberrant sensory nerve sprouting may partly explain increased pain signaling and partly, by release of neuronal mediators, contribute to the fibrotic alterations observed in tendinopathy. The initial nonoperative treatment should involve eccentric exercise, which should be the cornerstone (basis) of treatment of tendinopathy. Eccentric training combined with extracorporeal shockwave treatment has in some reports shown higher success rates compared to any therapies alone. Injection therapies (cortisone, sclerosing agents, blood products including platelet-rich plasma) may have short-term effects but have no proven long-term treatment effects or meta-analyses to support them. For epicondylitis, cortisone injections have demonstrated poorer long-time results than conservative physiotherapy. Today surgery is less indicated because of successful conservative therapies. New minioperative procedures that, via the endoscope, remove pathologic tissue or abnormal neoinnervation demonstrate promising results but need confirmation by Level 1 studies. Conclusions
Elias, David A; Carne, Andrew; Bethapudi, Sarath; Engebretsen, Lars; Budgett, Richard; O'Connor, Philip
Plantar fascia and distal Achilles injuries are common in elite athletes. Acute athletic injuries of the plantar fascia include acute plantar fasciopathy and partial or complete tears. Underlying most acute injuries is a background of underlying chronic plantar fasciopathy. Injuries may affect the central or less commonly lateral portions of the fascia and acute tears are generally proximal. Athletic Achilles injuries may occur at the mid tendon or the distal insertion, and there may be an underlying chronic tendinopathy. Acute or chronic paratendinopathy may occur as a separate entity or combined with Achilles injury. In this article, the spectrum of athletic injuries of the plantar fascia and Achilles is described, illustrated by imaging findings from the London 2012 Olympic games.
Ellison, Philip; Mason, Lyndon William; Molloy, Andrew
Chronic rupture of the Achilles tendon (delayed diagnosis of more than 4 weeks) can result in retraction of the tendon and inadequate healing. Direct repair may not be possible and augmentation methods are challenging when the defect exceeds 5-6 cm, especially if the distal stump is grossly tendinopathic. We describe our method of Achilles tendon reconstruction with ipsilateral semitendinosis autograft and interference screw fixation in a patient with chronic rupture, a 9 cm defect and gross distal tendinopathy. Patient reported outcome measures consistently demonstrated improved health status at 12 months post surgery: MOXFQ-Index 38-25, EQ5D-5L 18-9, EQ VAS 70-90 and VISA-A 1-64. The patient was back to full daily function, could single leg heel raise and was gradually returning to sport. No complications or adverse events were recorded. Reconstruction of chronic tears of the Achilles tendon with large defects and gross tendinopathy using an ipsilateral semitendinosis autograft and interference screw fixation can achieve satisfactory improvements in patient reported outcomes up to 1 year post-surgery. Copyright © 2015 Elsevier Ltd. All rights reserved.
Notarnicola, A; Maccagnano, G; Tafuri, S; Fiore, A; Margiotta, C; Pesce, V; Moretti, B
Extracorporeal shock wave therapy is very widely used for the management of tendinopathies and plantar fasciitis. The aim of the study is to determine whether there are prognostic factors that may influence the outcome of extracorporeal shock wave therapy for these diseases. Three hundred fifty-five patients were analyzed 2 months after shock wave treatment for rotator cuff tendinitis, epicondylitis, Achilles tendinopathy, trocanteritis, jumper's knee or plantar fasciitis. We recorded the epidemiological, clinical and treatment protocol, and these data were correlated with treatment outcome. Clinical improvement was achieved in 45.9 % of these patients. We discovered that laterality different to the dominant limb (p < 0.0001) and repeated shock wave treatments (p = 0.004) are prognostic factors in an unsuccessful therapy, while being male (p = 0.015) and a high body mass index (p = 0.004) are factors for success. We found no differences in relation to age, diet, blood type, work or sport activity, presence of co-morbidities, drugs, type of tendinopathy, density of energy delivered and other physiotherapy treatment. Knowledge of these prognostic factors may lead to improved insight for physicians and physiotherapists to predict the extent of the recovery and adjust rehabilitation and patient expectations accordingly.
Edama, Mutsuaki; Kubo, Masayoshi; Onishi, Hideaki; Takabayashi, Tomoya; Yokoyama, Erika; Inai, Takuma; Watanabe, Hiroshi; Nashimoto, Satoshi; Kageyama, Ikuo
Findings on the twisting structure and insertional location of the AT on the calcaneal tuberosity are inconsistent. Therefore, to obtain a better understanding of the mechanisms underlying insertional Achilles tendinopathy, clarification of the anatomy of the twisting structure and location of the AT insertion onto the calcaneal tuberosity is important. The purpose of this study was to reveal the twisted structure of the AT and the location of its insertion onto the calcaneal tuberosity using Japanese cadavers. The study was conducted using 132 legs from 74 cadavers (mean age at death, 78.3 ± 11.1 years; 87 sides from men, 45 from women). Only soleus (Sol) attached to the deep layer of the calcaneal tuberosity was classified as least twist (Type I), both the lateral head of the gastrocnemius (LG) and Sol attached to the deep layer of the calcaneal tuberosity were classified as moderate twist (Type II), and only LG attached to the deep layer of the calcaneal tuberosity was classified as extreme twist (Type III). The Achilles tendon insertion onto the calcaneal tuberosity was classified as a superior, middle or inferior facet. Twist structure was Type I (least) in 31 legs (24%), Type II (moderate) in 87 legs (67%), and Type III (extreme) in 12 legs (9%). A comparison between males and females revealed that among men, 20 legs (24%) were Type I, 57 legs (67%) Type II, and eight legs (9%) Type III. Among women, 11 legs (24%) were Type I, 30 legs (67%) Type II, and four legs (9%) Type III. No significant differences were apparent between sexes. The fascicles of the Achilles tendon attach mainly in the middle facet. Anterior fibers of the Achilles tendon, where insertional Achilles tendinopathy is most likely, are Sol in Type I, LG and Sol in Type II, and LG only in Type III. This suggests the possibility that a different strain is produced in the anterior fibers of the Achilles tendon (calcaneal side) where insertional Achilles tendinopathy is most likely to occur in
Maffulli, Nicola; Longo, Umile Giuseppe; Spiezia, Filippo; Denaro, Vincenzo
Minimally invasive trauma and orthopedic surgery is increasingly common, though technically demanding. Its use for pathologies of the Achilles tendon (AT) hold the promise to allow faster recovery times, shorter hospital stays, and improved functional outcomes when compared to traditional open procedures, which can lead to difficulty with wound healing because of the tenuous blood supply and increased chance of wound breakdown and infection. We present the recent advances in the field of minimally invasive AT surgery for tendinopathy, acute ruptures, chronic tears, and chronic avulsions of the AT. In our hands, minimally invasive surgery has provided similar results to those obtained with open surgery, with decreased perioperative morbidity, decreased duration of hospital stay, and reduced costs. So far, the studies on minimally invasive orthopedic techniques are of moderate scientific quality with short follow-up periods. Multicenter studies with longer follow-up are needed to justify the long-term advantages of these techniques over traditional ones. PMID:24198547
Yuan, Jun; Wang, Min-Xia; Murrell, George A C
Apoptosis and necrosis are presently recognized as the two major types of physiological and pathological cell death. Apoptosis is a tightly regulated cell deletion process that differs morphologically and biochemically from necrotic cell death. Tendinopathy is defined as a tendon injury that originates from intrinsic and extrinsic etiological factors. Excessive apoptosis has recently been described in degenerative tendon. The increased number of apoptotic tendon cells in degenerative tendon tissue could affect the rate of collagen synthesis and repair. Impaired or dysfunctional protein synthesis may lead to weaker tendon tissue and eventually increase the risk for tendon rupture. Clearly, there are many details to insert into this pathway, but there is hope that if the fine details of the pathway can be fleshed out, then strategies may be able to be developed to break the cycle at one or more points and prevent or treat tendinopathy more effectively.
Del Buono, Angelo; Oliva, Francesco; Osti, Leonardo; Maffulli, Nicola
Summary Matrix metalloproteinases (MMP) are involved in the development of tendinopathy. These potent enzymes completely degrade all components of the connective tissue, modify the extracellular matrix (ECM), and mediate the development of painful tendinopathy. To control the local activity of activated proteinases, the same cells produce tissue inhibitors of metalloproteinases (TIMP). These latter bind to the enzyme and prevent degradation. The balance between the activities of MMPs and TIMPs regulates tendon remodeling, whereas an imbalance produces a collagen dis-regulation and disturbances in tendons. ADAMs (a disintegrin and metalloproteinase) are cell membrane-linked enzymes with proteolytic and cell signaling functions. ADAMTSs (ADAM with thrombospondin motifs) are secreted into the circulation and constitute a heterogenous family of proteases with both anabolic and catabolic functions. Further studies are needed to better define the mechanism of action, and whether these new strategies are safe and effective in larger models. PMID:23885345
Del Buono, Angelo; Oliva, Francesco; Osti, Leonardo; Maffulli, Nicola
Matrix metalloproteinases (MMP) are involved in the development of tendinopathy. These potent enzymes completely degrade all components of the connective tissue, modify the extracellular matrix (ECM), and mediate the development of painful tendinopathy. To control the local activity of activated proteinases, the same cells produce tissue inhibitors of metalloproteinases (TIMP). These latter bind to the enzyme and prevent degradation. The balance between the activities of MMPs and TIMPs regulates tendon remodeling, whereas an imbalance produces a collagen dis-regulation and disturbances in tendons. ADAMs (a disintegrin and metalloproteinase) are cell membrane-linked enzymes with proteolytic and cell signaling functions. ADAMTSs (ADAM with thrombospondin motifs) are secreted into the circulation and constitute a heterogenous family of proteases with both anabolic and catabolic functions. Further studies are needed to better define the mechanism of action, and whether these new strategies are safe and effective in larger models.
Lewis, J S
A review was conducted to synthesise the available research literature on the pathogenesis of rotator cuff tendinopathy. Musculoskeletal disorders of the shoulder are extremely common, with reports of prevalence ranging from one in three people experiencing shoulder pain at some stage of their lives to approximately half the population experiencing at least one episode of shoulder pain annually. Pathology of the soft tissues of the shoulder, including the musculotendinous rotator cuff and subacromial bursa, is a principal cause of pain and suffering. The pathoaetiology of rotator cuff failure is multifactorial and results from a combination of intrinsic, extrinsic and environmental factors. The specialised morphology of the rotator cuff, together with the effects of stress shielding, may contribute to the development of rotator cuff tendinopathy. Profound changes within the subacromial bursa are strongly related to the pathology and resulting symptoms. A considerable body of research is necessary to more fully understand the aetiology and pathohistology of rotator cuff tendinopathy and its relationship with bursal pathology. Once this knowledge exists more effective management will become available.
Camargo, Paula R; Alburquerque-Sendín, Francisco; Salvini, Tania F
Excessive mechanical loading is considered the major cause of rotator cuff tendinopathy. Although tendon problems are very common, they are not always easy to treat. Eccentric training has been proposed as an effective conservative treatment for the Achilles and patellar tendinopathies, but less evidence exists about its effectiveness for the rotator cuff tendinopathy. The mechanotransduction process associated with an adequate dose of mechanical load might explain the beneficial results of applying the eccentric training to the tendons. An adequate load increases healing and an inadequate (over or underuse) load can deteriorate the tendon structure. Different eccentric training protocols have been used in the few studies conducted for people with rotator cuff tendinopathy. Further, the effects of the eccentric training for rotator cuff tendinopathy were only evaluated on pain, function and strength. Future studies should assess the effects of the eccentric training also on shoulder kinematics and muscle activity. Individualization of the exercise prescription, comprehension and motivation of the patients, and the establishment of specific goals, practice and efforts should all be considered when prescribing the eccentric training. In conclusion, eccentric training should be used aiming improvement of the tendon degeneration, but more evidence is necessary to establish the adequate dose-response and to determine long-term follow-up effects. PMID:25405092
Camargo, Paula R; Alburquerque-Sendín, Francisco; Salvini, Tania F
Excessive mechanical loading is considered the major cause of rotator cuff tendinopathy. Although tendon problems are very common, they are not always easy to treat. Eccentric training has been proposed as an effective conservative treatment for the Achilles and patellar tendinopathies, but less evidence exists about its effectiveness for the rotator cuff tendinopathy. The mechanotransduction process associated with an adequate dose of mechanical load might explain the beneficial results of applying the eccentric training to the tendons. An adequate load increases healing and an inadequate (over or underuse) load can deteriorate the tendon structure. Different eccentric training protocols have been used in the few studies conducted for people with rotator cuff tendinopathy. Further, the effects of the eccentric training for rotator cuff tendinopathy were only evaluated on pain, function and strength. Future studies should assess the effects of the eccentric training also on shoulder kinematics and muscle activity. Individualization of the exercise prescription, comprehension and motivation of the patients, and the establishment of specific goals, practice and efforts should all be considered when prescribing the eccentric training. In conclusion, eccentric training should be used aiming improvement of the tendon degeneration, but more evidence is necessary to establish the adequate dose-response and to determine long-term follow-up effects.
Hsu, Andrew R; Jones, Carroll P; Cohen, Bruce E; Davis, W Hodges; Ellington, J Kent; Anderson, Robert B
Limited incision techniques for acute Achilles tendon ruptures have been developed in recent years to improve recovery and reduce postoperative complications compared with traditional open repair. The purpose of this retrospective cohort study was to analyze the clinical outcomes and postoperative complications between acute Achilles tendon ruptures treated using a percutaneous Achilles repair system (PARS [Arthrex, Inc, Naples, FL]) versus open repair and evaluate the overall outcomes for operatively treated Achilles ruptures. Between 2005 and 2014, 270 consecutive cases of operatively treated acute Achilles tendon ruptures were reviewed (101 PARS, 169 open). Patients with Achilles tendinopathy, insertional ruptures, chronic tears, or less than 3-month follow-up were excluded. Operative treatment consisted of a percutaneous technique (PARS) using a 2-cm transverse incision with FiberWire (Arthrex, Inc, Naples, FL) sutures or open repair using a 5- to 8-cm posteromedial incision with FiberWire in a Krackow fashion reinforced with absorbable sutures. Patient demographics were recorded along with medical comorbidities, activity at injury, time from injury to surgery, length of follow-up, return to baseline activities by 5 months, and postoperative complications. The most common activity during injury for both groups was basketball (PARS: 39%, open: 47%). A greater number of patients treated with PARS were able to return to baseline physical activities by 5 months compared with the open group (PARS: 98%, open: 82%; P = .0001). There were no significant differences (P > .05) between groups in rates of rerupture (P = 1.0), sural neuritis (P = .16), wound dehiscence (P = .74), superficial (P = .29) and/or deep infection (P = .29), or reoperation (P = .13). There were no deep vein thromboses (DVTs) or reruptures in either group. In the PARS group, there were no cases of sural neuritis, 3 cases (3%) of superficial wound dehiscence, and 2 reoperations (2%) for superficial
Nourissat, Geoffroy; Ornetti, Paul; Berenbaum, Francis; Sellam, Jérémie; Richette, Pascal; Chevalier, Xavier
Although tendinopathies constitute a heterogeneous group of conditions, they are often treated by similar combinations of local and systemic symptomatic interventions. The vast number of causes, pathophysiological mechanisms, and histological changes that characterizes tendinopathies may explain that the standard treatment fails in some patients. Platelet-rich plasma (PRP), which contains a host of soluble mediators including growth factors, has been suggested as a second-line treatment for refractory tendinopathy, with the goal of expediting tendon healing or remodeling. Here, we report a systematic literature review of basic research data from humans and animals that support the clinical use of PRP in tendinopathies and of clinical studies in the most common tendinopathies (elbow, knee, shoulder, and Achilles tendon). Our objective is to clarify the role for this new injectable treatment, which is garnering increasing attention. The level of evidence remains low, as few well-designed randomized controlled trials have been published. The available scientific evidence does not warrant the use of PRP for the first-line treatment of tendinopathy. PRP therapy may deserve consideration in specific tendinopathy subtypes, after failure of ultrasound-guided corticosteroid injections. Nevertheless, further studies are needed to define these potential indications and the optimal treatment protocols. A key point is that the complexity of the tendon healing process cannot be replicated simply by injecting a subset of growth factors, whose effects may occur in opposite directions over time. Topics not discussed in this review are the regulatory framework for PRP therapy, PRP nomenclature, and precautions for use, which are described in a previous article (Does platelet-rich plasma have a role in the treatment of osteoarthritis, Ornetti P, et al. ). Copyright © 2015 Société française de rhumatologie. Published by Elsevier SAS. All rights reserved.
Franceschi, Francesco; Papalia, Rocco; Franceschetti, Edoardo; Denaro, Vincenzo
Purpose. In the last few years, evidence has emerged to support the possible association between increased BMI and susceptibility to some musculoskeletal diseases. We systematically review the literature to clarify whether obesity is a risk factor for the onset of tendinopathy. Methods. We searched PubMed, Cochrane Central, and Embase Biomedical databases using the keywords “obesity,” “overweight,” and “body mass index” linked in different combinations with the terms “tendinopathy,” “tendinitis,” “tendinosis,” “rotator cuff,” “epicondylitis,” “wrist,” “patellar,” “quadriceps,” “Achilles,” “Plantar Fascia,” and “tendon.” Results. Fifteen studies were included. No level I study on this subject was available, and the results provided are ambiguous. However, all the 5 level II studies report the association between obesity measured in terms of BMI and tendon conditions, with OR ranging between 1.9 (95% CI: 1.1–2.2) and 5.6 (1.9–16.6). Conclusions. The best evidence available to date indicates that obesity is a risk factor for tendinopathy. Nevertheless, further studies should be performed to establish the real strength of the association for each type of tendinopathy, especially because the design of the published studies does not allow identifying a precise cause-effect relationship and the specific role of obesity independently of other metabolic conditions. PMID:25214839
Gärdin, Anna; Brismar, Torkel B; Movin, Tomas; Shalabi, Adel
Chronic Achilles tendinosis is a common problem. When evaluating and comparing different therapies there is a need for reliable imaging methods. Our aim was to evaluate if chronic Achilles tendinosis affects the dynamic contrast-enhancement in the tendon and its surroundings and if short-term eccentric calf-muscle training normalizes the dynamic contrast-enhancement. 20 patients with chronic Achilles tendinopathy were included. Median duration of symptoms was 31 months (range 6 to 120 months). Both Achilles tendons were examined with dynamic contrast enhanced MRI before and after a 12- week exercise programme of eccentric calf-muscle training. The dynamic MRI was evaluated in tendon, vessel and in fat ventrally of tendon. Area under the curve (AUC), time to peak of signal, signal increase per second (SI/s) and increase in signal between start and peak as a percentage (SI%) was calculated. Pain and performance were evaluated using a questionnaire. In the fat ventrally of the tendon, dynamic contrast enhancement was significantly higher in the symptomatic leg compared to the contralateral non-symptomatic leg before but not after treatment. Despite decreased pain and improved performance there was no significant change of dynamic contrast enhancement in symptomatic tendons after treatment. In Achilles tendinosis there is an increased contrast enhancement in the fat ventrally of the tendon. The lack of correlation with symptoms and the lack of significant changes in tendon contrast enhancement parameters do however indicate that dynamic enhanced MRI is currently not a useful method to evaluate chronic Achilles tendinosis.
Background Chronic Achilles tendinosis is a common problem. When evaluating and comparing different therapies there is a need for reliable imaging methods. Our aim was to evaluate if chronic Achilles tendinosis affects the dynamic contrast-enhancement in the tendon and its surroundings and if short-term eccentric calf-muscle training normalizes the dynamic contrast-enhancement. Methods 20 patients with chronic Achilles tendinopathy were included. Median duration of symptoms was 31 months (range 6 to 120 months). Both Achilles tendons were examined with dynamic contrast enhanced MRI before and after a 12- week exercise programme of eccentric calf-muscle training. The dynamic MRI was evaluated in tendon, vessel and in fat ventrally of tendon. Area under the curve (AUC), time to peak of signal, signal increase per second (SI/s) and increase in signal between start and peak as a percentage (SI%) was calculated. Pain and performance were evaluated using a questionnaire. Results In the fat ventrally of the tendon, dynamic contrast enhancement was significantly higher in the symptomatic leg compared to the contralateral non-symptomatic leg before but not after treatment. Despite decreased pain and improved performance there was no significant change of dynamic contrast enhancement in symptomatic tendons after treatment. Conclusion In Achilles tendinosis there is an increased contrast enhancement in the fat ventrally of the tendon. The lack of correlation with symptoms and the lack of significant changes in tendon contrast enhancement parameters do however indicate that dynamic enhanced MRI is currently not a useful method to evaluate chronic Achilles tendinosis. PMID:24261480
Heinemeier, K M; Skovgaard, D; Bayer, M L; Qvortrup, K; Kjaer, A; Kjaer, M; Magnusson, S P; Kongsgaard, M
Overuse Achilles tendinopathy is a common and challenging problem in sports medicine. Little is known about the etiology of this disorder, and the development of a good animal model for overuse tendinopathy is essential for advancing insight into the disease mechanisms. Our aim was to test a previously proposed rat model for Achilles tendon overuse. Ten adult male Sprague-Dawley rats ran on a treadmill with 10° incline, 1 h/day, 5 days/wk (17-20 m/min) for 12 wk and were compared with 12 control rats. Histological, mechanical, and gene-expression changes were measured on the Achilles tendons after the intervention, and local tendon glucose-uptake was measured before and after the intervention with positron emission tomography. No differences were detected between runners and controls in tissue histology or in glucose uptake, indicating that tendon pathology was not induced. Greater tendon tissue modulus (P < 0.005) and failure stress/body weight (P < 0.02) in runners compared with controls further supported that tendons successfully adapted to uphill running. Several genes of interest were regulated after 12 wk of running. Expression of collagen III and insulin-like growth factor I was increased, while collagen I was unchanged, and decreases were seen in noncollagen matrix components (fibromodulin and biglycan), matrix degrading enzymes, transforming growth factor-β1, and connective tissue growth factor. In conclusion, the tested model could not be validated as a model for Achilles tendinopathy, as the rats were able to adapt to 12 wk of uphill running without any signs of tendinopathy. Improved mechanical properties were observed, as well as changes in gene-expression that were distinctly different from what is seen in tendinopathy and in response to short-term tendon loading.
Lian, Øystein; Refsnes, Per-Egil; Engebretsen, Lars; Bahr, Roald
Patellar tendinopathy is assumed to result from chronic tendon overload. There may be a relationship between tendon pain and jumping ability. There is no difference in performance characteristics between volleyball players with patellar tendinopathy and those without. Prospective cohort study. We examined the performance of the leg extensor apparatus in high-level male volleyball players with patellar tendinopathy (N = 24) compared with a control group (N = 23) without knee symptoms. The testing program consisted of different jump tests with and without added load, and a composite jump score was calculated to reflect overall performance. The groups were similar in age, height, and playing experience, but the patellar tendinopathy group did more specific strength training and had greater body weight. They scored significantly higher than the control group on the composite jump score (50.3 versus 39.2), and significant differences were also observed for work done in the drop-jump and average force and power in the standing jumps with half- and full-body weight loads. Greater body weight, more weight training, and better jumping performance may increase susceptibility to patellar tendinopathy in volleyball players.
Scott, Alexander; Bahr, Roald
Tendinopathy is a clinical syndrome of pain, tendon thickening, and increased blood flow. The current review highlights evidence supporting an underlying role of neuropeptides in the etiology, clinical presentation, and treatment of painful overuse tendinopathy. Painful tendons demonstrate an increased presence of Substance P-containing nerves which are strongly implicated as a potential source of pain, but which also play important roles in the tendon’s attempt to self-repair. Recent findings have identified potential roles of additional sensory and autonomic neuropeptides which regulate pain, tissue remodeling, and vascular flow, including acetylcholine, noradrenaline and neuropeptide Y. Neuropeptide production within tendons is stimulated by mechanical load and exercise, and both direct and indirect neuropeptide effects may be responsible for the potential benefits of heavy-load eccentric loading. A model is presented which delineates the physiologic basis for signalling pathways between tenocytes, mast cells and sensory and autonomic nerves, with implications for understanding the mechanisms of traditional as well as emerging treatment strategies including sclerosing therapy and nitric oxide. PMID:19273194
Castro, Adham do Amaral E; Skare, Thelma Larocca; Nassif, Paulo Afonso Nunes; Sakuma, Alexandre Kaue; Barros, Wagner Haese
Tendinopathies and tendon tears account for over 30% of all musculoskeletal consultations. Obesity, which is becoming one of the world´s most prevalent public health issues, may be associated with this condition. To review the literature about tendinopathies and obesity association. This is a descriptive exploratory study using the portal Medline. Literature in English language from 2006 to 2014 were reviewed. The pathogenesis of tendinopathies includes inflammatory, regenerative and degenerative processes that happen simultaneously from early to late phases of the disease. Mechanical stress upon tendons seems to be one of the most important factors to initiate the inflammatory response, but it´s not the only one that can deflagrate it: there are other extrinsic, genetic and metabolic factors that may be involved. Therefore, tendinopathies in obese patients can be due to tendon overload because of the excess of weight, but also because of increased production of pro-inflammatory mediators related to fat tissue such as adipokines. This pro-inflammatory state that obese people can suffer is known as adiposopathy, or sick fat syndrome. Weight loss is associated with decrease in adipokines and improvement of musculoskeletal symptoms. The relation of obesity and tendinopathies is supported by evidences of recent studies, exemplified in this review of literature. As tendinopatias e as fissuras em tendões respondem por 30% de todas as consultas médicas. A obesidade, que está se tornando um dos problemas de saúde pública mais prevalentes no mundo, pode estar associada com esta condição. Revisar a literatura acerca da associação entre obesidade e tendinopatias. Este é um estudo exploratório e descritivo utilizando artigos em língua inglesa do portal médico Medline, do período de 2006 a 2014. Na patogênese das tendinopatias incluem-se elementos inflamatórios, regenerativos e degenerativos que aparecem de maneira simultânea em todos os estágios da doen
Hsu, Yu-Chun; Wu, Wei-Ting; Chang, Ke-Vin; Han, Der-Sheng; Chou, Li-Wei
Achilles tendinopathy is a common cause of posterior heel pain and can progress to partial tendon tear without adequate treatment. Effects of traditional treatments vary, and many recent reports focus on the use of extracorporeal shockwave therapy (ESWT) for Achilles tendinopathy but not for Achilles tendon partial tear. Here, we report the case of a 64-year-old female suffering from severe left heel pain for half a year. All treatment and rehabilitation were less effective until ESWT was applied. Each course of focused shockwave therapy included 2500 shots with energy flux density from 0.142 mJ/mm2 to 0.341 mJ/mm2. The visual analog scale decreased from nine to one degree. High-resolution musculoskeletal ultrasonography was performed before and 1 month after the treatment, which revealed healing of the torn region and decrease in inflammation. ESWT had shown to be an alternative treatment for Achilles tendon partial tear under safety procedure and ultrasound observation. PMID:28579818
Weinfeld, Steven B
Achilles tendon disorders include tendinosis, paratenonitis, insertional tendinitis, retrocalcaneal bursitis, and frank rupture. Patients present with pain and swelling in the posterior aspect of the ankle. Magnetic resonance imaging and ultrasound are helpful in confirming the diagnosis and guiding treatment. Nonsurgical management of Achilles tendon disorders includes nonsteroidal anti-inflammatory drugs, physical therapy, bracing, and footwear modification. Surgical treatment includes debridement of the diseased area of the tendon with direct repair. Tendon transfer may be necessary to augment the strength of the Achilles tendon. Copyright © 2014 Elsevier Inc. All rights reserved.
Mautner, Ken; Kneer, Lee
Pain and dysfunction related to tendinopathy are often refractory to traditional treatments and offer a unique challenge to physicians, because no gold standard treatment exists. Injectable biologics may represent a new modality in conjunction with a multifaceted treatment approach. Platelet-rich plasma (PRP) injections are not associated with the systemic or tendon degradation risks of corticosteroids or the inherent risks of surgery. Studies are promising but have not been replicated with high-powered evidence at the clinical level. Further evidence to expand understanding of the role of PRP in the treatment of tendinopathy is needed.
Jackson, Gillian; Sinclair, Victoria F; McLaughlin, Charles; Barrie, James
The introduction of functional rehabilitation for patients with Achilles tendon rupture has dramatically changed treatment programs for this condition. The authors introduced a functional weight-bearing protocol for patients with an acute Achilles tendon rupture treated operatively and nonoperatively in 2002. They hypothesized that no significant differences would exist in the rerupture rates and functional outcomes between the groups. Between 2002 and 2008, the authors collected data on 80 consecutive patients treated with a weight-bearing functional orthosis for complete Achilles tendon rupture. Following evidence-based counseling, 51 patients chose nonoperative treatment and 29 chose operative treatment. Outcome measures included rerupture rates, other complications, and functional scoring. The nonoperative group was a decade older (median age, 47 years [range, 27-80 years]) than the operative group (median age, 37 years [range, 24-55 years]). Rerupture was noted in 2 (4%) patients in the nonoperative treatment group and 1 (3%) patient in the operative group. Two (7%) patients in the operative group developed superficial wound infections and reported no nerve injuries. Median Achilles Tendon Total Rupture Score was 82 points in the nonoperative group and 94 in the operative group. Median Victorian Institute of Sports Assessment-Achilles tendinopathy questionnaire scores were 60 and 91 for the nonoperative and operative groups, respectively. Both groups had low rerupture rates. Functional scores, using the newly validated Achilles Tendon Total Rupture Score, were lower in the nonoperative group. Copyright 2013, SLACK Incorporated.
Cho, Nam Soon; Hwang, Ji Hye; Lee, Yong Taek; Chae, Seoung Wan
Tendinopathy (pain and tendon degeneration) is associated with repetitive use and mechanical overload. However, the etiology of tendinopathy remains unclear. Clarification of histologic and molecular changes of tendon to repetitive stress could provide better understanding of Achilles tendon disorders related to repetitive stress. We asked whether repetitive stress simulating overuse of the Achilles tendon induced (1) histologic changes in rats similar to tendinosis (increased cellularity of fibrocytes, increased disorganization of collagen fiber, and increased roundness of the nucleus of the fibrocyte), (2) increased collagen Type III occurrence, and (3) increased inducible nitric oxide synthase (iNOS) expression. We used an exercise protocol simulating repetitive, jerky, eccentric contraction of the triceps surae in 15 rats. We conducted the exercise for 2 hours per day, three times per week using the right rear legs only and the left legs as internal controls. We harvested Achilles tendons after either 2, 4, or 6 weeks of exercise, and evaluated changes in tendon thickness, fibrocyte count, collagen fiber arrangement, collagen fiber type, and occurrence of iNOS. Exercised Achilles tendons showed increased cellularity of fibrocytes at 4 and 6 weeks of exercise, and disorganized collagen fiber arrangement at 6 weeks of exercise. There was a trend for Type III collagen occurrence being greater in experimental groups. Expression of iNOS increased after 2 and 4 weeks of exercise when compared with that of the controls, but decreased after 6 weeks. These observations suggest repetitive, synchronized, passive, and jerky exercise induced by electrical stimulation can lead to the tendinosis-like changes in the Achilles tendons in rats with imbalance between synthesis and degeneration after 4 weeks of exercise. This newly designed exercise protocol may be used to design an animal model of Achilles tendon overuse. With this model, therapeutic interventions of tendinopathy
Galletti, Stefano; Oliva, Francesco; Masiero, Stefano; Frizziero, Antonio; Galletti, Riccardo; Schiavone, Cosima; Salini, Vincenzo; Abate, Michele
Summary Background sonoelastography helps in the detection of abnormalities not yet evident on B-mode exam. Methods in this observational study, we report a collection of cases of symptomatic patients without alterations at ultrasound imaging but with evidence of pathological findings at sonoelastography. Patients, with clinical history suggestive for tendinopathies or surgically treated, and negative at the ultrasound exam, were submitted to sonoelastography. Out of 846, 632 patients with positive ultrasound exam were excluded. Sonoelastography was therefore performed in the remaining 214. Results the examination was positive in 168 cases: 78 patients were affected with shoulder diseases, while elbow pathology was observed in 31 subjects; patellar, Achilles and plantar fascia disorders were reported in 19, 27, and 13 patients, respectively. Conclusion sonoelastography can reveal tendon abnormalities of clinical relevance in a high percentage of cases, where the ultrasound exam was negative, making the method a complementary tool to ultrasound evaluation. PMID:26958544
Yuan, Ting; Zhang, Jianying; Zhao, Guangyi; Zhou, Yiqin; Zhang, Chang-Qing; Wang, James H-C.
Previous animal studies have shown that long term rat treadmill running induces over-use tendinopathy, which manifests as proteoglycan accumulation and chondrocytes-like cells within the affected tendons. Creating this animal model of tendinopathy by long term treadmill running is however time-consuming, costly and may vary among animals. In this study, we used a new approach to develop an animal model of tendinopathy using kartogenin (KGN), a bio-compound that can stimulate endogenous stem/progenitor cells to differentiate into chondrocytes. KGN-beads were fabricated and implanted into rat Achilles tendons. Five weeks after implantation, chondrocytes and proteoglycan accumulation were found at the KGN implanted site. Vascularity as well as disorganization in collagen fibers were also present in the same site along with increased expression of the chondrocyte specific marker, collagen type II (Col. II). In vitro studies confirmed that KGN was released continuously from KGN-alginate in vivo beads and induced chondrogenic differentiation of tendon stem/progenitor cells (TSCs) suggesting that chondrogenesis after KGN-bead implantation into the rat tendons is likely due to the aberrant differentiation of TSCs into chondrocytes. Taken together, our results showed that KGN-alginate beads can be used to create a rat model of tendinopathy, which, at least in part, reproduces the features of over-use tendinopathy model created by long term treadmill running. This model is mechanistic (stem cell differentiation), highly reproducible and precise in creating localized tendinopathic lesions. It is expected that this model will be useful to evaluate the effects of various topical treatments such as NSAIDs and platelet-rich plasma (PRP) for the treatment of tendinopathy. PMID:26848746
Yuan, Ting; Zhang, Jianying; Zhao, Guangyi; Zhou, Yiqin; Zhang, Chang-Qing; Wang, James H-C
Previous animal studies have shown that long term rat treadmill running induces over-use tendinopathy, which manifests as proteoglycan accumulation and chondrocytes-like cells within the affected tendons. Creating this animal model of tendinopathy by long term treadmill running is however time-consuming, costly and may vary among animals. In this study, we used a new approach to develop an animal model of tendinopathy using kartogenin (KGN), a bio-compound that can stimulate endogenous stem/progenitor cells to differentiate into chondrocytes. KGN-beads were fabricated and implanted into rat Achilles tendons. Five weeks after implantation, chondrocytes and proteoglycan accumulation were found at the KGN implanted site. Vascularity as well as disorganization in collagen fibers were also present in the same site along with increased expression of the chondrocyte specific marker, collagen type II (Col. II). In vitro studies confirmed that KGN was released continuously from KGN-alginate in vivo beads and induced chondrogenic differentiation of tendon stem/progenitor cells (TSCs) suggesting that chondrogenesis after KGN-bead implantation into the rat tendons is likely due to the aberrant differentiation of TSCs into chondrocytes. Taken together, our results showed that KGN-alginate beads can be used to create a rat model of tendinopathy, which, at least in part, reproduces the features of over-use tendinopathy model created by long term treadmill running. This model is mechanistic (stem cell differentiation), highly reproducible and precise in creating localized tendinopathic lesions. It is expected that this model will be useful to evaluate the effects of various topical treatments such as NSAIDs and platelet-rich plasma (PRP) for the treatment of tendinopathy.
Balasubramaniam, Umatheepan; Dissanayake, Ravi; Annabell, Lucas
Chronic tendinopathy has often been a management dilemma for general practitioners. With our understanding of the pathophysiology of tendinopathy evolving, so has our management, with the advent of newer strategies such as topical glycerol trinitrate, extracorporeal shock-wave therapy, as well as platelet-rich plasma (PRP). To systematically review the literature regarding PRP therapy in chronic tendinopathy. The databases used in our search include the Elton B. Stephens Co. (EBSCO) database, Medline, the Cochrane library, Ovid, and Embase (the Excerpta Medica database). A total of 389 articles were reviewed from Feb 2010 to April 2014, for possible inclusion. Of these articles, a total of 9 randomized controlled trials (RCTs) met our inclusion criteria. Only 1 RCT was excluded due to previous surgery in both the trial and control groups. Each article was reviewed independently by 2 authors. Each article was analyzed using the Cochrane Criteria checklist. Where any discrepancy occurred in results, a third independent reviewer was consulted. Our review found that PRP was most effective in patellar and lateral epicondylar tendinopathy, with both RCTs in the patellar section of our study supporting the use of PRP in pain reduction at 3 and 12 months, whereas 2 of 4 studies in the lateral epicondylar section showed improvements in pain and disability at 6 and 12 months. There was a lack of evidence to support the use of PRP in Achilles and rotator cuff tendinopathy. Although the results of this review show promise for the use of PRP in chronic tendinopathy, the analysis highlighted the need for more controlled clinical trials comparing PRP with placebo.
... shoes with proper cushioning in the heels. Increase training intensity slowly. Achilles tendon injuries commonly occur after abruptly increasing training intensity. Increase the distance, duration and frequency of your ...
van Dijk, Wietse; Meijneke, Cory; van der Kooij, Herman
This paper evaluates the Achilles exoskeleton. The exoskeleton is intended to provide push-off assistance for healthy subjects during walking. The assistance is provided by a series elastic actuator that has been optimized to provide maximal push-off power. The paper presents the control method of the exoskeleton and the evaluation of the exoskeleton.
Scott, Alex; Backman, Ludvig J; Speed, Cathy
Synopsis Tendinopathy has become the accepted term to describe a spectrum of changes that occur in damaged and/or diseased tendons. Over the past 2 decades, there have been new insights into tendon pathophysiology of relevance to clinicians, including (1) better characterization of the overuse injury process and the resultant structural and functional disruption in chronically painful tendons, (2) improved understanding of the pathomechanics associated with chronic tendon injury, and (3) greater knowledge about the influence of lifestyle factors and drugs on tendon pathology. The implications of these new insights are discussed. J Orthop Sports Phys Ther 2015;45(11):833-841. Epub 21 Sep 2015. doi:10.2519/jospt.2015.5884.
Docking, S I; Rosengarten, S D; Cook, J
Pre-season injuries are common and may be due to a reintroduction of training loads. Tendons are sensitive to changes in load, making them vulnerable to injury in the pre-season. This study investigated changes in Achilles tendon structure on ultrasound tissue characterization (UTC) over the course of a 5-month pre-season in elite male Australian football players. Eighteen elite male Australian football players with no history of Achilles tendinopathy and normal Achilles tendons were recruited. The left Achilles tendon was scanned with UTC to quantify the stability of the echopattern. Participants were scanned at the start and completion of a 5-month pre-season. Fifteen players remained asymptomatic over the course of the pre-season. All four echo-types were significantly different at the end of the pre-season, with the overall echopattern suggesting an improvement in Achilles tendon structure. Three of the 18 participants developed Achilles tendon pain that coincided with a change in the UTC echopattern. This study demonstrates that the UTC echopattern of the Achilles tendon improves over a 5-month pre-season training period, representing increased fibrillar alignment. However, further investigation is needed to elucidate with this alteration in the UTC echopattern results in improved tendon resilience and load capacity. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
Sanderson, Lane M; Bryant, Alan
The aim of this review was to identify and evaluate existing research to determine the clinical effectiveness and safety of prolotherapy injections for treatment of lower limb tendinopathy and fasciopathy. Nine databases were searched (Medline, Science Direct, AMED, Australian Medical Index, APAIS-Health, ATSIhealth, EMBASE, Web of Science, OneSearch) without language, publication or data restrictions for all relevant articles between January 1960 and September 2014. All prospective randomised and non-randomised trials, cohort studies, case-series, cross-sectional studies and controlled trials assessing the effectiveness of one or more prolotherapy injections for tendinopathy or fasciopathy at or below the superior aspect of the tibia/fibula were included. Methodological quality of studies was determined using a modified evaluation tool developed by the Cochrane Musculoskeletal Injuries Group. Data analysis was carried out to determine the mean change of outcome measure scores from baseline to final follow-up for trials with no comparative group, and for randomised controlled trials, standardised mean differences between intervention groups were calculated. Pooled SMD data were calculated where possible to determine the statistical heterogeneity and overall effect for short-, intermediate- and long-term data. Adverse events were also reported. Two hundred and three studies were identified, eight of which met the inclusion criteria. These were then grouped according to tendinopathy or fasciopathy being treated with prolotherapy injections: Achilles tendinopathy, plantar fasciopathy and Osgood-Schlatter disease. The methodological quality of the eight included studies was generally poor, particularly in regards to allocation concealment, intention to treat analysis and blinding procedures. Results of the analysis provide limited support for the hypothesis that prolotherapy is effective in both reducing pain and improving function for lower limb tendinopathy and
Smith, William Bret; Melton, Will; Davies, James
The focus of this article is to present the current options available for noninvasive and percutaneous treatment options for noninsertional Achilles tendinopathy. An attempt is made to offer recommendations for both the treatment techniques as well as postprocedure protocols to be considered. Additionally, because there are numerous treatment options in this category, the different techniques are summarized in a chart format with a short list of pros and cons as well as the levels of evidence in the literature to support the different modalities. Copyright © 2017 Elsevier Inc. All rights reserved.
O'Brien, Etienne J O; Frank, Cyril B; Shrive, Nigel G; Hallgrímsson, Benedikt; Hart, David A
Heterotopic tendon mineralization (ossification or calcification), which may be a feature of tendinopathy or which may develop following surgical trauma (repair or graft harvest), has not received much attention. The purpose of this article is to review the prevalence, mechanisms and consequences of heterotopic tendon mineralization and to identify the gaps in our current understanding. We focus on endochondral heterotopic ossification and draw on knowledge of the mechanisms of this process in other tissues and conditions. Finally, we introduce a novel murine Achilles tendon needle injury model, which will enable us to further study the mechanisms and biomechanical consequences of tendon mineralization. PMID:22974213
Cox, Joseph T; Shorten, Peter L; Gould, Gregory C; Markert, Ronald J; Barnett, Michael D; Laughlin, Richard T
Surgical treatment of insertional Achilles tendinopathy often involves detachment and debridement of the Achilles tendon insertion. A recent study has shown that knotted suture bridge fixation of the Achilles to the calcaneus is biomechanically superior to single-row fixation, but there is an absence of literature on the use of different suture bridge constructs to repair the Achilles tendon. There will be no significant difference in the load to failure, mode of failure, tendon strain, tendon stiffness, repair site gapping, or footprint size when comparing knotted suture bridge repair to knotless suture bridge repair of the Achilles tendon after detachment for insertional Achilles tendinopathy. Controlled laboratory study. A single specimen from each pair of 10 cadaveric Achilles tendons was randomized to 1 of 2 Achilles insertion repair groups: knotted (n = 10) or knotless (n = 10) suture bridge repair. Repaired footprint size was measured, and then cyclic testing from 10 to 100 N for 2000 cycles was performed. This was followed by measurement of tendon strain, repair site displacement, load to failure, and tendon stiffness. The knotted suture bridge repair had a significantly higher load to failure compared with the knotless suture bridge (mean ± SD, 317.8 ± 93.6 N vs 196.1 ± 12.1 N, respectively; P = .001). All constructs failed at the tendon-suture interface. Tendon strain after cyclic testing was significantly greater in the knotless (1.20 ± 1.05) compared with the knotted (0.39 ± 0.4) suture repair groups (P = .011). There was no significant difference in footprint size between the knotted (230.3 ± 63.3 mm(2)) and knotless (248.5 ± 48.8 mm(2)) groups (P = .40). There was also no significant difference in stiffness (knotted = 76.4 ± 8.0 N/mm; knotless = 69.6 ± 10.9 N/mm; P = .17) and repair site displacement after cyclic testing (knotted = 2.8 ± 1.2 mm; knotless = 3.6 ± 1.1 mm; P = .17). During suture bridge repair of the Achilles tendon after
Huh, Jeannie; Easley, Mark E; Nunley, James A
An Achilles sleeve avulsion occurs when the tendon ruptures distally from its calcaneal insertion as a continuous "sleeve." This relatively rare injury pattern may not be appreciated until the time of surgery and can be challenging to treat because, unlike a midsubstance rupture, insufficient tendon remains on the calcaneus to allow for end-to-end repair, and unlike a tuberosity avulsion fracture, any bony element avulsed with the tendon is inadequate for internal fixation. This study aimed to highlight the characteristics of Achilles sleeve avulsions and present the outcomes of operative repair using suture anchor fixation. A retrospective analysis was conducted on 11 consecutive Achilles tendon sleeve avulsions (10 males, 1 female; mean age 44 years) that underwent operative repair between 2008 and 2014. Patient demographics, injury presentation, and operative details were reviewed. Postoperative outcomes were collected at a mean follow-up of 38.4 (range, 12-83.5) months, including the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot score, visual analog scale (VAS) for pain, plantarflexion strength, patient satisfaction, and complications. Eight patients (72.7%) had preexisting symptoms of insertional Achilles disease. Ten of 11 (90.9%) injuries were sustained during recreational athletic activity. An Achilles sleeve avulsion was recognized preoperatively in 7 of 11 (64%) cases, where lateral ankle radiographs demonstrated a small radiodensity several centimeters proximal to the calcaneal insertion. Intraoperatively, 90.9% of sleeve avulsions had a concomitant Haglund deformity and macroscopic evidence of insertional tendinopathy. All patients healed after suture anchor repair. The average AOFAS score was 92.8 and VAS score was 0.9. Ten patients (90.9%) were completely satisfied. One complication occurred, consisting of delayed wound healing. Achilles tendon sleeve avulsions predominantly occurred in middle-aged men with preexisting insertional
Carmont, Michael R; Maffulli, Nicola
The optimal management of chronic ruptures of the Achilles tendon is surgical reconstruction. Reconstruction of the Achilles tendon using peroneus brevis has been widely reported. Classically, these procedures involve relatively long surgical wounds in a relatively hypovascular area which is susceptible to wound breakdown. We describe our current method of peroneus brevis reconstruction for the Achilles tendon using two para-midline incisions. This technique allows reconstruction of the Achilles tendon using peroneus brevis preserving skin integrity over the site most prone to wound breakdown, and can be especially used to reconstruct the Achilles tendon in the presence of previous surgery.
Carmont, Michael R; Maffulli, Nicola
Background The optimal management of chronic ruptures of the Achilles tendon is surgical reconstruction. Reconstruction of the Achilles tendon using peroneus brevis has been widely reported. Classically, these procedures involve relatively long surgical wounds in a relatively hypovascular area which is susceptible to wound breakdown. Results We describe our current method of peroneus brevis reconstruction for the Achilles tendon using two para-midline incisions. Conclusion This technique allows reconstruction of the Achilles tendon using peroneus brevis preserving skin integrity over the site most prone to wound breakdown, and can be especially used to reconstruct the Achilles tendon in the presence of previous surgery. PMID:17963499
Figueroa, David; Figueroa, Francisco; Calvo, Rafael
Patellar tendinopathy is a common cause of pain in athletes' knees. Historically, it has been related to jumping sports, such as volleyball and basketball. Repetitive jumping generates a considerable load of energy in the extensor mechanism, leading to symptoms. The main pathophysiologic phenomenon in patellar tendinopathy is tendinosis, which is a degenerative disorder rather than an inflammatory disorder; therefore, the other popular term for this disease, tendinitis, is not appropriate. The nonsurgical treatment of patellar tendinopathy is focused on eccentric exercises and often has good results. Other experimental options, with variable levels of evidence, are available for recalcitrant cases. Surgical treatment is indicated for cases that are refractory to nonsurgical treatment. Open or arthroscopic surgery can be performed; the two methods are comparable, but arthroscopic surgery results in a faster recovery time.
Leung, Wilson K C; Chu, K L; Lai, Christopher
Mechanical loading is crucial for muscle and tendon tissue remodeling. Eccentric heel drop exercise has been proven to be effective in the management of Achilles tendinopathy, yet its induced change in the mechanical property (i.e., stiffness) of the Achilles tendon (AT), medial and lateral gastrocnemius muscles (MG and LG) was unknown. Given that shear wave elastography has emerged as a powerful tool in assessing soft tissue stiffness with promising intra- and inter-operator reliability, the objective of this study was hence to characterize the stiffness of the AT, MG and LG in response to an acute bout of eccentric heel drop exercise. Forty-five healthy young adults (36 males and nine females) performed 10 sets of 15-repetition heel drop exercise on their dominant leg with fully-extended knee, during which the AT and gastrocnemius muscles, but not soleus, were highly stretched. Before and immediately after the heel drop exercise, elastic moduli of the AT, MG and LG were measured by shear wave elastography. After the heel drop exercise, the stiffness of AT increased significantly by 41.8 + 33.5% (P < 0.001), whereas the increases in the MG and LG stiffness were found to be more drastic by 75 + 47.7% (P < 0.001) and 71.7 + 51.8% (P < 0.001), respectively. Regarding the AT, MG and LG stiffness measurements, the inter-operator reliability was 0.940, 0.987 and 0.986, and the intra-operator reliability was 0.916 to 0.978, 0.801 to 0.961 and 0.889 to 0.985, respectively. The gastrocnemius muscles were shown to bear larger mechanical loads than the AT during an acute bout of eccentric heel drop exercise. The findings from this pilot study shed some light on how and to what extent the AT and gastrocnemius muscles mechanically responds to an isolated set of heel drop exercise. Taken together, appropriate eccentric load might potentially benefit mechanical adaptations of the AT and gastrocnemius muscles in the rehabilitation of patients with Achilles tendinopathy.
Notarnicola, A; Maccagnano, G; Di Leo, M; Tafuri, S; Moretti, B
The incidence of Achilles tendinopathy is very high in young female gymnasts (17.5 %). According to literature, ecography screenings show the tendons thickening, but at the same time it does not reveal a direct link to the clinical picture. The neovessels are involved in the pathophysiological process of Achilles tendinopathy. For this reason, we wanted to verify there between perfusion tendon values and the type of sport activity. We performed a clinical observational study monitoring the oximetry of the Achilles tendon and the epidemiological data of 52 elite female (artistic and rhythmic) gymnasts versus 21 age-matched controls. Analyzing the main limb, we revealed statistically higher oximetry values in the artistic gymnasts group (69.5 %) compared to the rhythmic gymnasts group (67.1 %) (t = 2.13; p = 0.01) and the sedentary group (66.2 %) (t = 2.70; p = 0.004), but we did not find any differences between rhythmic gymnasts group and the sedentary group (t = 0.68; p = 0.24). The multiple logistic regression model highlighted that the oximetry value of the main limb is not influenced by age, knowledge of the main limb, years of general and gymnastic sports activity (p > 0.05). We discovered an increase of Achilles tendon perfusion in the main limb in the artistic gymnast group. We hypothesize that specific figures of artistic sports activity are responsible for muscle overload and gastrocnemius-soleus group and, at the same time, these figures cause hyperperfusion of the tendon. Prospective longitudinal studies could explain if this could become a predictive sign of the next Achilles tendinopathy onset.
Shibuya, Naohiro; Thorud, Jakob C; Humphers, Jon M; Devall, J Marshall; Jupiter, Daniel C
Insertional Achilles tendinosis results in isolated pain at the Achilles tendon insertion site due to intratendinous degeneration. When conservative measures fail, surgical treatment may be necessary. Radiofrequency coblation has been suggested to be an effective procedure for treatment of tendon pathologies. Percutaneous execution of this procedure is very simple as well as minimally invasive, and thus if effective, would be an excellent alternative to an open treatment of insertional Achilles tendinopathy. A review of 47 cases with this percutaneous technique was conducted. In our relatively short-term follow-up (mean = 8.6 months, SD = 9.71, range 1 to 40), the incidence of reoperation was 14.9% (7/47). Rupture of the Achilles tendon was identified in 3 (6.4%) patients. Our cohort had a relatively high body mass index (mean = 37.1, SD = 6.96, range 24.3 to 52.8). We recommend surgeons to be cautious about selecting this procedure in similar, high body mass index patient cohorts for treatment of Achilles tendinosis.
Wang, Po-Hsun; Chen, Wen-Shiang; Li, Meng-Lin
Assessments of vascularity are important when assessing inflammation changes in tendon injuries since Achilles tendinitis is often accompanied with neovascularization or hypervascularity. In this study, we have investigated the feasibility of photoacoustic imaging in noninvasive monitoring of morphological and vascular changes in Achilles tendon injuries. Collagenase-induced Achilles tendinitis model of mice was adopted here. During collagenase-induced tendinitis, a 25-MHz photoacoustic microscopy (PAM) was used to image micro-vascular changes in Achilles tendons longitudinally up to 23 days. The positions of vessels imaged by PAM were identified by co-registration of PAM Bmode images with 25-MHz ultrasound (USM) ones. Morphological changes in Achilles tendons due to inflammation and edema were revealed by the PAM and USM images. Proliferation of new blood vessels within the tendons was also observed. Observed micro-vascular changes during tendinitis were similar to the findings in the literatures. This study demonstrates that photoacoustic imaging, owning required sensitivity and penetration, has the potential for high sensitive diagnosis and assessment of treatment performance in tendinopathy.
Petrescu, Pompiliu HoraŢiu; Izvernariu, Dragoş Andrei; Iancu, Cătălina; Dinu, Gabriel Ovidiu; Crişan, Dan; Popescu, Simona Alina; Şirli, Roxana Lucia Denisa; Nistor, Bogdan Mihai; RăuŢia, Ion Călin; Lăzureanu, Dorela CodruŢa; Dema, Sorin; Prejbeanu, Ion Radu; Sporea, Ioan
Tendinopathy covers a range of several tendon conditions, mostly caused by overuse but at least in Achilles tendon pathology, favored by obesity, diabetes, inflammatory and autoimmune conditions. Subclinical tendon pathology is difficult to diagnose, as magnetic resonance imaging (MRI) examinations are sometimes inconclusive and not cost-effective. Elastography is an ultrasound examination method that uses mechanical impulses to produce shear waves in the tissue of interest, then measures the tissue displacement and calculates the shear wave speed or the elastic modulus of the examined tissue. We have used B-mode ultrasonography and shear wave elastography on 80 Achilles tendons from healthy volunteers with or without tendon pathology history, and correlated the data obtained with the clinical parameters of the volunteers, such as age, body mass index (BMI) and sports practice. We have shown that there is no significant correlation between the elastic modulus of the Achilles tendon and age, sports practice and body mass index with the exception of the correlation between the elastic modulus of the right Achilles tendon in men and age. Shear wave elastography has proved to be cost-effective for the evaluation of the Achilles tendon in healthy volunteers and was able to monitor the evolution of one patient with old tendon rupture treated by surgery. It can complete MRI investigation and it can replace B-mode ultrasonography particularly in monitoring the post-surgery evolution.
Lui, Tun Hing
Insertional and non-insertional Achilles tendinopathy is usually treated conservatively. Surgery is indicated if conservative treatment fails to relieve the pain. Endoscopic surgery has the advantages of less morbidity, a shorter operating time, reduced postoperative pain, and a lower rate of wound and soft-tissue healing problems. Patients will have a short recovery time and quickly resume work and sports because of less soft-tissue disruption. Moreover, the pathology can be better differentiated and precisely treated. Achilles tendoscopy is classically performed with the patient in the prone position, whereas endoscopic calcaneoplasty can be performed with the patient in the prone or supine position. This technical note describes the technique of Achilles tendoscopy and endoscopic calcaneoplasty with the patient in the supine position. This has the advantages of more ergonomic hand motion for the Achilles tendon debridement, easier access to the ventral surface of the Achilles tendon, and better orientation of the inside structures; moreover, concomitant chondral lesions of the ankle can be dealt with arthroscopically.
Lopez, Roberto Gabriel L; Jung, Hong-Geun
Athletes usually complain of an ongoing or chronic pain over the Achilles tendon, but recently even non-athletes are experiencing the same kind of pain which affects their daily activities. Achilles tendinosis refers to a degenerative process of the tendon without histologic or clinical signs of intratendinous inflammation. Treatment is based on whether to stimulate or prevent neovascularization. Thus, until now, there is no consensus as to the best treatment for this condition. This paper aims to review the common ways of treating this condition from the conservative to the surgical options.
Lopez, Roberto Gabriel L.
Athletes usually complain of an ongoing or chronic pain over the Achilles tendon, but recently even non-athletes are experiencing the same kind of pain which affects their daily activities. Achilles tendinosis refers to a degenerative process of the tendon without histologic or clinical signs of intratendinous inflammation. Treatment is based on whether to stimulate or prevent neovascularization. Thus, until now, there is no consensus as to the best treatment for this condition. This paper aims to review the common ways of treating this condition from the conservative to the surgical options. PMID:25729512
Landvater, S J; Renström, P A
Achilles tendon ruptures can be treated nonsurgically in the nonathletic or low-end recreational athletic patient, particularly those more than 50 years of age, provided the treating physician does not delay in the diagnosis and treatment (preferably less than 48 hrs and possibly less than 1 week). The patient should be advised of the higher incidence of re-rupture of the tendon when treated nonsurgically. Surgical treatment is recommended for patients who are young and athletic. This is particularly true because the major criticism of surgical treatment has been the complication rate, which has decreased to a low level and to a mild degree, usually not significantly affecting the repair over time. Surgical treatment in these individuals seems to be superior not only in regard to re-rupture but also in assuring the correct apposition of the tendon ends and in placing the necessary tension on the tendon to secure appropriate orientation of the collagen fibers. This in turn allows them to regain full strength, power, endurance, and an early return to sports. Surgery is also recommended for late diagnosed ruptures where there is significant lengthening of the tendon. Surgical technique should involve a medial incision to avoid the sural nerve, absorbable suture, and augmentation with fascia or tendon where there is a gap or late rupture. Postoperatively, the immobilization should be 7 to 10 days in a splint. A walking boot with early motion in plantar flexion or a short leg cast with the tendon under slight tension should thereafter be used for 4 to 5 weeks. An early and well-supervised rehabilitation program should be initiated to restore the patient to the preinjury activity level.
Johansson, Kristian; Lempainen, Lasse; Sarimo, Janne; Laitala-Leinonen, Tiina; Orava, Sakari
Summary Background the origin of chronic Achilles tendinopathy (AT) is currently unclear and epidemiological factors, such as ethnicity, may be associated. Methods intraoperative findings from the treatment of 865 Finnish and 156 Italian athletic patients with chronic Achilles tendon related pain were evaluated, retrospectively. The mean age was 34 years (range, 18 to 65 years) in the Finnish and 29 years (range, 17–63 years) in the Italian patients. In total, 786 patients were males and 226 females of which 84 and 87% Finnish, respectively. Data were collected, retrospectively from patient records. The differences in the frequencies of operative findings were assessed for statistical significance. Results retrocalcaneal bursitis, partial tear and chronic paratenonitis were the most prevalent findings in patients with chronic AT undergoing surgery. Tendinosis and chronic paratenonitis were significantly (p=0.011) more common in Finnish athletes. Italian patients exhibited significantly (p<0.001) more insertional calcific tendinopathy (heel spurs) and prominent posterosuperior calcaneal corners (Haglund’s heel). Conclusion ethnicity appears to be associated with specific characteristics of overuse-related Achilles tendon pathology. This is an issue that should be considered in the planning of genetic research on AT. PMID:27331038
Johansson, Kristian; Lempainen, Lasse; Sarimo, Janne; Laitala-Leinonen, Tiina; Orava, Sakari
Background: Nonsurgical treatments for chronic Achilles tendinopathy (AT) results in unpredictable success rates. Surgical treatment may be chosen as reports show mostly encouraging but variable success rates depending on the pathology. The distribution of surgically confirmed pathologies in AT is largely unknown. Purpose: To ascertain the distributions of macroscopically observed anomalies in participants undergoing surgical treatment for chronic AT. Study Design: Case series; Level of evidence, 4. Methods: The main macroscopic pathologies of 1661 chronic Achilles tendon overuse injuries, which were diagnosed and surgically treated by a single surgeon, were reviewed. The surgeries were performed on professional and recreational athletes during the years 1976-1980, 1986-1990, 1996-2000, and 2006-2010. Surgical diagnoses, along with age- and sport-specific characteristics, were collected retrospectively from patient records. Results: The relative proportion of tendinosis increased during the study period from 4.2% to 21%, and paratenonitis decreased from 50% to 26%. Retrocalcaneal pathologies were the most common surgically confirmed lesions at 30%, while the mean age at surgery increased by 11 years over the entire study period. Conclusion: Surgically confirmed pathologies in and around the Achilles tendon showed coherent changes, chronic paratenonitis, and retrocalcaneal problems as the most prevalent findings. The classification of midportion and insertional tendinopathy and retrocalcaneal bursitis in AT should strictly be used as a clinical diagnosis. During surgical evaluations, the diagnosis is further clarified as more specific pathologies may be identified. PMID:26535293
Xu, Shao-Yong; Li, Shu-Fen; Ni, Guo-Xin
Background Although tendinopathy is common, its underlying pathogenesis is poorly understood. This study aimed to investigate the possible pathogenesis of tendinopathy. Material/Methods In this study, a total of 24 rats were randomly and evenly divided into a control (CON) group and a strenuous treadmill running (STR) group. Animals in the STR group were subjected to a 12-week treadmill running protocol. Subsequently, all Achilles tendons were harvested to perform histological observation or biochemical analyses. Results Histologically, hypercellularity and round cells, as well as disorganized collagen fibrils, were presented in rat Achilles tendon sections from the STR group. Furthermore, our results showed that the expression of aggrecan, collagen type II (Col II), and Sex-Determining Region Y Box 9 (Sox 9) were markedly increased in the STR group compared with that in the CON group. Additionally, the mRNA expression of bone morphogenetic protein-2 (BMP-2) and biglycan was significantly up-regulated in the STR group in contrast to that in CON group. Conclusions These results suggest that a 12-week strenuous treadmill running regimen can induce chondrocyte phenotype in rat Achilles tendons through chondrogenic differentiation of tendon stem cells (TSCs) by BMP-2 signaling. PMID:27742920
Tendinopathy is a common clinical problem with athletes and in many occupational settings. Tendinopathy can occur in any tendon, often near its insertion or enthesis where there is an area of stress concentration, and is directly related to the volume of repetitive load to which the tendon is exposed. Recent studies indicate tendinopathy is more likely to occur in situations that increase the “dose” of load to the tendon enthesis – including increased activity, weight, advancing age, and genetic factors. The cells in tendinopathic tendon are rounder, more numerous, and show evidence of oxidative damage and more apoptosis. These cells also produce a matrix that is thicker and weaker with more water, more immature and cartilage-like matrix proteins, and less organization. There is now evidence of a population of regenerating stem cells within tendon. These studies suggest prevention of tendinopathy should be directed at reducing the volume of repetitive loads to below that which induces oxidative-induced apoptosis and cartilage-like genes. The management strategies might involve agents or cells that induce tendon stem cell proliferation, repair and restoration of matrix integrity. PMID:18478310
Rice, Hannah; Patel, Mubarak
The Achilles tendon is the most common site of tendon overuse injury in humans. Running with a forefoot strike pattern and in minimal shoes is a topic of recent interest, yet evidence is currently limited regarding the combined influence of foot strike and footwear on Achilles tendon loading. To investigate the influence of both foot strike and footwear on Achilles tendon loading in habitual rearfoot strike runners. Controlled laboratory study. Synchronized kinematic and force data were collected from 22 habitual rearfoot strikers (11 male), who habitually ran in nonminimal running shoes, during overground running at 3.6 m·s(-1). Participants ran in 3 different footwear conditions (standard running shoe, minimal running shoe, and barefoot) with both a rearfoot strike (RFS) and an imposed forefoot strike (FFS) in each footwear condition. Achilles tendon loading was estimated by use of inverse dynamics, where the Achilles tendon moment arm was determined with a regression equation. A 2-way, repeated-measures analysis of variance was used to compare conditions. Achilles tendon impulse was greater when subjects ran with an FFS rather than an RFS in minimal shoes. Achilles tendon loading rates were higher when subjects ran either in minimal shoes or barefoot than in standard shoes, regardless of foot strike. In runners who habitually rearfoot strike in standard running shoes, running in minimal shoes or barefoot increased the rate of tendon loading, and running with a forefoot strike in minimal shoes increased the magnitude of tendon loading. Transitioning to these running conditions may increase the risk of tendinopathy.
Peck, Evan; Jelsing, Elena; Onishi, Kentaro
Tendinopathy is increasingly recognized as an important cause of musculoskeletal pain and disability. Tendinopathy is thought to be principally a degenerative process, rather than inflammatory as was traditionally believed. Consequently, traditional tendinopathy treatments focused solely on decreasing inflammation have often been ineffective or even harmful. The advancement of ultrasonography as for guidance of outpatient musculoskeletal procedures has facilitated the development of novel percutaneous procedures for the treatment of tendinopathy, mostly by using mechanical intervention to stimulate regeneration. Several of these techniques, including percutaneous needle tenotomy, percutaneous ultrasonic tenotomy, high-volume injection, and percutaneous needle scraping, are reviewed in this article. Copyright © 2016 Elsevier Inc. All rights reserved.
Said, M Nader; Al Ateeq Al Dosari, Mohamed; Al Subaii, Nasser; Kawas, Alaa; Al Mas, Ali; Al Ser, Yaser; Abuodeh, Yousef; Shakil, Malik; Habash, Ali; Mukhter, Khalid
In contrast to closed Achilles tendon ruptures, open injuries are rarely reported in the literature. This paper provides information about open Achilles tendon wounds that are eventually seen in the Middle East. The reporting unit, Hamad Medical Corporation, is one of the biggest trauma centers in the Gulf area and the major health provider in Qatar. This is a retrospective study including patients admitted and operated for open Achilles tendon injuries between January 2011 and December 2013. Two hundred and five cases of open Achilles tendon lacerations were operated in Hamad General Hospital in this period. Forty-eight cases showed partial injuries, and the remaining are complete tendons cut. In the same period, fifty-one closed ruptured Achilles tendons were operated in the same trauma unit. In the majority of cases, the open injury resulted from a slip in the floor-leveled traditional toilette seats. Local damage to the toilette seats resulted in sharp edges causing the laceration of the heel if the patient was slipping over the wet floor. This occurrence is the cause in the vast majority of the cases. Wounds were located 1-5 cm proximal to tendon insertion. Standard treatment principles were applied. This included thorough irrigation in the emergency room, intravenous antibiotics, surgical debridement and primary repair within 24 h. Patients were kept in the hospital 1-7 days for intravenous antibiotics and possible dressing changes. Postoperatively below knee slabs were applied in the majority of patients and were kept for about 4 weeks followed by gradual weight bearing and range of motion exercises. Outpatients follow up in 1-2 weeks. Further follow-up visits at around 2-, 4-, 8- and 12-week intervals until complete wound healing and satisfactory rehabilitation outcome. Sixteen cases needed a second procedure. A high incidence of Achilles tendon open injuries is reported. This seems to be related to partially damaged floor-level toilettes in the
Real-time ultrasonography (US) using linear-array probes and a stand-off pad as a ''waterpath'' was performed to evaluate the Achilles tendon in 67 patients (including 24 athletes) believed to have acute or chronic traumatic or inflammatory pathologic conditions. Tendons in 23 patients appeared normal on US scans. The 44 abnormal tendons comprised five complete and four partial ruptures, seven instances of postoperative change, and 28 cases of tendonitis. US depiction of the inner structure of the tendon resulted in the diagnosis of focal abnormalities, including partial ruptures, nodules, and calcifications. Tendonitis was characterized by enlargement and decreased echogenicity of the tendon. The normal US appearance of the Achilles tendon is described.
Xu, Yinghua; Bonar, Fiona; Murrell, George A C
The aim of this study was to determine whether there are more nerves in tendinopathic human tendon, and if so, where are they located. Tendon biopsies were collected from normal, tendinopathic, and torn human rotator cuff tendons and then analyzed using immunohistochemistry and antibodies against a general nerve marker (protein gene product 9.5, PGP9.5), a nerve regeneration marker (growth-associated protein 43, GAP43), and an endothelial cell marker (CD34). Nerve fibers exhibiting PGP9.5 or GAP43 immunoreactivity were often observed intimately in association with tiny blood vessels in the endotendineum of tendinopathic tendons. The expression of PGP9.5 and GAP43 were significantly higher in tendinopathic tendon compared with control tendon and torn tendon. These data support the hypothesis that early tendinopathy is associated with increases of newly grown nerve fibers and blood vessels inside and around tendinopathic tendon, and these may be the source of pain in tendinopathy.
Kraeutler, Matthew J.; Garabekyan, Tigran; Pascual-Garrido, Cecilia; Mei-Dan, Omer
Summary Background The ligamentum teres (LT) consists of two bands that originate on the ischial and pubic sides of the acetabular notch and insert on the fovea capitis of the femoral head. Recent studies have established the LT as an important hip stabilizer in a squatting position, particularly in patients with osseous instability. Purpose This review aims to concisely present the literature on LT tendinopathy and tears in order to guide health care professionals in the appropriate diagnosis and treatment of these disorders. Methods We reviewed the literature on the diagnosis and surgical management of ligamentum teres tendinopathy and tears. Conclusions The ligamentum teres is an important stabilizer to the hip joint, particularly with hip flexion and external rotation. Older age and acetabular bony pathomorphology are two of the known risk factors for LT tears. Symptoms of LT tendinopathy are largely non-specific, mimicking a wide range of other hip disorders including impingement and instability. Debridement of LT tears or reactive tissue has been reported with good outcomes, with more recent studies describing reconstruction of a completely torn, nonfunctional, or absent LT using various graft sources including synthetic grafts, autografts, and allografts. Level of evidence II. PMID:28066738
de Oliveira, Rodrigo R.; Martins, Conceição S.; Rocha, Yuri R.; Braga, Allysson B. R.; Mattos, Rômulo M.; Hecht, Fábio; Brito, Gerly A. C.; Nasciutti, Luiz E.
This study aims to demonstrate how the state of chronic hyperglycemia from experimental Diabetes Mellitus can influence the homeostatic imbalance of tendons and, consequently, lead to the characteristics of tendinopathy. Twenty animals were randomly divided into two experimental groups: control group, consisting of healthy rats and diabetic group constituted by rats induced to Diabetes Mellitus I. After twenty-four days of the induction of Diabetes type I, the Achilles tendon were removed for morphological evaluation, cellularity, number and cross-sectional area of blood vessel, immunohistochemistry for Collagen type I, VEGF and NF-κB nuclear localization sequence (NLS) and nitrate and nitrite level. The Achilles tendon thickness (µm/100g) of diabetic animals was significantly increased and, similarly, an increase was observed in the density of fibrocytes and mast cells in the tendons of the diabetic group. The average number of blood vessels per field, in peritendinous tissue, was statistically higher in the diabetic group 3.39 (2.98) vessels/field when compared to the control group 0.89 (1.68) vessels/field p = 0.001 and in the intratendinous region, it was observed that blood vessels were extremely rare in the control group 0.035 (0.18) vessels/field and were often present in the tendons of the diabetic group 0.89 (0.99) vessels/field. The immunohistochemistry analysis identified higher density of type 1 collagen and increased expression of VEGF as well as increased immunostaining for NFκB p50 NLS in the nucleus in Achilles tendon of the diabetic group when compared to the control group. Higher levels of nitrite/nitrate were observed in the experimental group induced to diabetes. We conclude that experimental DM induces notable structural, inflammatory and vascular changes in the Achilles tendon which are compatible with the process of chronic tendinopathy. PMID:24130676
de Oliveira, Rodrigo R; Martins, Conceição S; Rocha, Yuri R; Braga, Allysson B R; Mattos, Rômulo M; Hecht, Fábio; Brito, Gerly A C; Nasciutti, Luiz E
This study aims to demonstrate how the state of chronic hyperglycemia from experimental Diabetes Mellitus can influence the homeostatic imbalance of tendons and, consequently, lead to the characteristics of tendinopathy. Twenty animals were randomly divided into two experimental groups: control group, consisting of healthy rats and diabetic group constituted by rats induced to Diabetes Mellitus I. After twenty-four days of the induction of Diabetes type I, the Achilles tendon were removed for morphological evaluation, cellularity, number and cross-sectional area of blood vessel, immunohistochemistry for Collagen type I, VEGF and NF-κB nuclear localization sequence (NLS) and nitrate and nitrite level. The Achilles tendon thickness (µm/100g) of diabetic animals was significantly increased and, similarly, an increase was observed in the density of fibrocytes and mast cells in the tendons of the diabetic group. The average number of blood vessels per field, in peritendinous tissue, was statistically higher in the diabetic group 3.39 (2.98) vessels/field when compared to the control group 0.89 (1.68) vessels/field p = 0.001 and in the intratendinous region, it was observed that blood vessels were extremely rare in the control group 0.035 (0.18) vessels/field and were often present in the tendons of the diabetic group 0.89 (0.99) vessels/field. The immunohistochemistry analysis identified higher density of type 1 collagen and increased expression of VEGF as well as increased immunostaining for NFκB p50 NLS in the nucleus in Achilles tendon of the diabetic group when compared to the control group. Higher levels of nitrite/nitrate were observed in the experimental group induced to diabetes. We conclude that experimental DM induces notable structural, inflammatory and vascular changes in the Achilles tendon which are compatible with the process of chronic tendinopathy.
O'Connell, Dennis; Brismée, Jean-Michel; Sizer, Phil; Apte, Gail; O'Connell, Janelle
Chronic tendinopathy is a common musculoskeletal disorder that frequently affects athletes who train and compete at all levels. This Clinical Commentary presents a review of the etiology, incidence, and contributory factors related specifically to patellar tendinopathy. Examination and differential diagnosis considerations are provided, and an evidence-based, staged rehabilitation program is described. PMID:21589672
Sorenson, Shawn C; Arya, Shruti; Souza, Richard B; Pollard, Christine D; Salem, George J; Kulig, Kornelia
Controlled laboratory study using a cross-sectional design. To evaluate knee joint dynamics in elite volleyball players with and without a history of patellar tendinopathy, focusing on mechanical energy absorption and generation. We hypothesized that tendinopathy would be associated withreduced net joint work and net joint power. Patellar tendinopathy is a common, debilitating injury affecting competitive volleyball players. Thirteen elite male players with and without a history of patellar tendinopathy (mean ± SD age, 27 ± 7 years) performed maximum-effort volleyball approach jumps. Sagittal plane knee joint kinematics, kinetics, and energetics were quantified in the lead limb, using data obtained from a force platform and an 8-camera motion analysis system. Vertical ground reaction forces and pelvis vertical velocity at takeoff were examined. Independent sample t tests were used to evaluate group differences (α = .05). The tendinopathy group, compared to controls, demonstrated significant reductions (approximately 30%) in net joint work and net joint power during the eccentric phase of the jump, with no differences in the concentric phase. Positive to-negative net joint work and net joint power ratios were significantly higher in the tendinopathy group, which had a net joint work ratio of 1.00 (95% CI: 0.77, 1.24) versus 0.76 (95% CI: 0.64, 0.88) for controls, and a net joint power ratio of 1.62 (95% CI: 1.15, 2.10) versus 1.00 (95% CI: 0.80, 1.21) for controls. There were no significant differences in net joint moment, angular velocity, or range of motion. Peak vertical ground reaction forces were lower for the tendinopathy group, while average vertical ground reaction forces and pelvis vertical velocity were similar. Patellar tendinopathy is associated with differences in sagittal plane mechanical energy absorption at the knee during maximum-effort volleyball approach jumps. Net joint work and net joint power may help define underlying mechanisms, adaptive
Bley, Bradley; Abid, Waqas
Imaging plays an important role in the clinical evaluation of patients with musculoskeletal-related pain, but its utility for the management of tendinopathy is debatable. Findings on ultrasound and magnetic resonance imaging may not correlate with clinical symptoms, and it is not uncommon to find anatomical changes associated with tendinopathy in tendons of asymptomatic individuals. Likewise, patients with clinical symptoms of tendinopathy can present with normal imaging evaluation. The use of diagnostic and interventional ultrasound has significantly increased over the past decade in a bid for better treatments of tendinopathy. Despite the limitations of traditional imaging in the diagnosis and management of tendinopathy, interventional procedures that utilize ultrasound hold promise. J Orthop Sports Phys Ther 2015;45(11):826-828. doi:10.2519/jospt.2015.0113.
Khan, K M; Cook, J L; Bonar, F; Harcourt, P; Astrom, M
Tendon disorders are a major problem for participants in competitive and recreational sports. To try to determine whether the histopathology underlying these conditions explains why they often prove recalcitrant to treatment, we reviewed studies of the histopathology of sports-related, symptomatic Achilles, patellar, extensor carpi radialis brevis and rotator cuff tendons. The literature indicates that healthy tendons appear glistening white to the naked eye and microscopy reveals a hierarchical arrangement of tightly packed, parallel bundles of collagen fibres that have a characteristic reflectivity under polarised light. Stainable ground substance (extracellular matrix) is absent and vasculature is inconspicuous. Tenocytes are generally inconspicuous and fibroblasts and myofibroblasts absent. In stark contrast, symptomatic tendons in athletes appear grey and amorphous to the naked eye and microscopy reveals discontinuous and disorganised collagen fibres that lack reflectivity under polarised light. This is associated with an increase in the amount of mucoid ground substance, which is confirmed with Alcian blue stain. At sites of maximal mucoid change, tenocytes, when present, are plump and chondroid in appearance (exaggerated fibrocartilaginous metaplasia). These changes are accompanied by the increasingly conspicuous presence of cells within the tendon tissue, most of which have a fibroblastic or myofibroblastic appearance (smooth muscle actin is demonstrated using an avidin biotin technique). Maximal cellular proliferation is accompanied by prominent capillary proliferation and a tendency for discontinuity of collagen fibres in this area. Often, there is an abrupt discontinuity of both vascular and myofibroblastic proliferation immediately adjacent to the area of greatest abnormality. The most significant feature is the absence of inflammatory cells. These observations confirm that the histopathological findings in athletes with overuse tendinopathies are
Joseph, Michael F; Taft, Kathryn; Moskwa, Maria; Denegar, Craig R
Systematic literature review. To assess the efficacy of deep friction massage (DFM) in the treatment of tendinopathy. Anecdotal evidence supports the efficacy of DFM for the treatment of tendinopathy. An advanced understanding of the etiopathogenesis of tendinopathy and the resultant paradigm shift away from an active inflammatory model has taken place since the popularization of the DFM technique by Cyriax for the treatment of "tendinitis." However, increasing mechanical load to the tendinopathic tissue, as well as reducing molecular cross-linking during the healing process via transverse massage, offers a plausible explanation for observed responses in light of the contemporary understanding of tendinopathy. The authors surveyed research articles in all languages by searching PubMed, Scopus, Pedro, CINAHL, PsycINFO, and the Cochrane Library using the terms deep friction massage, deep tissue massage, deep transverse massage, Cyriax, soft tissue mobilization, soft tissue mobilisation, cross friction massage, and transverse friction massage. They included 4 randomized comparison trials, 3 at the extensor carpi radialis brevis (ECRB) and 1 supraspinatus outlet tendinopathy; 2 nonrandomized comparison trials, both receiving DFM at the ECRB; and 3 prospective noncomparison trials-supraspinatus, ECRB, and Achilles tendons. Articles meeting inclusion criteria were assessed based on PEDro and Centre for Evidence-Based Medicine rating scales. Nine studies met the inclusion criteria. The heterogeneity of dependent measures did not allow for meta-analysis. The varied locations, study designs, etiopathogenesis, and outcome tools used to examine the efficacy of DFM make a unified conclusion tenuous. There is some evidence of benefit at the elbow in combination with a Mills manipulation, as well as for supraspinatus tendinopathy in the presence of outlet impingement and along with joint mobilization. The examination of DFM as a single modality of treatment in comparison with
Helland, Christian; Bojsen-Møller, Jens; Raastad, Truls; Seynnes, Olivier R; Moltubakk, Marie M; Jakobsen, Vidar; Visnes, Håvard; Bahr, Roald
Although differences in mechanical properties between symptomatic and healthy tendons have been observed for the Achilles tendon, the impact of tendinopathy on patellar tendon mechanics is not fully documented. The aim of the present case-control study was to assess the mechanical properties of the tendon and jump performance in elite athletes with and without patellar tendinopathy. We identified 17 male volleyball players with patellar tendinopathy and 18 healthy matched controls from a 5-year prospective cohort study on junior elite volleyball players. Outcome variables included three measures of maximal vertical jump performance and ultrasound-based assessments of patellar tendon cross-sectional area, stiffness and Young's modulus. The proximal cross-sectional area of the patellar tendon was significantly larger in the tendinopathic group (133 ± 11 vs 112 ± 9 mm(2), respectively; p < 0.001). Pathological tendons presented lower stiffness (2254 ± 280 vs 2826 ± 603 N/mm, respectively; p = 0.006) and Young's modulus (0.99 ± 0.16 vs 1.17 ± 0.25 GPa, respectively; p = 0.04) than healthy tendons. However, the difference between the countermovement jump height and the squat jump height (3.4 ± 2.2 vs 1.2 ± 1.5 cm, p = 0.005) was significantly higher in the tendinopathic group compared with the control group. Patellar tendinopathy is associated with a decrease in the mechanical and material properties of the tendon in elite athletes subjected to a high volume of jumping activity. However, compared with their healthy counterparts, tendinopathic volleyball players have a better ability to utilise the stretch-shortening cycle when jumping.
Mani-Babu, Sethu; Morrissey, Dylan; Waugh, Charlotte; Screen, Hazel; Barton, Christian
There is accumulating evidence for the effectiveness of extracorporeal shock wave therapy (ESWT) when treating lower limb tendinopathies including greater trochanteric pain syndrome (GTPS), patellar tendinopathy (PT), and Achilles tendinopathy (AT). To evaluate the effectiveness of ESWT for lower limb tendinopathies. Systematic review and meta-analysis. PubMed (Medline), Embase, Web of Knowledge, Cochrane, and CINAHL were searched from inception to February 2013 for studies of any design investigating the effectiveness of ESWT in GTPS, PT, and AT. Citation tracking was performed using PubMed and Google Scholar. Animal and non-English language studies were excluded. A quality assessment was performed by 2 independent reviewers, and effect size calculations were computed when sufficient data were provided. A total of 20 studies were identified, with 13 providing sufficient data to compute effect size calculations. The energy level, number of impulses, number of sessions, and use of a local anesthetic varied between studies. Additionally, current evidence is limited by low participant numbers and a number of methodological weaknesses including inadequate randomization. Moderate evidence indicates that ESWT is more effective than home training and corticosteroid injection in the short (<12 months) and long (>12 months) term for GTPS. Limited evidence indicates that ESWT is more effective than alternative nonoperative treatments including nonsteroidal anti-inflammatory drugs, physical therapy, and an exercise program and equal to patellar tenotomy surgery in the long term for PT. Moderate evidence indicates that ESWT is more effective than eccentric loading for insertional AT and equal to eccentric loading for midportion AT in the short term. Additionally, there is moderate evidence that combining ESWT and eccentric loading in midportion AT may produce superior outcomes to eccentric loading alone. Extracorporeal shock wave therapy is an effective intervention and should
Donaldson, Oliver; Vannet, Nicola; Gosens, Taco; Kulkarni, Rohit
In the second part of this review article the management of medial elbow tendinopathy, distal biceps and distal triceps tendinopathy will be discussed. There is a scarcity of publications concerning any of these tendinopathies. This review will summarise the current best available evidence in their management. Medial elbow tendinopathy, also known as Golfer's elbow, is up to 6 times less common than lateral elbow tendinopathy. The tendinopathy occurs in the insertion of pronator teres and flexor carpi radialis. Diagnosis is usually apparent through a detailed history and examination but care must be made to exclude other conditions affecting the ulnar nerve or less commonly the ulnar collateral ligament complex. If doubt exists then MRI/US and electrophysiology can be used. Treatment follows a similar pattern to that of lateral elbow tendinopathy. Acute management is with activity modification and topical NSAIDs. Injection therapy and surgical excision are utilised for recalcitrant cases. Distal biceps and triceps tendinopathies are very rare and there is limited evidence published. Sequelae of tendinopathy include tendon rupture and so it is vital to manage these tendinopathies appropriately in order to minimise this significant complication. Their management and that of partial tears will be considered.
Spang, Christoph; Alfredson, Håkan; Ferguson, Mark; Roos, Beverley; Bagge, Johan; Forsgren, Sture
The plantaris tendon is often neglected in morphological/clinical studies on the lower extremity. There is, however, clinical evidence that the plantaris tendon is involved in cases with Achilles midportion tendinopathy/tendinosis. It is nevertheless unclear if the plantaris tendon exhibits tendinosis-like features in this situation. We therefore investigated the plantaris tendon of patients with midportion Achilles tendinosis when the plantaris tendon was found to be located very close to or invaginated into the Achilles tendon, a situation which very often has been found to be the case. There was a very large number of tenocytes in the tendon tissue and the tenocytes showed abnormal and irregular appearances, exhibiting widened/rounded and wavy appearances, and were frequently lined up in rows. These features are characteristic features in Achilles tendinosis tendons. The tendon cells showed a distinct immunoreaction for the acetylcholine (ACh) -producing enzyme choline acetyltransferase (ChAT). Frequent fibroblasts were found in the loose connective tissue and these cells also showed a marked ChAT immunoreaction. The study shows that the plantaris tendon is morphologically affected in a similar way to the Achilles tendon in cases with midportion Achilles tendinosis and medial pain. The plantaris tendon may accordingly be a co-factor in these cases. The results also favour that there is a local ACh production both within the tendon tissue of the plantaris tendon and in the loose connective tissue. In conclusion, it is evident that plantaris tendons lying invaginated into or very close to the Achilles tendon in cases with midportion Achilles tendinosis show similar tendinosis features, as previously shown for the Achilles tendon itself in these cases.
Raney, Elise B; Thankam, Finosh G; Dilisio, Matthew F; Agrawal, Devendra K
Biceps tendinopathy is a relatively common ailment that typically presents as pain, tenderness, and weakness in the tendon of the long head of the biceps brachii. Though it is often associated with degenerative processes of the rotator cuff and the joint, this is not always the case, thus, the etiology remains considerably unknown. There has been recent interest in elucidating the pathogenesis of tendinopathy, since it can be an agent of chronic pain, and is difficult to manage. The purpose of this article is to critically evaluate relevant published research that reflects the current understanding of pain and how it relates to biceps tendinopathy. A review of the literature was conducted to create an organized picture of how pain arises and manifests itself, and how the mechanism behind biceps tendinopathy possibly results in pain. Chronic pain is thought to arise from neurogenic inflammation, central pain sensitization, excitatory nerve augmentation, inhibitory nerve loss, and/or dysregulation of supraspinal structures; thus, the connections of these theories to the ones regarding the generation of biceps tendinopathy, particularly the neural theory, are discussed. Pain mediators such as tachykinins, CGRP, and alarmins, in addition to nervous system ion channels, are highlighted as possible avenues for research in tendinopathy pain. Recognition of the nociceptive mechanisms and molecular of biceps tendinopathy might aid in the development of novel treatment strategies for managing anterior shoulder pain due to a symptomatic biceps tendon. PMID:28670360
Sharma, Pankaj; Maffulli, Nicola
Tendon disorders are frequent and are responsible for substantial morbidity both in sports and in the workplace. Tendinopathy, as opposed to tendinitis or tendinosis, is the best generic descriptive term for the clinical conditions in and around tendons arising from overuse. Tendinopathy is a difficult problem requiring lengthy management, and patients often respond poorly to treatment. Preexisting degeneration has been implicated as a risk factor for acute tendon rupture. Several physical modalities have been developed to treat tendinopathy. There is limited and mixed high-level evidence to support the, albeit common, clinical use of these modalities. Further research and scientific evaluation are required before biological solutions become realistic options.
Park, Giyoung; Kwon, Dongrak; Park, Junghyun
Conventional ultrasonography or magnetic resonance (MR) imaging is commonly performed to obtain information about the severity of the disease, location of the injury, and differential diagnosis. The aim of this research was to investigate the diagnostic confidence of sonoelastography as an adjunct to greyscale ultrasonography in lateral elbow tendinopathy. A single experienced physiatrist performed greyscale ultrasonography and sonoelastography in 28 patients (9 men, 19 women; mean age, 48.5 years; age range, 36-67 years) with unilateral symptoms of lateral elbow tendinopathy; the asymptomatic elbows were used as controls. Greyscale images were described as normal, tendinosis, partial-thickness tear, and full-thickness tear. Sonoelastographic images of the common extensor tendon were analyzed qualitatively (scoring of the elastic spectrum) and quantitatively (based on a color histogram). Both the imaging methods had high sensitivity, specificity, and accuracy for diagnosing lateral elbow tendinopathy. Considering the clinical diagnosis of lateral elbow tendinopathy, sonoelastography showed significantly higher diagnostic accuracy (96.4%) than ultrasonography (89.5%, P < 0.01). Quantitative analysis showed objective interpretation of the sonoelastographic images that revealed greater intensity of green and blue pixels in symptomatic elbows (P < 0.01). Sonoelastography increases diagnostic confidence in tennis elbow pathology over greyscale ultrasonography alone and may be an additional powerful diagnostic tool in cases of lateral elbow tendinopathy with inconclusive greyscale ultrasonographic findings.
Hamilton, Bruce; Remedios, Denis; Loosemore, Mike; Maffulli, Nicola
Achilles tendinopathy is common, and its management continues to be challenging, especially in elite athletes. Despite a wide range of novel management options, none guarantees a rapid return to high level sporting activity. Eccentric exercise has been shown to reduce symptoms and normalise imaging abnormalities, but time constraints on professional athletes often make this an unrewarding isolated management strategy. Eccentric exercises concurrent with ongoing training may not be as successful as eccentric training alone, reducing one's confidence in this modality for the "in-season" tendinopathy in the elite athlete. When a professional athlete is faced with a tendinopathy recalcitrant to eccentric exercise, manual therapy and orthotics, a more invasive approach is often attempted to expedite a return to unencumbered training. Numerous injection therapies are described, ranging from homeopathic products to glucocorticosteroids. The robustness of the literature surrounding these techniques is variable, but when an athlete is desperate to return to full training, clinicians working with elite athletes are often tempted to utilise more empirical management options. We present a patient who illustrates the potential dangers of injection therapy in the elite athlete, in particular sequential injection therapy involving vascular sclerosants, which to our knowledge has not previously been described. Written consent for the presentation of this case was obtained from the athlete concerned.
Background Chronic tendon injuries, also known as tendinopathies, are common among professional and recreational athletes. These injuries result in a significant amount of morbidity and health care expenditure, yet little is known about the molecular mechanisms leading to tendinopathy. Methods We have used histological evaluation and molecular profiling to determine gene expression changes in 23 human patients undergoing surgical procedures for the treatment of chronic tendinopathy. Results Diseased tendons exhibit altered extracellular matrix, fiber disorientation, increased cellular content and vasculature, and the absence of inflammatory cells. Global gene expression profiling identified 983 transcripts with significantly different expression patterns in the diseased tendons. Global pathway analysis further suggested altered expression of extracellular matrix proteins and the lack of an appreciable inflammatory response. Conclusions Identification of the pathways and genes that are differentially regulated in tendinopathy samples will contribute to our understanding of the disease and the development of novel therapeutics. PMID:21539748
Chimenti, Ruth L; Flemister, A Samuel; Ketz, John; Bucklin, Mary; Buckley, Mark R; Richards, Michael S
Heel lifts are commonly prescribed to patients with Achilles tendinopathy, yet little is known about the effect on tendon compressive strain. The purposes of the current study were to (1) develop a valid and reliable ultrasound elastography technique and algorithm to measure compressive strain of human Achilles tendon in vivo, (2) examine the effects of ankle dorsiflexion (lowering via controlled removal of a heel lift and partial squat) on compressive strain of the Achilles tendon insertion and (3) examine the relative compressive strain between the deep and superficial regions of the Achilles tendon insertion. All tasks started in a position equivalent to standing with a 30mm heel lift. An ultrasound transducer positioned over the Achilles tendon insertion was used to capture radiofrequency images. A non-rigid image registration-based algorithm was used to estimate compressive strain of the tendon, which was divided into 2 regions (superficial, deep). The bland-Altman test and intraclass correlation coefficient were used to test validity and reliability. One-way repeated measures ANOVA was used to compare compressive strain between regions and across tasks. Compressive strain was accurately and reliably (ICC>0.75) quantified. There was greater compressive strain during the combined task of lowering and partial squat compared to the lowering (P=.001) and partial squat (P<.001) tasks separately. There was greater compressive strain in the deep region of the tendon compared to the superficial for all tasks (P=.001). While these findings need to be examined in a pathological population, heel lifts may reduce tendon compressive strain during daily activities. Copyright © 2015 Elsevier Ltd. All rights reserved.
To improve its mechanical advantage, the extensor carpi ulnaris (ECU) muscle uses, as if it was a pulley, the 6(th) extensor compartment, a dorsal fibro-osseous tunnel formed by the ulnar sulcus and the ECU tendon sub-sheath. Rupture or insufficiency of that sheath may allow anteromedial ECU tendon subluxation and subsequent destabilization of the distal radioulnar and ulnocarpal joints. Sometimes, it is not sheath problem, but excessive friction between the sheath and the tendon what causes a painful degeneration of the tendon (tendinosis) with or without tendon entrapment. The term "ECU tendinopathy" has been chosen to designate all painful ECU anomalies resulting from a dysfunctional 6(th) extensor compartment. ECU tendinopathies are frequent among sportsmen using bats, sticks or clubs. There are 2 major types of tendinopathy: 1) constrained tendinopathies, where there is entrapment of a thickened overused tendon, and 2) unconstrained tendinopathies, where a ruptured ECU sub-sheath allows the ECU to sublux in a volar direction, a position precluding all its stabilizing potential. In the first type, the goal of the treatment is to avoid further degeneration and subsequent rupture of the diseased tendon; in the second, to re-establish the normal connections between the ulna and the ECU tendon. This article reviews the management of the most frequent ECU tendinopathies. © Georg Thieme Verlag KG Stuttgart · New York.
Ingwersen, Kim G; Christensen, Robin; Sørensen, Lilli; Jørgensen, Hans Ri; Jensen, Steen Lund; Rasmussen, Sten; Søgaard, Karen; Juul-Kristensen, Birgit
Shoulder pain is the third most common musculoskeletal disorder, often affecting people's daily living and work capacity. The most common shoulder disorder is the subacromial impingement syndrome (SIS) which, among other pathophysiological changes, is often characterised by rotator cuff tendinopathy. Exercise is often considered the primary treatment option for rotator cuff tendinopathy, but there is no consensus on which exercise strategy is the most effective. As eccentric and high-load strength training have been shown to have a positive effect on patella and Achilles tendinopathy, the aim of this trial is to compare the efficacy of progressive high-load exercises with traditional low-load exercises in patients with rotator cuff tendinopathy. The current study is a randomised, participant- and assessor-blinded, controlled multicentre trial. A total of 260 patients with rotator cuff tendinopathy will be recruited from three outpatient shoulder departments in Denmark, and randomised to either 12 weeks of progressive high-load strength training or to general low-load exercises. Patients will receive six individually guided exercise sessions with a physiotherapist and perform home-based exercises three times a week. The primary outcome measure will be change from baseline to 12 weeks in the patient-reported outcome Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Previous studies of exercise treatment for SIS have not differentiated between subgroups of SIS and have often had methodological flaws, making it difficult to specifically design target treatment for patients diagnosed with SIS. Therefore, it was considered important to focus on a subgroup such as tendinopathy, with a specific tailored intervention strategy based on evidence from other regions of the body, and to clearly describe the intervention in a methodologically strong study. The trial was registered with Clinicaltrials.gov ( NCT01984203 ) on 31 October 2013.
Carlisi, Ettore; Lisi, Claudio; Dall'angelo, Anna; Monteleone, Serena; Nola, Vincenza; Tinelli, Carmine; Dalla Toffola, Elena
Extracorporeal shock wave therapy is effective in reducing shoulder pain and improving function in calcific supraspinatus tendinopathy. Eccentric exercise has been introduced as an effective treatment choice for Achilles tendinopathy, but poor evidence exists about its role in the treatment of rotator cuff tendinopathy. To investigate if adding a supervised eccentric training of the shoulder abductor muscles could improve the outcome of extracorporeal shock wave therapy. Pre-post intervention pilot study with matched control-group. Outpatient, University Hospital. Twenty-two subjects affected by painful supraspinatus calcific tendinopathy. The study-group was assigned to receive focal extracorporeal shockwave therapy (f-ESWT) plus a supervised eccentric training (SET) of the shoulder abductor muscles. The matched control-group received f-ESWT only. The post-treatment assessment (follow-up t1) was performed nine weeks after the enrollment (t0). We assessed shoulder pain and function by the means of a numeric rating scale (p-NRS) and a DASH scale. As secondary outcome, we measured the isometric strength of the abductor muscles of the affected shoulder using a handheld dynamometer. At t1, we recorded a significant decrease in pain (p<0.001) and an improvement in upper limb function (p<0.001) in both groups. However, we observed no statistical differences in favour of the study-group, in terms of p-NRS and DASH total score. A mild increase (13% from the baseline) of the maximum isometric abduction strength was noticed in the study- group at t1. Our findings did not support the hypothesis that adding a supervised eccentric training of the shoulder abductor muscles could improve the outcome (pain and function) of shock wave therapy. Our study confirmed that f-ESWT is effective in reducing shoulder pain and improving function in calcific supraspinatus tendinopathy. Adding a supervised eccentric training, focused on the abductor muscles, was useful to improve maximum
Ahmad, Jamal; Repka, Michael; Raikin, Steven M
There is scant literature regarding the treatment of myotendinous Achilles ruptures. The purpose of this study was to retrospectively examine clinical outcomes from uniform nonsurgical treatment of these injuries. Between November 2005 and May 2011, 30 patients presented with an acute, complete myotendinous Achilles rupture. The location of the Achilles injury was confirmed on magnetic resonance imaging (MRI) for all patients. All patients were treated nonsurgically, which involved 3 weeks of non-weight-bearing and then 3 weeks of progressive to full weight-bearing in an Achilles boot. Physical therapy was provided for 4 to 6 weeks after this period of immobilization. 21 patients were male and 9 were female. The patients had a mean age of 40.8 years (range, 24-54). Patients were followed an average of 40.5 months (range, 23-81). Full healing of the Achilles myotendinous junction was achieved clinically in all 30 patients . All patients experienced improved function and less pain at their latest follow-up. Mean Foot and Ankle Ability Measure-Sports (FAAM-Sports) increased from 20.2% at the time of initial presentation to 95.2% at the latest follow-up (P < .05). Mean Visual Analog Scores (VAS) of pain decreased from 8.2 at the time of initial presentation to 1.3 at latest follow-up (P < .01). In all, 23 (76.7%), 6 (20%), and 1 (3.3%) patients rated their satisfaction as excellent, good, and fair, respectively. No patients have developed recurrent myotendinous Achilles ruptures to date. Nonsurgical treatment of myotendinous Achilles ruptures results in a high rate of myotendinous healing with improved patient function and pain relief. Level IV, retrospective case series.
Trella, Katie J; Li, Jun; Stylianou, Eleni; Wang, Vincent M; Frank, Jonathan M; Galante, Jorge; Sandy, John D; Plaas, Anna; Wysocki, Robert
We have used a murine Achilles tendinopathy model to investigate whether tissue changes (such as collagen disorganization, chondroid metaplasia, and loss of tensile properties) which are broadly characteristic of human tendinopathies, are accompanied by changes in the expression of chromatin-modifying enzymes and the methylation status of promoter regions of tendon cell DNA. Tendinopathy was induced by two intra-tendinous TGF-β1 injections followed by cage activity or treadmill running for up to 28 days. Activation of DNA methyltransferases occurred at 3 days after the TGF-β1 injections and also at 14 days, but only with treadmill activity. Genome-wide Methyl Mini-Seq™ analysis identified 19 genes with differentially methylated promoters, five of which perform functions with an apparent direct relevance to tendinopathy (Leprel2, Foxf1, Mmp25, Igfbp6, and Peg12). The functions of the genes identified included collagen fiber assembly and pericellular interactions, therefore their perturbation could play a role in the characteristic disorganization of fibers in affected tendons. We postulate that a study of the functional genomics of these genes in animal and human tendon could further delineate the pathogenesis of this multi-factorial complex disease. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:947-955, 2017. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.
Lenskjold, A; Kongsgaard, M; Larsen, J O; Nielsen, R H; Kovanen, V; Aagaard, P; Kjaer, M; Magnusson, S P
Achilles tendinopathy is a highly prevalent sports injury. Animal studies show a growth response in tendons in response to loading in the immature phase but not after puberty maturation. The aim of this investigation was to examine the structural and material properties in long distance runners who were either physically active (HAY) or inactive (LAY) in young age. Twelve men in HAY group and eight men in LAY group participated. Structural, functional, and biochemical properties of Achilles tendon were estimated from magnetic resonance imaging, ultrasound video recordings, mechanical tests, and tendon biopsies, respectively. There was no difference between the groups with respect to tendon cross-sectional area or tendon free length. There was no difference between the groups with respect to maximal force or mechanical properties. The collagen content, enzymatic and nonenzymatic cross-link density did not differ between the groups, nor did collagen fibril density, diameter, and area. There was a correlation between age and pentosidine/collagen within the groups [(HAY: P < 0.05 and r(2) = 0.47) and (LAY: P < 0.05 and r(2) = 0.52)]. The data suggest that high or low activity during youth did not appreciably influence the mechanical, structural, or biochemical properties of the Achilles tendon in adult long distance runners.
Perry, Mark; Tillett, Eleanor; Mitchell, Sophie; Maffulli, Nicola; Morrissey, Dylan
Summary This cross-sectional study assessed the prevalence of Achilles tendinopathy symptoms and ultrasound (US) abnormalities in male and female ice skaters, and compared this to age-matched controls. The 20 skaters of mean (sd) age 17.3 (7.9) were recruited from British figure skating clubs. The 17 non-skaters of mean age 18.0 (3.7) were recruited from a secondary school and university. Each group had 12 females. All participants completed a questionnaire, and Achilles tendons were ultrasound-scanned for thickening, hypoechoic areas, paratenon blurring and neovascularization. Skaters experienced significantly more lifetime symptoms (p=0.012) than the control group but there were no differences in present symptoms. Mid-tendon longitudinal thickness and the coefficient of variation (CoV) for longitudinal tendon thickness were significantly greater in the skaters (p=0.001 and p=0.017 respectively). No other ultrasound abnormalities were detected in either group. Figure skaters may be at a greater risk of Achilles tendon problems than the general population and have adaptive changes in their tendons. PMID:23738283
Johansson, Kristian Jarl Johan; Sarimo, Janne Julius; Lempainen, Lasse Lennart; Laitala-Leinonen, Tiina; Orava, Sakari Yrjö
Summary In active people, insertional calcific tendinopathy (CT) of the Achilles tendon is rare. We evaluated the results of surgical treatment for Achilles tendon CT and analyzed post-surgery Achilles tendon histological features. The study included 36 operations in 34 patients. Twenty-eight (78%) cases had a resection of a Haglund’s deformity performed. The mean age of the patients was 42 years (range=23 to 68). Thirteen of the patients were professional athletes and 20 recreational athletes. In twenty-five (69%) cases, the result of surgery was rated good, in nine cases (25%) moderate and in two (6%) cases poor. The mean age of those with a good result was 10 years lower (40 versus 50 years) than those with a moderate result (p=0.0239). Higher athletic activity was also related to a better outcome (p=0.0205). Histology samples showed fast remodellation and stem-cell activation. Surgery seemed to result in a good outcome in patients with or without a Haglund’s deformity which failed conservative treatment. PMID:23738309
Wearing, Scott C; Locke, Simon; Smeathers, James E; Hooper, Sue L
This research evaluated the effect of tendinopathy on the cumulative transverse strain response of the patellar tendon to a bout of resistive quadriceps exercise. Nine adults with unilateral patellar tendinopathy (age, 18.2 ± 0.7 yr; height, 1.92 ± 0.06 m; weight, 76.8 ± 6.8 kg) and 10 healthy adults free of knee pain (age, 17.8 ± 0.8 yr; height, 1.83 ± 0.05 m; weight, 73.2 ± 7.6 kg) underwent standardized sagittal sonograms (7.2-14 MHz linear array transducer) of both patellar tendons immediately before and after 45 repetitions of a double-leg decline squat exercise performed against a resistance of 145% body weight. Tendon thickness was determined 5 and 25 mm distal to the patellar pole. Transverse Hencky strain was calculated as the natural log of the ratio of post- to preexercise tendon thickness and expressed as percentage. Measures of tendon echogenicity were calculated within the superficial and deep aspects of each tendon site from grayscale profiles. Intratendinous microvessels were evaluated using power Doppler ultrasound. The cumulative transverse strain response to exercise in symptomatic tendinopathy was significantly lower than that in asymptomatic and healthy tendons (P < 0.05). There was also significant reduction (57%) in the area of microvascularity immediately after exercise (P = 0.05), which was positively correlated (r = 0.93, P < 0.05) with a Victorian Institute of Sport Assessment for patellar tendinopathy score. This study is the first to show that patellar tendinopathy is associated with altered morphological and mechanical response of the tendon to exercise, which is manifest by reduction in cumulative transverse strain and microvascularity, when present. Research directed toward identifying factors that influence the acute microvascular and transverse strain response of the patellar tendon to exercise in the various stages of tendinopathy is warranted.
Szebeszczyk, Janina; Straszecka, Joanna
The examination of Achilles tendon reflex is widely used as a simple, noninvasive clinical test in diagnosis and pharmacological therapy monitoring in such diseases as: hypothyroidism, hyperthyroidism, diabetic neuropathy, the lower limbs obstructive angiopathies and intermittent claudication. Presented Achilles tendon reflect measuring system is based on the piezoresistive sensor connected with the cylinder-piston system. To determinate the moment of Achilles tendon stimulation a detecting circuit was used. The outputs of the measuring system are connected to the PC-based data acquisition board. Experimental results showed that the measurement accuracy and repeatability is good enough for diagnostics and therapy monitoring purposes. A user friendly, easy-to-operate measurement system fulfills all the requirements related to recording, presentation and storing of the patients' reflexograms.
Wertz, Jess; Galli, Melissa; Borchers, James R.
Context: Achilles tendon (AT) rupture in athletes is increasing in incidence and accounts for one of the most devastating sports injuries because of the threat to alter or end a career. Despite the magnitude of this injury, reliable risk assessment has not been clearly defined, and prevention strategies have been limited. The purpose of this review is to identify potential intrinsic and extrinsic risk factors for AT rupture in aerial and ground athletes stated in the current literature. Evidence Acquisition: A MEDLINE search was conducted on AT rupture, or “injury” and “risk factors” and “athletes” from 1980 to 2011. Emphasis was placed on epidemiology, etiology, and review articles focusing on the risk for lower extremity injury in runners and gymnasts. Thirty articles were reviewed, and 22 were included in this assessment. Results: Aerial and ground athletes share many intrinsic risk factors for AT rupture, including overuse and degeneration of the tendon as well as anatomical variations that mechanically put an athlete at risk. Older athletes, athletes atypical in size for their sport, high tensile loads, leg dominance, and fatigue also may increase risk. Aerial athletes tend to have more extrinsic factors that play a role in this injury due to the varying landing surfaces from heights and technical maneuvers performed at various skill levels. Conclusion: Risk assessment for AT rupture in aerial and ground athletes is multivariable and difficult in terms of developing prevention strategies. Quantitative measures of individual risk factors may help identify major contributors to injury. PMID:24427410
Campbell, Abigail L.; Smith, Nicola C.; Reilly, James H.; Kerr, Shauna C.; Leach, William J.; Fazzi, Umberto G.; Rooney, Brian P.; Murrell, George A. C.; Millar, Neal L.
The pathogenetic mechanisms underlying tendinopathy remain unclear, with much debate as to whether inflammation or degradation has the prominent role. Increasing evidence points toward an early inflammatory infiltrate and associated inflammatory cytokine production in human and animal models of tendon disease. The IL-21/IL-21R axis is a proinflammatory cytokine complex that has been associated with chronic inflammatory diseases including rheumatoid arthritis and inflammatory bowel disease. This project aimed to investigate the role and expression of the cytokine/receptor pair IL-21/IL-21R in human tendinopathy. We found significantly elevated expression of IL-21 receptor message and protein in human tendon samples but found no convincing evidence of the presence of IL-21 at message or protein level. The level of expression of IL-21R message/protein in human tenocytes was significantly upregulated by proinflammatory cytokines (TNFα/IL-1β) in vitro. These findings demonstrate that IL-21R is present in early human tendinopathy mainly expressed by tenocytes and macrophages. Despite a lack of IL-21 expression, these data again suggest that early tendinopathy has an inflammatory/cytokine phenotype, which may provide novel translational targets in the treatment of tendinopathy. PMID:24757284
Warden, S J
Tendinopathy is a common and significant clinical problem characterised by activity-related pain, focal tendon tenderness and intratendinous imaging changes. Recent histopathological studies have indicated the underlying pathology to be one of tendinosis (degeneration) as opposed to tendinitis (inflammation). Relatively little is known about tendinosis and its pathogenesis. Contributing to this is an absence of validated animal models of the pathology. Animal models of tendinosis represent potential efficient and effective means of furthering our understanding of human tendinopathy and its underlying pathology. By selecting an appropriate species and introducing known risk factors for tendinopathy in humans, it is possible to develop tendon changes in animal models that are consistent with the human condition. This paper overviews the role of animal models in tendinopathy research by discussing the benefits and development of animal models of tendinosis, highlighting potential outcome measures that may be used in animal tendon research, and reviewing current animal models of tendinosis. It is hoped that with further development of animal models of tendinosis, new strategies for the prevention and treatment of tendinopathy in humans will be generated.
Warden, S J
Tendinopathy is a common and significant clinical problem characterised by activity‐related pain, focal tendon tenderness and intratendinous imaging changes. Recent histopathological studies have indicated the underlying pathology to be one of tendinosis (degeneration) as opposed to tendinitis (inflammation). Relatively little is known about tendinosis and its pathogenesis. Contributing to this is an absence of validated animal models of the pathology. Animal models of tendinosis represent potential efficient and effective means of furthering our understanding of human tendinopathy and its underlying pathology. By selecting an appropriate species and introducing known risk factors for tendinopathy in humans, it is possible to develop tendon changes in animal models that are consistent with the human condition. This paper overviews the role of animal models in tendinopathy research by discussing the benefits and development of animal models of tendinosis, highlighting potential outcome measures that may be used in animal tendon research, and reviewing current animal models of tendinosis. It is hoped that with further development of animal models of tendinosis, new strategies for the prevention and treatment of tendinopathy in humans will be generated. PMID:17127722
Qiao, Yang; Tao, Hong-Yue; Ma, Kui; Wu, Zi-Ying; Qu, Jian-Xun; Chen, Shuang
Objective. To compare T2(⁎) value of healthy and diseased Achilles tendons (AT) with a recently introduced three-dimensional ultrashort echo time (3D-UTE) sequence and analyze the correlation between T2(⁎) value and clinical scores. Methods. Ten patients with symptomatic Achilles tendon and ten healthy volunteers were investigated with 3D-UTE sequence on a 3T magnetic resonance (MR) scanner. T2(⁎) values of four regions in Achilles tendons were calculated. The clinical outcomes of patients were evaluated according to the American Orthopaedic Foot and Ankle Society (AOFAS) score and Achilles Tendon Rupture Score (ATRS). An independent sample t-test was used to compare the differences of T2(⁎) value and clinical scores between two groups. The Pearson correlation coefficient between clinical scores and T2(⁎) values was assessed. Results. The T2(⁎) values of Achilles tendon were statistically significantly different between patients and volunteers. The Pearson correlation coefficients between T2(⁎) and AOFAS or ATRS scores of patients were r = -0.733 and r = -0.634, respectively. Conclusion. The variability of T2(⁎) in healthy and pathologic AT can be quantified by UTE-T2(⁎). T2(⁎) may be a promising marker to detect and diagnose AT tendinopathy. UTE-T2(⁎) could give a precise guidance to clinical outcome.
Qiao, Yang; Tao, Hong-Yue; Ma, Kui; Wu, Zi-Ying; Qu, Jian-Xun
Objective. To compare T2⁎ value of healthy and diseased Achilles tendons (AT) with a recently introduced three-dimensional ultrashort echo time (3D-UTE) sequence and analyze the correlation between T2⁎ value and clinical scores. Methods. Ten patients with symptomatic Achilles tendon and ten healthy volunteers were investigated with 3D-UTE sequence on a 3T magnetic resonance (MR) scanner. T2⁎ values of four regions in Achilles tendons were calculated. The clinical outcomes of patients were evaluated according to the American Orthopaedic Foot and Ankle Society (AOFAS) score and Achilles Tendon Rupture Score (ATRS). An independent sample t-test was used to compare the differences of T2⁎ value and clinical scores between two groups. The Pearson correlation coefficient between clinical scores and T2⁎ values was assessed. Results. The T2⁎ values of Achilles tendon were statistically significantly different between patients and volunteers. The Pearson correlation coefficients between T2⁎ and AOFAS or ATRS scores of patients were r = −0.733 and r = −0.634, respectively. Conclusion. The variability of T2⁎ in healthy and pathologic AT can be quantified by UTE-T2⁎. T2⁎ may be a promising marker to detect and diagnose AT tendinopathy. UTE-T2⁎ could give a precise guidance to clinical outcome. PMID:28154823
Williams, J G
Achillodynia (Achilles tendon pain) is a significant source of disability to many people taking part in sports. Papers in the English language published since 1986 are reviewed here, grouped into specific subject areas including biomechanics, pathology, general clinical presentations, experimental treatments, steroids, podiatry and surgery. While there has been no dramatic breakthrough in the field, there have been various interesting advances with particular reference to imaging and conservative management, which will hopefully stimulate further studies. Many problems of Achilles tendon lesions in athletes remain unsolved, however, and much is yet to be done to provide adequate and generally effective methods of prevention and conservative treatment.
Waugh, C M; Morrissey, D; Jones, E; Riley, G P; Langberg, H; Screen, H R C
Extracorporeal shock wave therapy (ESWT) is a non-invasive treatment for chronic tendinopathies, however little is known about the in-vivo biological mechanisms of ESWT. Using microdialysis, we examined the real-time biological response of healthy and pathological tendons to ESWT. A single session of ESWT was administered to the mid-portion of the Achilles tendon in thirteen healthy individuals (aged 25.7 ± 7.0 years) and patellar or Achilles tendon of six patients with tendinopathies (aged 39.0 ± 14.9 years). Dialysate samples from the surrounding peri-tendon were collected before and immediately after ESWT. Interleukins (IL)-1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-17A, vascular endothelial growth factor and interferon-γ were quantified using a cytometric bead array while gelatinase activity (MMP-2 and -9) was examined using zymography. There were no statistical differences between the biological tissue response to ESWT in healthy and pathological tendons. IL-1β, IL-2, IL-6 and IL-8 were the cytokines predominantly detected in the tendon dialysate. IL-1β and IL-2 did not change significantly with ESWT. IL-6 and IL-8 concentrations were elevated immediately after ESWT and remained significantly elevated for four hours post-ESWT (p < 0.001). Pro-forms of MMP-2 and -9 also increased after ESWT (p < 0.003), whereas there were no significant changes in active MMP forms. In addition, the biological response to ESWT treatment could be differentiated between possible responders and non-responders based on a minimum 5-fold increase in any inflammatory marker or MMP from pre- to post-ESWT. Our findings provide novel evidence of the biological mechanisms underpinning ESWT in humans in vivo. They suggest that the mechanical stimulus provided by ESWT might aid tendon remodelling in tendinopathy by promoting the inflammatory and catabolic processes that are associated with removing damaged matrix constituents. The non-response of some individuals may help to
Fusini, Federico; Bisicchia, Salvatore; Bottegoni, Carlo; Gigante, Antonio; Zanchini, Fabio; Busilacchi, Alberto
Summary Background nutraceuticals are common support therapy for management of tendinopathies. Even if they are widely diffused, our knowledge is still poor. The aim of this systematic review is to analyze the most commonly used nutraceuticals and their effects on tendons. Methods glucosamine and chondroitin sulphate, vitamin C, hydrolazed type 1 collagen, arginine alpha-keto-glutarate, bromelain, curcumin, boswellic acid, and methil-sulfonil-methane were considered. During the last week of Dicember 2015 a comprehensive research of main databases for each substance was made in relation with tendinopathy. Repeated articles, articles not in English nor in Italian, not common nutraceuticals, and articles not related with tendons or tenocytes were excluded. Clinical article quality was assessed independently by two reviewers using the modified Coleman methodology score. Results preclinical and clinical data from 46 articles from all databases were analyzed. All these nutraceuticals demonstrated several effects on normal and pathological tendons. Preclinical and clinical studies showed a possible role on collagen synthesis, inflammation, mechanical properties, and maturation of collagen bundles, antioxidant effect, edema, and analgesia. The majority clinical studies had some methodological limitations with an average Modified Coleman Methodology Score of 51.3 points and SD of 20.5 points. In particular, there were very low values in power, error, outcome assessment, and clinical effect. Conclusion preclinical results are very encouraging, however they are not fully confirmed by clinical studies. There are few clinical papers on the use of nutraceuticals in tendon disorders, and their methodological quality is poor. Furthermore, in most of the studies more than one supplement was administered at the same time. This may bias the results, and the effect of each single component cannot be determined. Furthermore, the interactions between nutraceuticals and drugs, or other
Lui, Pauline Po Yee
The pathogenesis of tendinopathy remains unclear. Chondro-osteogenic BMPs such as BMP-2, BMP-4 and BMP-7 have been reported in clinical samples and animal models of tendinopathy. As chondrocyte-like cells and ossified deposits have been observed in both clinical samples and animal models of failed tendon healing tendinopathy, chondro-osteogenic BMPs might contribute to tissue metaplasia and other histopathological changes in tendinopathy. In this review I have summarized the current evidence supporting the roles of chondro-osteogenic BMPs in the histopathological changes of tendinopathy. The potential targets, effects and sources of these BMPs are discussed. I have also provided directions for future studies about the potential roles of BMPs in the pathogenesis of tendinopathy. Better understanding of the roles of these BMPs in the histopathological changes of tendinopathy could provide new options for the prevention and treatment of this disabling tendon disorder.
Dirks, R C; Warden, S J
Tendinopathy refers to the clinical presentation of activity-related pain, focal tendon tenderness, and intratendinous imaging changes. The underlying pathology was once thought to be due to inflammation ('tendinitis'), but is now considered to predominantly result from degeneration ('tendinosis'). While some progress has been made in understanding tendinosis, the condition remains poorly understood and a need exists for suitable exploratory preclinical models. It is unlikely that one suitable model exists because of the complexity of the underlying pathology and myriad of possible causes. This paper provides an overview of current models utilized in tendinopathy research. It progresses hierarchically from in vitro and ex vivo models to in vivo models. For each model, rationale for use, pertinent findings, and advantages and disadvantages are discussed. By improving on these models, new methods for the prevention and treatment of tendinopathy may be explored with the ultimate outcome being a reduction in the occurrence and effects of the condition in humans.
Maffulli, Nicola; Longo, Umile Giuseppe; Loppini, Mattia; Spiezia, Filippo; Denaro, Vincenzo
Tendon injuries can be acute or chronic, and caused by intrinsic or extrinsic factors, either alone or in combination. Tendinopathies are a common cause of disability in occupational medicine and account for a substantial proportion of overuse injuries in sports. Tendinopathy is essentially a failed healing response, with haphazard proliferation of tenocytes, abnormalities in tenocytes, with disruption of collagen fibres and subsequent increase in noncollagenous matrix. The scientific evidence base for managing tendinopathies is limited. What may appear clinically as an “acute tendinopathy” is actually a well advanced failure of a chronic healing response in which there is neither histologic nor biochemical evidence of inflammation. In this review we report the new options for the management of tendinopathy, including eccentric exercises, extracorporeal shockwave therapy, injections (intratendinous injections of corticosteroids, aprotinin, polidocanol platelet-rich plasma, autologous blood injection, high-volume injections) and surgery. Open surgery aims to excise fibrotic adhesions, remove areas of failed healing and make multiple longitudinal incisions in the tendon to detect intratendinous lesions, and to restore vascularity and possibly stimulate the remaining viable cells to initiate cell matrix response and healing. New surgical techniques aim to disrupt the abnormal neoinnervation to interfere with the pain sensation caused by tendinopathy. These procedures are intrinsically different from the classical ones in present use, because they do not attempt to address directly the pathologic lesion, but act only to denervate them. They include endoscopy, electrocoagulation, and minimally invasive stripping. Further randomized controlled trials are necessary to clarify better the best therapeutic options for the management of tendinopathy. PMID:24198540
de Oliveira, Rodrigo Ribeiro; Medina de Mattos, Rômulo; Magalhães Rebelo, Luciana; Guimarães Meireles Ferreira, Fernanda; Tovar-Moll, Fernanda; Eurico Nasciutti, Luiz; de Castro Brito, Gerly Anne
Although of several studies that associate chronic hyperglycemia with tendinopathy, the connection between morphometric changes as witnessed by magnetic resonance (MR) images, nanostructural changes, and inflammatory markers have not yet been fully established. Therefore, the present study has as a hypothesis that the Achilles tendons of rats with diabetes mellitus (DM) exhibit structural changes. The animals were randomly divided into two experimental groups: Control Group (n = 06) injected with a vehicle (sodium citrate buffer solution) and Diabetic Group (n = 06) consisting of rats submitted to intraperitoneal administration of streptozotocin. MR was performed 24 days after the induction of diabetes and images were used for morphometry using ImageJ software. Morphology of the collagen fibers within tendons was examined using Atomic Force microscopy (AFM). An increase in the dimension of the coronal plane area was observed in the diabetic group (8.583 ± 0.646 mm2/100g) when compared to the control group (4.823 ± 0.267 mm2/100g) resulting in a significant difference (p = 0.003) upon evaluating the Achilles tendons. Similarly, our analysis found an increase in the size of the transverse section area in the diabetic group (1.328 ± 0.103 mm2/100g) in comparison to the control group (0.940 ± 0.01 mm2/100g) p = 0.021. The tendons of the diabetic group showed great irregularity in fiber bundles, including modified grain direction and jagged junctions and deformities in the form of collagen fibrils bulges. Despite the morphological changes observed in the Achilles tendon of diabetic animals, IL1 and TNF-α did not change. Our results suggest that DM promotes changes to the Achilles tendon with important structural modifications as seen by MR and AFM, excluding major inflammatory changes. PMID:28095484
Abate, Michele; Gravare-Silbernagel, Karin; Siljeholm, Carl; Di Iorio, Angelo; De Amicis, Daniele; Salini, Vincenzo; Werner, Suzanne; Paganelli, Roberto
The intrinsic pathogenetic mechanisms of tendinopathies are largely unknown and whether inflammation or degeneration has the prominent role is still a matter of debate. Assuming that there is a continuum from physiology to pathology, overuse may be considered as the initial disease factor; in this context, microruptures of tendon fibers occur and several molecules are expressed, some of which promote the healing process, while others, including inflammatory cytokines, act as disease mediators. Neural in-growth that accompanies the neovessels explains the occurrence of pain and triggers neurogenic-mediated inflammation. It is conceivable that inflammation and degeneration are not mutually exclusive, but work together in the pathogenesis of tendinopathies. PMID:19591655
Zhang, Xin; Lin, Yu-cheng; Rui, Yun-feng; Xu, Hong-liang; Chen, Hui; Wang, Chen; Teng, Gao-jun
Tendinopathy is a tendon disorder characterized by activity-related pain, local edema, focal tenderness to palpation, and decreased strength in the affected area. Tendinopathy is prevalent in both athletes and the general population, highlighting the need to elucidate the pathogenesis of this disorder. Current treatments of tendinopathy are both conservative and symptomatic. The discovery of tendon stem/progenitor cells (TSPCs) and erroneous differentiation of TSPCs have provided new insights into the pathogenesis of tendinopathy. In this review, we firstly present the histopathological characteristics of tendinopathy and explore the cellular and molecular cues in the pathogenesis of tendinopathy. Current evidence of the depletion of the stem cell pool and altered TSPCs fate in the pathogenesis of tendinopathy has been presented. The potential regulatory factors for either tenogenic or nontenogenic differentiation of TSPCs are also summarized. The regulation of endogenous TSPCs or supplementation with exogenous TSPCs as therapeutic targets for the treatment of tendinopathy is proposed. Therefore, inhibiting the erroneous differentiation of TSPCs and regulating the differentiation of TSPCs into tendon cells might be important areas of future research and could provide new clinical treatments for tendinopathy. The current evidence suggests that TSPCs are promising therapeutic targets for the management of tendinopathy. PMID:27195010
Smith, Jay; Alfredson, Håkan; Masci, Lorenzo; Sellon, Jacob L; Woods, Charonn D
Differential motion between the plantaris and Achilles tendons has been hypothesized to contribute to pain in some patients presenting with Achilles tendinopathy. However, objective evidence of differential Achilles-plantaris motion is currently lacking from the literature. To determine whether differential, multidirectional motion exists between the plantaris tendon (PT) and Achilles tendon (AT) as documented by dynamic ultrasound (US) and postdissection examination in an unembalmed cadaveric model. Prospective, cadaveric laboratory investigation. Procedural skills laboratory in a tertiary medical center. Twenty unembalmed knee-ankle-foot specimens (9 right, 11 left) obtained from 6 male and 10 female donors ages 55-96 years (mean 80 years) with body mass indices of 14.1-33.2 kg/m(2) (mean 22.5 kg/m(2)). A single, experienced operator used high-resolution dynamic US to qualitatively document differential PT-AT motion during passive ankle dorsiflexion-plantarflexion. Specimens were then dissected and passive dorsiflexion-plantarflexion was repeated while differential PT-AT motion was visualized directly. Presence or absence of multidirectional differential PT-AT motion. All 20 specimens exhibited smooth but variable amplitude multidirectional differential PT-AT motion. Whereas US readily demonstrated medial-lateral and anterior-posterior PT motion relative to the AT, differential longitudinal motion was only appreciated on dissection and direct inspection. Many specimens exhibited partial or complete encasement of the PT between the gastrocnemius portion of the AT and the soleus aponeurosis. Some degree of multidirectional differential PT-AT motion appears to be a normal phenomenon, and PT motion can be evaluated sonographically in both the medial-lateral and anterior-posterior directions. The existence of normal differential PT-AT motion suggests that alterations in PT motion or repetitive stress within the PT-AT interval may produce symptoms in some patients
Taylor, Samuel A.; Hannafin, Jo A.
Context: Elbow tendinopathy is a common cause of pain and disability among patients presenting to orthopaedic surgeons, primary care physicians, physical therapists, and athletic trainers. Prompt and accurate diagnosis of these conditions facilitates a directed treatment regimen. A thorough understanding of the natural history of these injuries and treatment outcomes will enable the appropriate management of patients and their expectations. Evidence Acquisitions: The PubMed database was searched in December 2011 for English-language articles pertaining to elbow tendinopathy. Results: Epidemiologic data as well as multiple subjective and objective outcome measures were investigated to elucidate the incidence of medial epicondylitis, lateral epicondylitis, distal biceps and triceps ruptures, and the efficacy of various treatments. Conclusions: Medial and lateral epicondylitis are overuse injuries that respond well to nonoperative management. Their etiology is degenerative and related to repetitive overuse and underlying tendinopathy. Nonsteroidal anti-inflammatory drugs and localized corticosteroid injections yield moderate symptomatic relief in short term but do not demonstrate benefit on long-term follow-up. Platelet-rich plasma injections may be advantageous in cases of chronic lateral epicondylitis. If 6 to 12 months of nonoperative treatment fails, then surgical intervention can be undertaken. Distal biceps and triceps tendon ruptures, in contrast, have an acute traumatic etiology that may be superimposed on underlying tendinopathy. Prompt diagnosis and treatment improve outcomes. While partial ruptures confirmed with magnetic resonance imaging can be treated nonoperatively with immobilization, complete ruptures should be addressed with primary repair within 3 to 4 weeks of injury. PMID:23016111
Factor, David; Dale, Barry
Tendinopathies are a broad topic that can be examined from the lab to their impact upon function. Improved understanding will serve to bring this pathology to the forefront of discussion, whether in the clinic or the classroom. The purpose of this current concepts clinical commentary is to explore intrinsic and extrinsic mechanisms of rotator cuff (RC) tendinopathy in order to improve clinical and research understanding. Pubmed, Medline, Cinahl, PEDro, and Cochrane databases were searched, limiting results to those published in the English language, between the years of 2005 and 2012. The key search terms utilized were intrinsic mechanisms, tendinopathy, stem cells, biologics, platelet-rich plasma (PRP), healing, rotator cuff tears, full-thickness tears, tests, impingement, imaging, ultrasound, Magnetic Resonance Imaging (MRI), radiograph, shoulder advances, treatment, diagnoses, tendon disorders, pathogenesis, matrix metalloproteinase, injections, and RC repair. Over 150 abstracts were reviewed and 43 articles were analyzed for quality and relevance using the University of Alberta Evidence Based Medicine Toolkit. Current evidence suggests that tendinopathies arise from a multivariate etiology.It is increasingly evident that intrinsic mechanisms play a greater role than extrinsic mechanisms in this process. Emphasis should be placed on patient information (i.e. background information and personal description of symptoms) and imaging/ injection techniques in order to aid in diagnosis. Future treatment technologies such as cell therapy and biological engineering offer the hope of improving patient outcomes and quality of life. Level 5 - Clinical Commentary Related to a Review of Literature.
Millar, Neal L; Murrell, George A C; McInnes, Iain B
Tendinopathy is a multifactorial spectrum of tendon disorders that affects different anatomical sites and is characterized by activity-related tendon pain. These disorders are common, account for a high proportion (∼30%) of referrals to musculoskeletal practitioners and confer a large socioeconomic burden of disease. Our incomplete understanding of the mechanisms underpinning tendon pathophysiology continues to hamper the development of targeted therapies, which have been successful in other areas of musculoskeletal medicine. Debate remains among clinicians about the role of an inflammatory process in tendinopathy owing to a lack of clinical correlation. The advent of modern molecular techniques has highlighted the presence of immune cells and inflammatory mechanisms throughout the spectrum of tendinopathy in both animal and human models of disease. Key inflammatory mediators - such as cytokines, nitric oxide, prostaglandins and lipoxins - play crucial parts in modulating changes in the extracellular matrix within tendinopathy. Understanding the links between inflammatory mechanisms, tendon homeostasis and resolution of tendon damage will be crucial in developing novel therapeutics for human tendon disease.
The purpose of this article is to differentiate between acute Achilles tendinitis and chronic Achilles tendinosis and to highlight a specific treatment protocol for mid-portion Achilles tendinosis. Tendinosis (degeneration of the tendon) results from chronic tissue injury and has long-term implications for a dancer's career. An eccentric heavy-load exercise protocol has been used successfully to treat tendinosis in athletes. A modified eccentric exercise protocol is proposed as one component of an effective rehabilitation program for dancers. This protocol facilitates tissue remodeling to build strength, flexibility, and adaptability of the Achilles tendon tissue, so that dancers can continue to dance without further complications of the injury.
Goldin, Michael; Malanga, Gerard A
The understanding of tendinopathy has evolved over the past several decades. Initially thought to be a primarily inflammatory process, histologic evaluation has revealed that there is an absence of inflammatory cells, and rather, tendinopathy is more of a degenerative process. Various types of medications, rehabilitation, modalities, injections, and minimally invasive procedures have been described as treatment for this condition. The purpose of our article is to describe the pathophysiology of tendinopathy as currently understood and the evidence for the various available treatments. We performed a literature search to determine the types of reviews that have been performed previously regarding treatment for tendinopathy, and summarized these reviews. We then performed a systematic review of randomized controlled trials for treating patients with tendinopathy. It is our hope that our review of trial data will help providers to determine optimal management for their patients with tendinopathy.
Jielile, Jiasharete; Aibai, Minawa; Sabirhazi, Gulnur; Shawutali, Nuerai; Tangkejie, Wulanbai; Badelhan, Aynaz; Nuerduola, Yeermike; Satewalede, Turde; Buranbai, Darehan; Hunapia, Beicen; Jialihasi, Ayidaer; Bai, Jingping; Kizaibek, Murat
Active Achilles tendon kinesitherapy facilitates the functional recovery of a ruptured Achilles tendon. However, protein expression during the healing process remains a controversial issue. New Zealand rabbits, aged 14 weeks, underwent tenotomy followed immediately by Achilles tendon microsurgery to repair the Achilles tendon rupture. The tendon was then immobilized or subjected to postoperative early motion treatment (kinesitherapy). Mass spectrography results showed that after 14 days of motion treatment, 18 protein spots were differentially expressed, among which, 12 were up-regulated, consisting of gelsolin isoform b and neurite growth-related protein collapsing response mediator protein 2. Western blot analysis showed that gelsolin isoform b was up-regulated at days 7–21 of motion treatment. These findings suggest that active Achilles tendon kinesitherapy promotes the neurite regeneration of a ruptured Achilles tendon and gelsolin isoform b can be used as a biomarker for Achilles tendon healing after kinesitherapy. PMID:25317130
Wang, Tao; Lin, Zhen; Ni, Ming; Thien, Christine; Day, Robert E; Gardiner, Bruce; Rubenson, Jonas; Kirk, Thomas B; Smith, David W; Wang, Allan; Lloyd, David G; Wang, Yan; Zheng, Qiujian; Zheng, Ming H
Physiotherapy is one of the effective treatments for tendinopathy, whereby symptoms are relieved by changing the biomechanical environment of the pathological tendon. However, the underlying mechanism remains unclear. In this study, we first established a model of progressive tendinopathy-like degeneration in the rabbit Achilles. Following ex vivo loading deprivation culture in a bioreactor system for 6 and 12 days, tendons exhibited progressive degenerative changes, abnormal collagen type III production, increased cell apoptosis, and weakened mechanical properties. When intervention was applied at day 7 for another 6 days by using cyclic tensile mechanical stimulation (6% strain, 0.25 Hz, 8 h/day) in a bioreactor, the pathological changes and mechanical properties were almost restored to levels seen in healthy tendon. Our results indicated that a proper biomechanical environment was able to rescue early-stage pathological changes by increased collagen type I production, decreased collagen degradation and cell apoptosis. The ex vivo model developed in this study allows systematic study on the effect of mechanical stimulation on tendon biology. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.
Kaalund, S; Lass, P; Høgsaa, B; Nøhr, M
The typical badminton player with an Achilles tendon rupture is 36 years old and, despite limbering up, is injured at the rear line in a sudden forward movement. He resumes work within three months and has a slight lack of dorsiflexion in the ankle as the main complication. Most patients resume badminton within one year, but some finish their sports career, mainly due to fear of a new injury. The investigation discusses predisposing factors and prophylactic measures. PMID:2605439
Kaalund, S; Lass, P; Høgsaa, B; Nøhr, M
The typical badminton player with an Achilles tendon rupture is 36 years old and, despite limbering up, is injured at the rear line in a sudden forward movement. He resumes work within three months and has a slight lack of dorsiflexion in the ankle as the main complication. Most patients resume badminton within one year, but some finish their sports career, mainly due to fear of a new injury. The investigation discusses predisposing factors and prophylactic measures.
Three Months of Progressive High-Load Versus Traditional Low-Load Strength Training Among Patients With Rotator Cuff Tendinopathy: Primary Results From the Double-Blind Randomized Controlled RoCTEx Trial
Ingwersen, Kim Gordon; Jensen, Steen Lund; Sørensen, Lilli; Jørgensen, Hans Ri; Christensen, Robin; Søgaard, Karen; Juul-Kristensen, Birgit
Background: Progressive high-load exercise (PHLE) has led to positive clinical results in patients with patellar and Achilles tendinopathy. However, its effects on rotator cuff tendinopathy still need to be investigated. Purpose: To assess the clinical effects of PHLE versus low-load exercise (LLE) among patients with rotator cuff tendinopathy. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Patients with rotator cuff tendinopathy were recruited and randomized to 12 weeks of PHLE or LLE, stratified for concomitant administration of corticosteroid injection. The primary outcome measure was change from baseline to 12 weeks in the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, assessed in the intention-to-treat population. Results: A total of 100 patients were randomized to PHLE (n = 49) or LLE (n = 51). Mean changes in the DASH questionnaire were 7.11 points (95% CI, 3.07-11.16) and 8.39 points (95% CI, 4.35-12.44) in the PHLE and LLE groups, respectively; this corresponded to a statistically nonsignificant adjusted mean group difference of −1.37 points (95% CI, −6.72 to 3.99; P = .61). Similar nonsignificant results were seen for pain, range of motion, and strength. However, a significant interaction effect was found between the 2 groups and concomitant corticosteroid use (P = .028), with the largest positive change in DASH in favor of PHLE for the group receiving concomitant corticosteroid. Conclusion: The study results showed no superior benefit from PHLE over traditional LLE among patients with rotator cuff tendinopathy. Further investigation of the possible interaction between exercise type and corticosteroid injection is needed to establish optimal and potentially synergistic combinations of these 2 factors. Registration: NCT01984203 (ClinicalTrials.gov identifier): Rotator Cuff Tendinopathy Exercise Trial (RoCTEx).
When re-operating patients with midportion Achilles tendinosis, having had a poor effect of ultrasound (US) and Doppler-guided scraping, the author found the involvement of the plantaris tendon to be a likely reason for the poor result. The aim of this study was to investigate the occurrence of a plantaris tendon in close relation to the Achilles tendon in consecutive patients with midportion Achilles tendinosis undergoing treatment with US and Doppler-guided scraping. This study includes 73 consecutive tendons with chronic painful midportion Achilles tendinosis, where US+Doppler examination showed thickening, irregular tendon structure, hypo-echoic regions, and localised high blood flow outside and inside the ventral Achilles midportion. The tendons were treated with US+Doppler-guided scraping, via a medial incision. If there was a plantaris tendon located in close relation to the medial Achilles, it was extirpated. An invaginated, or 'close by located', enlarged plantaris tendon was found in 58 of 73 (80%) tendons. Preliminary clinical results of the combined procedure, US + Doppler-guided surgical scraping and extirpation of the plantaris tendon, are very promising. A thickened plantaris tendon located in close relation to the medial Achilles seems common in patients with chronic painful midportion tendinosis. The role of the plantaris tendon in midportion Achilles tendinosis needs to be further evaluated and should be kept in mind when treating this condition.
Mao, Haijiao; Shi, Zengyuan; Wapner, Keith L; Dong, Wenwei; Yin, Weigang; Xu, Dachuan
The purpose of the study was to describe the anatomical variations of the connection between the flexor hallucis longus (FHL) and flexor digitorum longus (FDL) tendons in the knot of Henry in Asians, and quantify the length of FHL tendon graft with different incisions. Sixty-four embalmed feet of 32 cadavers were analyzed anatomically with respect to the individual cross-links in the planta pedis. Single incision technique graft length was measured from the musculotendinous junction of FHL and the point at sustentaculum tali. Double incision technique was measured from musculotendinous junction of FHL and the level of the master knot of Henry. Additionally, minimally invasive incision technique was measured from musculotendinous junction of FHL to the first interphalangeal joint. These three techniques were then combined to determine the total potential tendon graft length obtainable using different approach. Only two different configurations were found. Type 1, a tendinous slip branched from the FHL to the FDL (62 of 64 feet). Type 2, a slip branched from the FHL to the FDL and another slip from the FDL to FHL (2 of 64). The average length of the FHL graft available from a single incision measured 5.08 cm (range 3.32-10.35, SD = 1.09), double incision technique measured 6.72 cm (range 4.69-12.09, SD = 1.03), and minimally invasive incision measured 17.49 cm (range 13.51-20.52, SD = 1.80). The difference between the lengths obtained from these three techniques was statistically significant (p < 0.001). The absence of no attachment and FDL tendon to the FHL between the two tendons in the foot may be more frequent than previously reported. Only two configurations of the anatomical relationship were found in this study. In over 96 % of the feet, a proximal to distal connection from the FHL to the FDL was found, which might contribute to the residual function of the lesser toes after FDL transfer.
Hess, Gregory William
Sports participation has undergone an increase in recent decades. Injury due to sporting activity has also recently risen. The Achilles tendon has been one of the most common sports-related injuries. A 2 in 100,000 individual Achilles tendon injury rate increased to a 12 in 100,000 individual injury rate in less than 10 years. The injury is typically observed in men in the fourth to fifth decades of life. Male to female injury ratios range from 2:1 to 12:1. Running, jumping, and agility activities involving eccentric loading and explosive plyometric contractions are usual mechanisms. Natural aging allows predisposing chronic degeneration of the tendon. Blood flow decreases and stiffness increases with aging to decrease the ability to withstand stress. Noninflammatory tendinosis and chronic tendinopathy are 2 separate processes proposed for tendon degeneration and subsequent rupture. Rupture typically occurs 2 to 6 cm proximal to the calcaneal insertion. Predisposing factors are grouped into 2 categories: intrinsic and extrinsic risk factors. Avoidance of degenerative changes within the tendon is the primary method to prevent rupture. Regular physical activity as athletes age also promotes tendon hypertrophy, increases nutrient delivery, and reduces collagen fiber fatigue.
Khayyeri, Hanifeh; Longo, Giacomo; Gustafsson, Anna; Isaksson, Hanna
The incidence of tendon injury (tendinopathy) has increased over the past decades due to greater participation in sports and recreational activities. But little is known about the aetiology of tendon injuries because of our limited knowledge in the complex structure-function relationship in tendons. Computer models can capture the biomechanical behaviour of tendons and its structural components, which is essential for understanding the underlying mechanisms of tendon injuries. This study compares three structural constitutive material models for the Achilles tendon and discusses their application on different biomechanical simulations. The models have been previously used to describe cardiovascular tissue and articular cartilage, and one model is novel to this study. All three constitutive models captured the tensile behaviour of rat Achilles tendon (root mean square errors between models and experimental data are 0.50-0.64). They further showed that collagen fibres are the main load-bearing component and that the non-collagenous matrix plays a minor role in tension. By introducing anisotropic behaviour also in the non-fibrillar matrix, the new biphasic structural model was also able to capture fluid exudation during tension and high values of Poisson׳s ratio that is reported in tendon experiments. Copyright © 2016 Elsevier Ltd. All rights reserved.
Allison, Kim; Wrigley, Tim V; Vicenzino, Bill; Bennell, Kim L; Grimaldi, Alison; Hodges, Paul W
Lateral hip pain during walking is a feature of gluteal tendinopathy but little is known how walking biomechanics differ in individuals with gluteal tendinopathy. This study aimed to compare walking kinematics and kinetics between individuals with and without gluteal tendinopathy. Three-dimensional walking-gait analysis was conducted on 40 individuals aged 35 to 70 years with unilateral gluteal tendinopathy and 40 pain-free controls. An analysis of covariance was used to compare kinematic and kinetic variables between groups. Linear regression was performed to investigate the relationship between kinematics and external hip adduction moment in the gluteal tendinopathy group. Individuals with gluteal tendinopathy demonstrated a greater hip adduction moment throughout stance than controls (standardized mean difference ranging from 0.60 (first peak moment) to 0.90 (second peak moment)). Contralateral trunk lean at the time of the first peak hip adduction moment was 1.2 degrees greater (P=0.04), and pelvic drop at the second peak hip adduction moment 1.4 degrees greater (P=0.04), in individuals with gluteal tendinopathy. Two opposite trunk and pelvic strategies were also identified within the gluteal tendinopathy group. Contralateral pelvic drop was significantly correlated with the first (R=0.35) and second peak (R=0.57) hip adduction moment, and hip adduction angle with the second peak hip adduction moment (R=-0.36) in those with gluteal tendinopathy. Individuals with gluteal tendinopathy exhibit greater hip adduction moments and alterations in trunk and pelvic kinematics during walking. Findings provide a basis to consider frontal plane pelvic control in the management of gluteal tendinopathy. Copyright © 2016 Elsevier Ltd. All rights reserved.
Redmond, John M.; Cregar, William M.; Gupta, Asheesh; Hammarstedt, Jon E.; Martin, Timothy J.; Domb, Benjamin G.
Lateral hip pain along with tenderness of the greater trochanter has been associated with greater trochanteric pain syndrome. Radiographically, this has been associated with gluteus medius pathology on magnetic resonance imaging. This has led some surgeons to conclude that abductor pathology is a primary cause of lateral hip pain. Failure of conservative treatment in the setting of gluteus medius pathology may lead to surgical intervention. In some patients a focal tear of the gluteus medius cannot be visualized and likely represents more diffuse tendinopathy. In these patients we propose micropuncture of the greater trochanter. Similar procedures have shown effectiveness in the elbow and shoulder by eliciting a healing response. Our experience suggests that trochanteric micropuncture at the insertion of the gluteus medius tendon can be effectively performed endoscopically for gluteus medius tendinopathy. PMID:25973381
Magnussen, Robert A; Glisson, Richard R; Moorman, Claude T
Achilles tendon rupture is a frequent injury in athletes and the general public. Cases of chronic rupture or poor tendon quality secondary to tendinopathy are challenging to repair primarily. Commercially available extracellular matrix materials have been utilized in recent years to augment tendon repair. Augmentation of Achilles tendon with extracellular matrix xenograft results in reduced repair site gapping and increased peak failure load in a cadaveric model featuring simulated physiologic loads. Controlled laboratory study. Ten matched pairs of fresh-frozen human lower extremities amputated just below the knee were obtained and each Achilles tendon was sharply tenotomized. One randomly selected specimen from each matched pair underwent Achilles repair using a 4-strand Krackow technique with extracellular matrix xenograft augmentation (TissueMend Soft Tissue Repair Matrix), while the opposite tendon underwent suture repair alone as a control. Each tendon was then subjected to 1000 sinusoidal tensile loading cycles to 86 N during which repair site gapping was monitored, followed by distraction to failure. One pair was used to evaluate the effects of graft orientation and not included in the analysis. Significantly less gapping was noted in the augmented tendon group at all time points after the 10th load cycle (P < .05). The mean repair site gapping after 1000 cycles of loading was 4.0 mm (range, 3.1-5.0 mm) in the augmented group and 6.5 mm (range, 4.1-8.6 mm) in the suture-only group. The ultimate failure load was 821 N (range, 613-1021 N) in the augmented group and 392 N (range, 322-481 N) in the suture-only group (P < .01). The augmentation of Achilles tendon repair with extracellular matrix xenograft decreases gapping and increases load to failure immediately after surgery in a cadaveric model. Tendon repair augmentation may allow more aggressive early rehabilitation, particularly in cases of chronic rupture or poor tendon quality. Further work is necessary
Adams, Julie E; Habbu, Rohan
Tendinopathies involving the hand and wrist are common. Many are diagnosed easily, and in many cases, the management is straightforward, provided the pathology and principles are understood. Common conditions involving the tendons of the hand and wrist include trigger finger, tenosynovitis of the first through sixth dorsal extensor compartments, and flexor carpi radialis tendonitis. Management strategies include nonsurgical treatments, such as splinting, injection, or therapy, and surgical techniques such as tendon release. Copyright 2015 by the American Academy of Orthopaedic Surgeons.
Frizziero, Antonio; Vittadini, Filippo; Pignataro, Andrea; Gasparre, Giuseppe; Biz, Carlo; Ruggieri, Pietro; Masiero, Stefano
Summary Background The anatomy of hip is widely complex and several anatomical structures interact and contribute to its functioning. For position and role, hip and the surrounding tendons, which have their insertion around, are overstressed and often overloaded, especially in athletes. This could lead to the developing of several tendinopathies, among which the differential diagnosis is often complicated. Many conservative treatments are used in clinical practice, while actually, no defined conservative protocol is recommended. Methods This is a review article. The aim of this manuscript is to evaluate the current evidences about the effectiveness of conservative management in hip tendinopathies. Conclusion Conservative treatment is effective in the management of hip tendinopathies and may be considered the first-line approach for patients affected. However, there is lack of evidences about which is the most effective treatment. Exercise therapy seems to provide long-term pain relief, but the literature is still lacking about the correct type, dose, posology, intensity of exercise prescribed. Further studies about different local approaches, as PRP or hyaluronic acid injections, may be encouraged. Level of evidence I. PMID:28066732
Wang, H-K; Lin, K-H; Su, S-C; Shih, T T-F; Huang, Y-C
The aim was to compare viscoelastic properties of Achilles tendons between legs in elite athletes with unilateral tendinosis, and to investigate relationships between the properties and explosive performance and clinical severity. Seventeen male athletes (mean ± standard deviation age, 27.3 ± 2.0 years) who had unilateral, chronic middle-portion tendinopathy of the Achilles tendon were assessed by the Victorian Institute of Sport Assessment questionnaire, measurements of tendon viscoelastic properties, voluntary electromechanical delay (EMD), normalized rate of force development (RFD), and one-leg hopping distance. Compared with the non-injured leg, the tendinopathic leg showed reduced tendon stiffness (-19.2%. P < 0.001), greater mechanical hysteresis (+21.2%, P = 0.004), lower elastic energy storage and release (-14.2%, P = 0.002 and -19.1%, P < 0.001), lower normalized RFD at one-fourth (-16.3%, P = 0.02), 2/4 (-17.3%, P = 0.006), and three-fourths maximal voluntary contraction (-13.7%, P = 0.02), longer soleus and medial gastrocnemius voluntary EMD (+26.9%, P = 0.009 and +24.0%, P = 0.004), and shorter hopping distances (-34.1%, P < 0.001). Tendon stiffness was correlated with normalized RFD, voluntary EMD in the medial gastrocnemius, and hopping distances (r ranged from -0.35 to 0.64, P < 0.05). Hysteresis was correlated to the soleus voluntary EMD and hopping distances (r = 0.42 and -0.39, P < 0.05). We concluded that altered tendon viscoelastic properties in Achilles tendinosis affect explosive performance in athletes. © 2012 John Wiley & Sons A/S.
Lui, Pauline Po Yee
Chronic tendinopathy is a frequent and disabling musculo-skeletal problem affecting the athletic and general populations. The affected tendon is presented with local tenderness, swelling, and pain which restrict the activity of the individual. Tendon degeneration reduces the mechanical strength and predisposes it to rupture. The pathogenic mechanisms of chronic tendinopathy are not fully understood and several major non-mutually exclusive hypotheses including activation of the hypoxia-apoptosis-pro-inflammatory cytokines cascade, neurovascular ingrowth, increased production of neuromediators, and erroneous stem cell differentiation have been proposed. Many intrinsic and extrinsic risk/causative factors can predispose to the development of tendinopathy. Among them, diabetes mellitus is an important risk/causative factor. This review aims to appraise the current literature on the epidemiology and pathology of tendinopathy in diabetic patients. Systematic reviews were done to summarize the literature on (a) the association between diabetes mellitus and tendinopathy/tendon tears, (b) the pathological changes in tendon under diabetic or hyperglycemic conditions, and (c) the effects of diabetes mellitus or hyperglycemia on the outcomes of tendon healing. The potential mechanisms of diabetes mellitus in causing and exacerbating tendinopathy with reference to the major non-mutually exclusive hypotheses of the pathogenic mechanisms of chronic tendinopathy as reported in the literature are also discussed. Potential strategies for the management of tendinopathy in diabetic patients are presented.
Bisseling, Rob W; Hof, At L; Bredeweg, Steef W; Zwerver, Johannes; Mulder, Theo
Objective The aetiology of patellar tendinopathy (jumper's knee) remains unclear. To see whether landing strategy might be a risk factor for the development of this injury, this study examined whether landing dynamics from drop jumps differed among healthy volleyball players (CON) and volleyball players with a jumper's knee. The patients with jumper's knee were divided into an asymptomatic group with a previous jumper's knee (PJK) and a symptomatic group with a recent jumper's knee (RJK). Methods Inverse dynamics analyses were used to estimate lower extremity joint dynamics from 30, 50 and 70 cm drop jumps in the three groups (CON, n = 8; PJK, n = 7; RJK, n = 9). A univariate repeated measures analysis of variance was used to compare the different landing techniques. Results Data analysis of the landing dynamics revealed that PJK showed higher knee angular velocities (p<0.01), and higher ankle plantar flexion moment loading rate (p<0.01). Furthermore, strong tendencies of higher loading rate of vertical ground reaction force (p = 0.05) and higher knee extensor moment loading rate (p = 0.08) were found compared with CON. Higher values for peak knee moment, peak knee power and knee work (all p<0.01) were found for CON compared with RJK. The comparison of the two jumper's knee groups yielded higher knee angular velocities (p<0.01), together with higher ankle plantar flexion and knee extensor moment loading rate (p<0.01 and p<0.05, respectively). Conclusion Where RJK used a landing technique to avoid high patellar tendon loading, PJK used a stiffer landing strategy, which may be a risk factor in the development of patellar tendinopathy. PMID:17224437
Gual, Gabriel; Fort-Vanmeerhaeghe, Azahara; Romero-Rodríguez, Daniel; Tesch, Per A
Gual, G, Fort-Vanmeerhaeghe, A, Romero-Rodríguez, D, and Tesch, PA. Effects of in-season inertial resistance training with eccentric overload in a sports population at risk for patellar tendinopathy. J Strength Cond Res 30(7): 1834-1842, 2016-Volleyball and basketball players can be considered as a population at risk for patellar tendinopathy. Given the paradox that eccentric training elicits therapeutic benefits yet might provoke such injury, we investigated the influence of a weekly bout of inertial squat resistance exercise offering eccentric overload on lower limb muscle power and patellar tendon complaints. Players of 8 (4 basketball and 4 volleyball) teams (38 women and 43 men) were randomly assigned to either the intervention (IG) or control (CG) group. Although IG and CG maintained scheduled in-season training routines over 24 weeks, IG, in addition, performed 1 weekly session of eccentric overload by 4 sets of 8 repetitions of the squat using flywheel inertial resistance. Victorian Institute of Sports Assessment patellar tendinopathy questionnaire (VISA-p), vertical countermovement jump, and squat power, both concentric (Squat-Con) and eccentric (Squat-Ecc), tests were performed before (T1), during (T2), and after (T3) the 24 weeks of intervention. Neither group suffered from patellar tendinopathy during the study period. VISA-p displayed no differences across groups at any measurement period. Countermovement jump scores significantly (p ≤ 0.05) differed between groups in favor of the IG. Both Squat-Con and Squat-Ecc mean scores from the IG were significantly (p < 0.01) higher than the CG. Adding a weekly eccentric overload squat training bout to a regular basketball and volleyball exercise routine enhances lower limb muscle power without triggering patellar tendon complaints. Future studies, using the current exercise paradigm, aim to explore its efficacy to prevent or combat patellar tendinopathy in sports calling for frequent explosive jumps.
Bevilacqua, Nicholas J
Achilles tendon ruptures are best managed acutely. Neglected Achilles tendon ruptures are debilitating injuries and the increased complexity of the situation must be appreciated. Surgical management is recommended, and only in the poorest surgical candidate is conservative treatment entertained. Numerous treatment algorithms and surgical techniques have been described. A V-Y advancement flap and flexor halluces longus tendon transfer have been found to be reliable and achieve good clinical outcomes for defects ranging from 2 cm to 8 cm. This article focuses on the treatment options for the neglected Achilles tendon rupture. Copyright Â© 2012 Elsevier Inc. All rights reserved.
Mellor, Rebecca; Grimaldi, Alison; Wajswelner, Henry; Hodges, Paul; Abbott, J Haxby; Bennell, Kim; Vicenzino, Bill
Lateral hip pain is common, particularly in females aged 40-60 years. The pain can affect sleep and daily activities, and is frequently recalcitrant. The condition is often diagnosed as trochanteric bursitis, however radiological and surgical studies have revealed that the most common pathology is gluteus medius/minimus tendinopathy. Patients are usually offered three treatment options: (a) corticosteroid injection (CSI), (b) physiotherapy, or (c) reassurance and observation. Research on Achilles and patellar tendons has shown that load modification and exercise appears to be more effective than other treatments for managing tendinopathy, however, it is unclear whether a CSI, or a load modification and exercise-based physiotherapy approach is more effective in gluteal tendinopathy. This randomised controlled trial aims to compare the efficacy on pain and function of a load modification and exercise-based programme with a CSI and a 'wait and see' approach for gluteal tendinopathy. Two hundred one people with gluteal tendinopathy will be randomly allocated into one of three groups: (i) CSI; (ii) physiotherapist-administered load modification and exercise intervention; and (iii) wait and see approach. The CSI therapy will consist of one ultrasound (US) guided CSI around the affected tendons and advice on tendon care. Education about load modification will be delivered in physiotherapy clinics and the exercise programme will be both home-based and supervised. The group allocated the wait and see approach will receive basic tendon care advice and reassurance in a single session by a trial physiotherapist. Outcomes will be evaluated at baseline, 4, 8, 12, 26 and 52 weeks using validated global rating of change, pain and physical function scales, psychological measures, quality of life and physical activity levels. Hip abductor muscle strength will be measured at baseline and 8 weeks. Economic evaluation will be performed to investigate the cost-effectiveness of the
Biernat, Ryszard; Trzaskoma, Zbigniew; Trzaskoma, Lukasz; Czaprowski, Dariusz
The aim of the study was to investigate the efficacy of rehabilitation protocol applied during competitive period for the treatment of patellar tendinopathy. A total of 28 male volleyball players were divided into two groups. Fifteen from experimental group (E) and 13 from control group (C) fulfilled the same tests 3 times: before the training program started (first measurement), after 12 weeks (second measurement) and after 24 weeks (third measurement). The above-mentioned protocol included the following: USG imagining with color Doppler function, clinical testing, pain intensity evaluation with VISA-P questionnaire, leg muscle strength and power and jumping ability measurements. The key element of the rehabilitation program was eccentric squat on decline board with additional unstable surface. The essential factor of the protocol was a set of preventive functional exercises, with focus on eccentric exercises of hamstrings. Patellar tendinopathy was observed in 18% of the tested young volleyball players. Implementation of the presented rehabilitation protocol with eccentric squat on decline board applied during sports season lowered the pain level of the young volleyball players. Presented rehabilitation protocol applied without interrupting the competitive period among young volleyball players together with functional exercises could be an effective method for the treatment of patellar tendinopathy.
Achilles tendinitis , 584 cases of patellar tendinitis , and 1228 cases plantar fasciitis were identified. Recent deployment was associated with an...consumption was marginally associated with an increased risk for Achilles tendinitis (AOR = 1.35, 95% CI = 1.00, 1.76). Overweight or obese individuals...were more likely to develop both Achilles tendinitis and plantar fasciitis. Specific occupations, including health care workers, were at
Expósito Molinero, María Rosa; de Miguel Mendieta, Eugenio
We want to know if the ultrasound examination of the Achilles tendon in spondyloarthritis is different compared to other rheumatic diseases. We studied 97 patients divided into five groups: rheumatoid arthritis, spondyloarthritis, gout, chondrocalcinosis and osteoarthritis, exploring six elementary lesions in 194 Achilles entheses examined. In our study the total index ultrasonographic Achilles is higher in spondyloarthritis with significant differences. The worst elementary spondyloarthritis lesions for discriminations against other pathologies were calcification. This study aims to demonstrate the discriminant validity of Achilles enthesitis observed by ultrasound in spondyloarthritis compared with other rheumatic diseases that may also have ultrasound abnormalities such enthesis level. Copyright © 2015 Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología. All rights reserved.
Sandrey, Michelle A.
Reference: de Vos RJ, van Veldhoven PLJ, Moen MH, Weir A, Tol JL. Autologous growth factor injections in chronic tendinopathy: a systematic review. Br Med Bull. 2010;95:63–77. Clinical Question: The authors of this systematic review evaluated the literature to critically consider the effects of growth factors delivered through autologous whole-blood and platelet-rich–plasma (PRP) injections in managing wrist-flexor and -extensor tendinopathies, plantar fasciopathy, and patellar tendinopathy. The primary question was, according to the published literature, is there sufficient evidence to support the use of growth factors delivered through autologous whole-blood and PRP injections for chronic tendinopathy? Data Sources: The authors performed a comprehensive, systematic literature search in October 2009 using PubMed, MEDLINE, EMBASE, CINAHL, and the Cochrane library without time limits. The following key words were used in different combinations: tendinopathy, tendinosis, tendinitis, tendons, tennis elbow, plantar fasciitis, platelet rich plasma, platelet transfusion, and autologous blood or injection. The search was limited to human studies in English. All bibliographies from the initial literature search were also viewed to identify additional relevant studies. Study Selection: Studies were eligible based on the following criteria: (1) Articles were suitable (inclusion criteria) if the participants had been clinically diagnosed as having chronic tendinopathy; (2) the design had to be a prospective clinical study, randomized controlled trial, nonrandomized clinical trial, or prospective case series; (3) a well-described intervention in the form of a growth factor injection with either PRP or autologous whole blood was used; and (4) the outcome was reported in terms of pain or function (or both). Data Extraction: All titles and abstracts were assessed by 2 researchers, and all relevant articles were obtained. Two researchers independently read the full text of
Sandrey, Michelle A
de Vos RJ, van Veldhoven PLJ, Moen MH, Weir A, Tol JL. Autologous growth factor injections in chronic tendinopathy: a systematic review. Br Med Bull. 2010;95:63-77. The authors of this systematic review evaluated the literature to critically consider the effects of growth factors delivered through autologous whole-blood and platelet-rich-plasma (PRP) injections in managing wrist-flexor and -extensor tendinopathies, plantar fasciopathy, and patellar tendinopathy. The primary question was, according to the published literature, is there sufficient evidence to support the use of growth factors delivered through autologous whole-blood and PRP injections for chronic tendinopathy? The authors performed a comprehensive, systematic literature search in October 2009 using PubMed, MEDLINE, EMBASE, CINAHL, and the Cochrane library without time limits. The following key words were used in different combinations: tendinopathy, tendinosis, tendinitis, tendons, tennis elbow, plantar fasciitis, platelet rich plasma, platelet transfusion, and autologous blood or injection. The search was limited to human studies in English. All bibliographies from the initial literature search were also viewed to identify additional relevant studies. Studies were eligible based on the following criteria: (1) Articles were suitable (inclusion criteria) if the participants had been clinically diagnosed as having chronic tendinopathy; (2) the design had to be a prospective clinical study, randomized controlled trial, nonrandomized clinical trial, or prospective case series; (3) a well-described intervention in the form of a growth factor injection with either PRP or autologous whole blood was used; and (4) the outcome was reported in terms of pain or function (or both). All titles and abstracts were assessed by 2 researchers, and all relevant articles were obtained. Two researchers independently read the full text of each article to determine if it met the inclusion criteria. If opinions differed on
Dierckman, Brian D; Shah, Nirav R; Larose, Connor R; Gerbrandt, Stacey; Getelman, Mark H
(1) Describe a previously unreported finding involving the intra-articular portion of the subscapularis, the Conrad lesion. (2) Describe a novel classification system for the spectrum of non-insertional tendinopathy of the subscapularis. (3) Report the outcomes of surgical treatment of this spectrum of pathology. Outcomes of 34 patients (23 males and 11 females, mean age 60.5 ± 7.5) with non-insertional tendinopathy of the subscapularis treated arthroscopically were retrospectively reviewed. All patients had anterior shoulder pain with no weakness during belly-press testing and no subscapularis footprint involvement on magnetic resonance imaging. All patients were managed with subscapularis tendon debridement and side-to-side repair along with treatment of concomitant pathology. Seven patients had a Type I lesion (so-called Conrad lesion) - a nodule on the leading edge of the subscapularis. Eighteen patients had a Type II lesion - a visible split tear with degeneration in the upper ½ of the intra-articular tendon. Nine patients had a Type III lesion - more extensive splitting in the tendon with advanced tendon degeneration. At a mean follow-up of 24 months, 97% of patients were completely satisfied. Significant improvements were seen in forward elevation (152 ± 12° to 172 ± 5°, P < 0.001) and visual analog scale pain scores (5.9 ± 1.7-0.6 ± 1.0, P < 0.001). Internal rotation strength and external rotation motion at the side were maintained. ASES scores averaged 95.4 ± 7.4, disabilities of arm, shoulder and hand scores averaged 6.19 ± 9.8, Western Ontario Rotator Cuff scores averaged 91.7 ± 9.3 and the average University of California at Los Angeles score was 33.1 ± 2.4. We present a previously unreported finding of the subscapularis, the Conrad lesion, along with a novel classification system for non-insertional tendinopathy of the subscapularis. Arthroscopic treatment of this spectrum of tendinopathy along with concomitant shoulder pathology eliminated
Oliva, Francesco; Via, Alessio Giai; Maffulli, Nicola
Calcific tendinopathy (CT) of the tendons of the rotator cuff is common in white populations, with a reported prevalence varying from 2.7% to 22%, mostly affecting women between 30 and 50 years. Although CT shows a strong tendency toward self-healing by spontaneous resorption of the deposits, it does not always follow this typical pattern. The etiopathogenesis of CT is still unknown. Many pathogenetic theories have been proposed, and clinical associations between CT and diabetes and thyroid disorders have been reported. The choice of therapeutic approach should depend on the evolution of the condition.
Lateral elbow tendinopathy (LET) is a common musculoskeletal/sports injury. A plethora of physiotherapy techniques has been proposed in the management of LET. The exercise programme is the most common treatment in the management of LET. The optimal protocol of exercise programme is still unknown. The effectiveness of the exercise programme is low when it is applied as monotherapy. Therefore, exercise programme is combined with other physiotherapy modalities such as soft tissue techniques, external support, acupuncture, manual therapy and electrotherapy, in the treatment of LET. Future research is needed to determine which treatment strategy combined with exercise programme will provide the best results in LET rehabilitation. PMID:27622145
Rasske, Kristen; Thelen, Darryl G; Franz, Jason R
The Achilles tendon (AT) moment arm is an important determinant of ankle moment and power generation during locomotion. Load and depth-dependent variations in the AT moment arm are generally not considered, but may be relevant given the complex triceps surae architecture. We coupled motion analysis and ultrasound imaging to characterize AT moment arms during walking in 10 subjects. Muscle loading during push-off amplified the AT moment arm by 10% relative to heel strike. AT moment arms also varied by 14% over the tendon thickness. In walking, AT moment arms are not strictly dependent on kinematics, but exhibit important load and spatial dependencies.
Stecco, Carla; Corradin, Marco; Macchi, Veronica; Morra, Aldo; Porzionato, Andrea; Biz, Carlo; De Caro, Raffaele
(99%CI and SD = 0.95), as opposed to 2.09 ± 0.24 mm (99%CI, SD = 0.47) in the patients in which the MRI revealed no Achilles tendon diseases; this difference in thickness of 1.29 ± 0.57 mm (99%CI) was statistically significant (P < 0.001). In the group of 27/52 patients with tendinopathies, the PF was more than 4.5 mm thick in 5, i.e. they exceeded the threshold for a diagnosis of plantar fasciitis. None of the other 25/52 paitents had a PF more than 4 mm thick. There was a statistically significant correlation between the thicknesses of the PF and the paratenon. These findings suggest that the plantar fascia has a role not only in supporting the longitudinal arch of the foot, but also in its proprioception and peripheral motor coordination. Its relationship with the paratenon of the Achilles tendon is consistent with the idea of triceps surae structures being involved in the PF pathology, so their rehabilitation can be considered appropriate. Finally, the high concentration of hyaluronan in the PF points to the feasibility of using hyaluronan injections in the fascia to treat plantar fasciitis. © 2013 Anatomical Society.
Stecco, Carla; Corradin, Marco; Macchi, Veronica; Morra, Aldo; Porzionato, Andrea; Biz, Carlo; De Caro, Raffaele
thick (99%CI and SD = 0.95), as opposed to 2.09 ± 0.24 mm (99%CI, SD = 0.47) in the patients in which the MRI revealed no Achilles tendon diseases; this difference in thickness of 1.29 ± 0.57 mm (99%CI) was statistically significant (P < 0.001). In the group of 27/52 patients with tendinopathies, the PF was more than 4.5 mm thick in 5, i.e. they exceeded the threshold for a diagnosis of plantar fasciitis. None of the other 25/52 paitents had a PF more than 4 mm thick. There was a statistically significant correlation between the thicknesses of the PF and the paratenon. These findings suggest that the plantar fascia has a role not only in supporting the longitudinal arch of the foot, but also in its proprioception and peripheral motor coordination. Its relationship with the paratenon of the Achilles tendon is consistent with the idea of triceps surae structures being involved in the PF pathology, so their rehabilitation can be considered appropriate. Finally, the high concentration of hyaluronan in the PF points to the feasibility of using hyaluronan injections in the fascia to treat plantar fasciitis. PMID:24028383
Oliva, Francesco; Piccirilli, Eleonora; Berardi, Anna C; Frizziero, Antonio; Tarantino, Umberto; Maffulli, Nicola
Tendinopathies negatively affect the quality of life of millions of people, but we still do not know the factors involved in the development of tendon conditions. Published articles in English in PubMed and Google Scholar up to June 2015 about hormonal influence on tendinopathies onset. One hundred and two papers were included following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. In vitro and in vivo, tenocytes showed changes in their morphology and in their functional properties according to hormonal imbalances. Genetic pattern, sex, age and comorbidities can influence the hormonal effect on tendons. The increasing prevalence of metabolic disorders prompts to investigate the possible connection between metabolic problems and musculoskeletal diseases. The influence of hormones on tendon structure and metabolism needs to be further investigated. If found to be significant, multidisciplinary preventive and therapeutic strategies should then be developed. © The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: firstname.lastname@example.org.
Tsai, Feng-Hua; Chu, I-Hua; Huang, Chun-Hao; Liang, Jing-Min; Wu, Jia-Hroung; Wu, Wen-Lan
It has been reported that there is high rate of Achilles tendon injury among kendo athletes. For protection and support the area, kendo athletes habitually use taping during practice or games. To investigate the effect of various taping techniques on injury prevention and functional performance in kendo athletes. Case-control study. Laboratory. Fifteen University Kendo Team athletes with at least 2 years kendo experience. Athletes completed 5 stepping backwards and striking cycles under four taping conditions: No taping; Athletic taping of ankle joint (AT-Ankle); Athletic taping of Achilles tendon (AT-Achilles); and Kinesio-Tex taping of Achilles tendon (KT-Achilles). Jump distance, lower limb angular motion, left foot-ground contact time, Achilles tendon force (ATF), and soleus and medial gastrocnemius muscle activities. Lowest peak ATF was found in AT-Achilles during heel-down phase, statistically significantly different from KT-Achilles peak force. Significant decline of soleus muscle EMG amplitude was also found when compared to No taping, during heel-down phase and other conditions during pushing phase. Conversely, KT-Achilles showed significant decrease in foot-ground contact time compared with No taping and greater ankle range of motion than in AT-Ankle. To protect the Achilles tendon, AT-Achilles taping is recommended since it tends to decrease ATF. Conversely, to enhance athletes' performance, we recommend KT-Achilles taping to speed up kendo striking motion. However, the Achilles tendon must withstand greatest forces concurrently. This finding implies that AT-Achilles taping can protect the injured Achilles tendon and KT-Achilles taping can enhance performance on the kendo striking motion.
Aydin, Sibel Zehra; Karadag, Omer; Filippucci, Emilio; Atagunduz, Pamir; Akdogan, Ali; Kalyoncu, Umut; Grassi, Walter; Direskeneli, Haner
Enthesitis is considered as the primary anatomical lesion in ankylosing spondylitis (AS). Therapeutic effects of TNF-alpha antagonist treatments for enthesitis on imaging changes are still limited to case reports or small sample-sized trials. We aimed to investigate the potential of ultrasonography (US) to detect early changes after TNF-alpha antagonist therapy of Achilles enthesis of AS patients. Forty-three AS patients with active disease, requiring TNF-alpha antagonist therapy, were included. Physical examination was performed to detect Achilles enthesitis and/or retrocalcaneal bursitis. US of the Achilles tendon was performed bilaterally. Grey-scale (GS) and power Doppler (PD) scores on a 0-2 semi-quantitative scale and total additive scores (TS) were calculated. Follow-up US examinations were performed 2 months after the initiation of therapy. At baseline, 11 patients (26.2%) were symptomatic in physical examination for either Achilles enthesitis or retrocalcaneal bursitis, whereas 36 (83%) had GS US pathological findings and 10 (23.3%) had PD signal. GS score and TS decreased significantly [3.6 (3.0) vs 2.3 (2.2), P < 0.001 and 4.7 (4.9) vs 2.7 (3.3), P < 0.001, respectively], whereas the decrease in PD score was not significant after 2 months of follow-up. The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), ESR and CRP levels also showed significant improvements. Subclinical Achilles enthesitis, detected only with GS US, is present in a subset of AS patients and a significant improvement can be demonstrated after 2 months of TNF-alpha antagonist therapy. In addition to standard outcome measures, US might be an additional useful tool to monitor therapy in SpA patients with Achilles enthesitis.
Gluteal tendinopathies have become significantly better understood over the past few years, primarily due to the work of Alison Grimaldi and her research associates. This brief summary highlights some key points of their work and some exercise suggestions for treatment.
Blei, C.L.; Nirschl, R.P.; Grant, E.G.
Twenty-three patients were prospectively examined with ultra-sound (US) for acute or recurrent Achilles tendon symptoms. Three types of pathologic conditions of the Achilles tendon were found: tendinitis/tenosynovitis, acute tendon trauma, and postoperative changes. US appears to enable differentiation of these conditions and to contribute to the diagnosis of a broad range of Achilles tendon disorders.
Syha, R; Würslin, C; Ketelsen, D; Martirosian, P; Grosse, U; Schick, F; Claussen, C D; Springer, F
Achilles tendinopathy has been reported to be frequently associated with increasing volume of the tendon. This work aims at reliable and accurate volumetric quantification of the Achilles tendon using a newly developed contour detection algorithm applied on high resolution MRI data sets recorded at 3T. A total of 26 healthy tendons and 4 degenerated tendons were examined for this study. Automated identification (AI) of tendon boundaries was performed in transverse slices with isotropic resolution (0.8mm) gained with a T2-weighted SPACE sequence at 3T. For AI a snake algorithm was applied and compared to manual tracing (MT). AI was feasible in all examined tendons without further correction. AI of both tendons was performed in each participant within 2 min (2 × 37 slices) compared to MT lasting 20 min. MT and AI showed excellent agreement and correlation (R(2) = 0.99, p<0.0001). AI provided a reduction of measurement error (0.4 cm(3) vs. 0.5 cm(3)) and coefficient of variation (1% vs. 2%). Compared to MT the AI allows assessment of tendon volumes in highly resolved MRI data in a more accurate and reliable time-saving way. Therefore automated volume detection is seen as a helpful clinical tool for evaluation of small volumetric changes of the Achilles tendon. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.
Kaleagasioglu, Ferda; Olcay, Ercan
Tendinopathy is a serious health problem and its etiology is not fully elucidated. Among intrinsic and extrinsic predisposing factors of tendinopathy, the impact of therapeutic agents, especially fluoroquinolone (FQ) group antibiotics, is recently being recognized. FQs are potent bactericidal agents widely used in various infectious diseases, including community acquired pneumonia and bronchitis, chronic osteomyelitis, traveler's diarrhea, typhoid fever, shigellosis, chronic bacterial prostatitis, uncomplicated cervical and urethral gonorrhea and prophylaxis of anthrax. FQs have an acceptable tolerability range. However, many lines of evidence for developing tendinitis and tendon rupture during FQ use have resulted in the addition of a warning in patient information leaflets. FQ-induced tendinopathy presents a challenge for the clinician because healing response is poor due to low metabolic rate in mature tendon tissue and tendinopathy is more likely to develop in patients who are already at high risk, such as elderly, solid organ transplant recipients and concomitant corticosteroid users. FQs become photo-activated under exposure to ultraviolet light, and this process results in formation and accumulation of intracellular reactive oxygen species (ROS). The subsequent FQ-related oxidative stress disturbs mitochondrial functions, leading to apoptosis. ROS overproduction also has direct cytotoxic effects on extracellular matrix components. Understanding the mechanisms of the FQ-associated tendinopathy may enable designing safer therapeutic strategies, hence optimization of clinical response. In this review, we evaluate multi-factorial etiology of the FQ-induced tendinopathy and discuss proposed preventive measures such as antioxidant use and protection from natural sunlight and artificial ultraviolet exposure.
Groot, H E; van der Worp, H; Nijenbanning, L; Diercks, R L; Zwerver, J; van den Akker-Scheek, I
Patellar tendinopathy is a highly prevalent overuse injury, and most treatments are only effective to some extent. This persistence of complaints could be linked to changed proprioception. One study showed diminished proprioception in athletes with lateral epicondylitis. Aim of this study was to determine differences in proprioception, by measuring threshold to detect passive motion (TTDPM) between recreational athletes diagnosed with patellar tendinopathy and healthy controls. The TTDPM as measure of proprioception was determined in 22 recreational athletes with patellar tendinopathy and 22 healthy recreational athletes using a validated instrument. Amount of knee flexion and extension before the movement was noticed by the subject was determined. 80 measurements per athlete (left and right leg, towards extension and flexion and with two starting angles of 20° and 40° flexion) were performed. Mean TTDPM was compared between groups and among the injured recreational athletes between the affected and unaffected knee. No significant difference in TTDPM was found between recreational athletes with patellar tendinopathy and healthy controls. We did find a significant difference between the injured and non-injured knee in recreational athletes with patellar tendinopathy; mean TTDPM was 0.02° higher in the injured knee (p=0.044). No difference was found in proprioception between recreational athletes with patellar tendinopathy and healthy recreational athletes. It is unclear whether such a small difference in TTDPM between affected and unaffected knee is important in clinical setting. Copyright © 2016 Elsevier B.V. All rights reserved.
McWilliam, James R; Mackay, Gordon
The efficient and effective function of the Achilles tendon is essential for normal gait and sporting performance. The optimal technique for the operative repair of the Achilles midsubstance rupture remains controversial. Suboptimal outcomes are common even after successful Achilles repair. Factors contributing to poor outcomes include a tenuous soft tissue envelope (leading to wound complications, peritendinous adhesions, and poor tendon healing,) as well as failure to maintain appropriate musculotendinous length, even after successful repair.We present a new technique using the InternalBrace (IB) and a modification of the Percutaneous Achilles Repair System (PARS; Arthrex Inc, Naples, FL), the Achilles Mid-Substance Speed Bridge Repair. This IB approach is knotless, respects the soft tissue envelope, and allows the appropriate musculotendinous length to be set intraoperatively. The IB principle enables direct fixation to bone allowing early mobilization while minimizing the risk of knot slippage, accelerating recovery, and allowing for restoration of normal function. Level V, expert opinion. © The Author(s) 2016.
Christian, Robert A; Rossy, William H; Sherman, Orrin H
Patellar tendinopathy (PT) is a clinical and chronic overuse condition of unknown pathogenesis and etiology marked by anterior knee pain typically manifested at the inferior pole of the patella. PT has been referred to as "jumper's knee" since it is particularly common among populations of jumping athletes, such as basketball and volleyball players. Due to its common refractory response to conservative treatment, a variety of new treatments have emerged recently that include dry-needling, sclerosing injections, platelet-rich plasma therapy, arthroscopic surgical procedures, surgical resection of the inferior patellar pole, extracorporeal shock wave treatment, and hyperthermia thermotherapy. Since PT has an unknown pathogenesis and etiology, PT treatment is more a result of physician experience than evidence-based science. This review will summarize the current literature on this topic, identify current research efforts aimed to understand the pathological changes in abnormal tendons, provide exposure to the emerging treatment techniques, and provide suggested direction for future research.
Mazzone, Michael F; McCue, Timothy
The Achilles tendon, the largest tendon in the body, is vulnerable to injury because of its limited blood supply and the combination of forces to which it is subjected. Aging and increased activity (particularly velocity sports) increase the chance of injury to the Achilles tendon. Although conditions of the Achilles tendon are occurring with increasing frequency because the aging U.S. population is remaining active, the diagnosis is missed in about one fourth of cases. Injury onset can be gradual or sudden, and the course of healing is often lengthy. A thorough history and specific physical examination are essential to make the appropriate diagnosis and facilitate a specific treatment plan. The mainstay of treatment for tendonitis, peritendonitis, tendinosis, and retrocalcaneobursitis is ice, rest, and nonsteroidal anti-inflammatory drugs, but physical therapy, orthoties, and surgery may be necessary in recalcitrant cases. In patients with tendon rupture, casting or surgery is required. Appropriate treatment often leads to full recovery.
Lui, T H
Achilles tendon ruptures occur commonly in the midsubstance of the tendon, usually 2-6 cm proximal to the insertion to the calcaneus. Ruptures near its insertion into the calcaneus are less common and mostly found in hyperpronators with a heel spur (Haglund's deformity). Avulsion of the bony insertion of the Achilles tendon at the calcaneus is infrequent and is diagnosed by radiography. Open reduction and internal fixation is indicated to achieve bone to bone healing and restoration of the function and continuity of the triceps surae mechanism. Screw fixation is not effective to resist the pull out tension of the triceps surae. Moreover, the prominent screw head may cause skin impingement. More secure fixation method is necessary in order to allow early functional rehabilitation. We describe a technique to fix the avulsed fragment of Achilles tendon insertion with 2 suture anchors. This can neutralize the pull of the triceps surae and early post-operative rehabilitation programme is allowed.
Segesser, B; Goesele, A; Renggli, P
Achillodynia is a generic term for various types of ailments in the region of the Achilles tendon. For adequate therapy a specific diagnosis is absolutely necessary. Besides an accurate anamnesis and the right choice of terrain and shoes, as well as a clinical examination where one has to specifically keep an eye on muscular imbalance between the gastrocnemius and the soleus muscle and disorders of the ligamentous control of the calcaneus caused by fibular ligament instabilities, a procedure such as radiology, ultrasound, and MR imaging is inevitable. From the differential diagnosis point of view a distinction between peritendinitis, mechanically triggered bursitis (calcaneal and subachilles), bony alterations of the calcaneus (calcaneus spur, Haglund exostosis persistent nucleus of the apophysis, fatigue fracture, etc) and a partial or total rupture (a one-time occurrence or multiple occurrences) has to be made. Occasionally, entrapment of the ramus calcaneus of the sural nerve causes calcaneal pain. If clinically not confirmed, lumbar pain ought to be taken into consideration (discopathy, Bechterew disease, etc). Metabolic disorders (especially uric acid) and underlying rheumatic diseases must be excluded. The therapy of achillodynia includes local and peroral antiphlogistic medication as a concomitant measure. More important is the causal influence of etiological factors, i.e., the correction of muscular imbalance, ensuring control of the calcaneus through bandages and adjustment of sport shoes, changes in training buildup and exercise intensity, just to mention a few. If necessary, surgically splitting the peritendineum, sanitation of a partial rupture, bursectomy and removal of mechanically obstructive exostosis must be done.
Thorpe, C T; Udeze, C P; Birch, H L; Clegg, P D; Screen, H Rc
Age-related tendinopathy is common in both humans and horses; the initiation and progression of which is similar between species. The majority of tendon injuries occur to high-strain energy storing tendons, such as the human Achilles tendon and equine superficial digital flexor (SDFT). By contrast, the low-strain positional human anterior tibialis tendon and equine common digital extensor (CDET) are rarely injured. It has previously been established that greater extension occurs at the fascicular interface in the SDFT than in the CDET; this may facilitate the large strains experienced during locomotion in the SDFT without damage occurring to the fascicles. This study investigated the alterations in whole tendon, fascicle and interfascicular mechanical properties in the SDFT and CDET with increasing age. It was hypothesised that the amount of sliding at the fascicular interface in the SDFT would decrease with increasing horse age, whereas the properties of the interface in the CDET would remain unchanged with ageing. Data support the hypothesis; there were no alterations in the mechanical properties of the whole SDFT or its constituent fascicles with increasing age. However, there was significantly less sliding at the fascicular interface at physiological loads in samples from aged tendons. There was no relationship between fascicle sliding and age in the CDET. The increase in stiffness of the interfascicular matrix in aged SDFT may result in the fascicles being loaded at an earlier point in the stress strain curve, increasing the risk of damage. This may predispose aged tendons to tendinopathy.
Skalec, A; Przyborowska-Zhalniarovich, P; Janus, I; Kirstein, K; Mieszkowska, M; Adamiak, Z; Chrószcz, A; Janeczek, M
In spite of recent advances in treatment protocols, tendinopathies continue to challenge orthopaedists and surgeons. Due to the complexity of both tendon injuries and the healing processes, animal models are essential for addressing fundamental questions in tendinopathy research. Diagnostic imaging could contribute to the evaluation of animal models, thus providing information, which could be translated to human tendinopathies. The objective of our study was to evaluate in situ appearance of the rabbit common calcanean tendon with ultrasonography and magnetic resonance imaging. Additionally, we sought to assess and compare the feasibility and usefulness of these techniques in a rabbit model while focusing on the imaging of the particular structures involved in calcaneal tendon disorders. Eight California rabbits were used for post-mortem sonographic and low-field magnetic resonance examination. Morphometry was performed on longitudinal sonograms and sagittal MRI scans. The craniocaudal diameter of the tendon was measured at four points of interest. Ultrasonography and magnetic resonance provided good visualisation of the tendon origin, the paratenon and the pre-Achilles fat pad. Magnetic resonance images presented in more detail the structure of the calcaneal insertion. Both modalities failed to visualise the individual components of the common calcanean tendon and the bursa of the calcaneal tendon. Statistical analysis of measurements obtained showed that the craniocaudal diameter of the common calcanean tendon in a rabbit increases significantly with a growing length from the calcaneal tuber. Both magnetic resonance and ultrasonography are feasible, and should be considered complementary, not alternative imaging techniques in a rabbit common calcanean tendon model.
Karzis, K; Kalogeris, M; Mandalidis, D; Geladas, N; Karteroliotis, K; Athanasopoulos, S
The purpose of this study was to investigate Achilles tendon blood flow in individuals with overpronated feet during non-weight- and weight-bearing positions. Achilles tendon blood flow was measured by means of the pulsatility index (PI) and the resistance index (RI) in 15 male individuals with overpronated feet and 15 counterparts with normal feet, using power Doppler ultrasonography (PDI). Achilles tendon ultrasonographic (US) assessment was performed at its musculo-tendinous junction (MTJ), mid-tendon (MT), and osseotendinous junction (OTJ) at a non-weight-bearing relaxed position (RP) and during two-leg stance (TLS) and one-leg upright stance (OLS). PI and RI indices were significantly greater in individuals with overpronated feet compared to individuals with normal feet at the OTJ in OLS position (P < 0.01), and at MT in both TLS (P < 0.001) and OLS positions (P < 0.001). All individuals demonstrated also greater PI and RI indices at MT followed by the OTJ and MTJ in all positions (P < 0.001), and in OLS compared to TLS and the RP at the OTJ (P < 0.01) as well as at MT and MTJ (P < 0.001). The findings of the present study suggest that foot overpronation may affect Achilles tendon blood flow, particularly at mid-tendon, thus enhancing the possibility for injury. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
Gulati, Vivek; Jaggard, Matthew; Al-Nammari, Shafic Said; Uzoigwe, Chika; Gulati, Pooja; Ismail, Nizar; Gibbons, Charles; Gupte, Chinmay
Achilles tendon rupture has been on the rise over recent years due to a variety of reasons. It is a debilitating injury with a protracted and sometimes incomplete recovery. Management strategy is a controversial topic and evidence supporting a definite approach is limited. Opinion is divided between surgical repair and conservative immobilisation in conjunction with functional orthoses. A systematic search of the literature was performed. Pubmed, Medline and EmBase databases were searched for Achilles tendon and a variety of synonymous terms. A recent wealth of reporting suggests that conservative regimens with early weight bearing or mobilisation have equivalent or improved rates of re-rupture to operative regimes. The application of dynamic ultrasound assessment of tendon gap may prove crucial in minimising re-rupture and improving outcomes. Studies employing functional assessments have found equivalent function between operative and conservative treatments. However, no specific tests in peak power, push off strength or athletic performance have been reported and whether an advantage in operative treatment exists remains undetermined. PMID:25992315
Pasternak, B; Schepull, T; Eliasson, P; Aspenberg, P
In this study, serum levels of matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) between patients with a history of Achilles tendon rupture and blood donor controls were compared, and their relation to mechanical properties of the tendons during healing were studied. More than 3 years after injury, serum levels of MMP-1, MMP-2, MMP-3, MMP-7, MMP-8, MMP-9 and MMP-13, TIMP-1 and TIMP-2 in eight patients who had Achilles tendon rupture were measured. Twelve blood donors served as controls. During the early phase of healing, the tendon modulus of elasticity was calculated from radiostereometric data and tendon cross-sectional area. Patients with a history of Achilles tendon rupture had increased levels of MMP-2 (median difference 10%, p=0.01), MMP-7 (median difference 15%, p=0.02) and TIMP-2 (median difference 36%, p=0.02), compared with controls. Levels of MMP-7, measured 3 years after injury, correlated inversely to tendon modulus of elasticity (r(s)=20.83, p=0.02) and positively to tendon elongation (r(s)=0.74, p=0.05) during the early phase of healing. There was a trend towards positive correlation between MMP-7 and cross-sectional area during the early phase of healing (r(s)=0.67, p=0.08). Patients with a history of Achilles tendon rupture appear to have elevated levels of MMP-2, MMP-7 and TIMP-2 in serum. In these pilot data, the view that the MMP-TIMP system is involved in tendinopathy is supported and that disturbances in proteolytic control might be generalised are suggested.
Nicholson, Luke T.; DiSegna, Steven; Newman, Joel S.; Miller, Suzanne L.
Background: Proximal hamstring tendinopathy is an uncommon but debilitating cause of posterior thigh pain in athletes subjected to repetitive eccentric hamstring contraction, such as runners. Minimal data exist evaluating treatment options for proximal hamstring tendinopathy. Purpose: This retrospective study evaluates the effectiveness of fluoroscopically guided corticosteroid injections in treating proximal hamstring tendinopathy. Study Design: Case series; Level of evidence, 4. Methods: Eighteen athletes with 22 cases of magnetic resonance imaging–confirmed proximal hamstring tendinopathy were treated with corticosteroid injection and later contacted to evaluate the efficacy of the injection with the use of a questionnaire. Results: The visual analog score decreased from 7.22 preinjection to 3.94 postinjection (P < .001), level of athletic participation increased from 28.76% to 68.82% (P < .001) at a mean follow-up of 21 months, and 38.8% of patients experienced complete resolution at a mean follow-up of 24.8 months. The mean lower extremity function score at the time of follow-up was 60. Conclusion: A trial of fluoroscopically guided corticosteroid injection is warranted in patients presenting with symptoms of proximal hamstring tendinopathy refractory to conservative therapy. PMID:26535310
Our understanding of the pathogenesis of "tendinopathy" is based on fragmented evidences like pieces of a jigsaw puzzle. We propose a "failed healing theory" to knit these fragments together, which can explain previous observations. We also propose that albeit "overuse injury" and other insidious "micro trauma" may well be primary triggers of the process, "tendinopathy" is not an "overuse injury" per se. The typical clinical, histological and biochemical presentation relates to a localized chronic pain condition which may lead to tendon rupture, the latter attributed to mechanical weakness. Characterization of pathological "tendinotic" tissues revealed coexistence of collagenolytic injuries and an active healing process, focal hypervascularity and tissue metaplasia. These observations suggest a failed healing process as response to a triggering injury. The pathogenesis of tendinopathy can be described as a three stage process: injury, failed healing and clinical presentation. It is likely that some of these "initial injuries" heal well and we speculate that predisposing intrinsic or extrinsic factors may be involved. The injury stage involves a progressive collagenolytic tendon injury. The failed healing stage mainly refers to prolonged activation and failed resolution of the normal healing process. Finally, the matrix disturbances, increased focal vascularity and abnormal cytokine profiles contribute to the clinical presentations of chronic tendon pain or rupture. With this integrative pathogenesis theory, we can relate the known manifestations of tendinopathy and point to the "missing links". This model may guide future research on tendinopathy, until we could ultimately decipher the complete pathogenesis process and provide better treatments. PMID:21144004
Walter, James A.
This paper discusses the book "Achilles in Vietnam" (Jonathan Shay) in relation to Homer's "Iliad" and the need for society to accept the consequences of veterans' experiences. Classical allusions to the epic are incorporated into the study and U.S. experience of the Vietnam War. The paper advocates student "ownership" of literature study and…
1. NAME AND TITLE OF DATA LIBRARY ACHILLES -Heat Transfer in PWR Core During LOCA Reflood Phase. 2. NAME AND TITLE OF DATA RETRIEVAL PROGRAMS N/A 3. CONTRIBUTOR AEA Technology, Winfrith Technology Centre, Dorchester DT2 8DH United Kingdom through the OECD Nuclear Energy Agency Data Bank, Issy-les-Moulineaux, France. 4. DESCRIPTION OF TEST FACILITY The most important features of the Achilles rig were the shroud vessel, which contained the test section, and the downcomer. These may be thought of as representing the core barrel and the annular downcomer in the reactor pressure vessel. The test section comprises a cluster of 69 rods in a square array within a circular shroud vessel. The rod diameter and pitch (9.5 mm and 12.6 mm) were typical of PWR dimensions. The internal diameter of the shroud vessel was 128 mm. Each rod was electrically heated over a length of 3.66 m, which is typical of the nuclear heated length in a PWR fuel rod, and each contained 6 internal thermocouples. These were arranged in one of 8 groupings which concentrated the thermocouples in different axial zones. The spacer grids were at prototypic PWR locations. Each grid had two thermocouples attached to its trailing edge at radial locations. The axial power profile along the rods was an 11 step approximation to a "chopped cosine". The shroud vessel had 5 heating zones whose power could be independently controlled. 5. DESCRIPTION OF TESTS The Achilles experiments investigated the heat transfer in the core of a Pressurized Water Reactor during the re-flood phase of a postulated large break loss of coolant accident. The results provided data to validate codes and to improve modeling. Different types of experiments were carried out which included single phase cooling, re-flood under low flow conditions, level swell and re-flood under high flow conditions. Three series of experiments were performed. The first and the third used the same test section but the second used another test section, similar in
Kang, Steve; Thordarson, David B; Charlton, Timothy P
Haglund's deformity is an enlargement of the posterosuperior prominence of the calcaneus, which is frequently associated with insertional Achilles tendinitis. To our knowledge, no study has been done successfully correlating the characteristics of a Haglund's deformity with insertional Achilles tendinitis. The purpose of our study was to analyze the characteristics of a Haglund's deformity in patients with and without insertional Achilles tendinitis to see if there was a correlation. The study was a retrospective radiographic review of a single surgeon's patients with insertional Achilles tendinitis from 2005 to 2008. Our study population consisted of 44 patients, 48 heels (22 male, 22 female) with insertional Achilles tendinitis, with a mean age of 52 (range, 23 to 79) years. Our control population consisted of 50 patients (25 males, 25 females) and 50 heels without insertional Achilles tendinitis with a mean age of 55.6 (range, 18 to 89) years. We introduced two new measurements of the Haglund's deformity in this study: the Haglund's deformity height and peak angle. A standing lateral foot or ankle radiograph was analyzed for each patient and the following measurements were made: Haglund deformity height and peak angle; Bohler's angle; Fowler-Philip angle; and parallel pitch sign. We also looked for the presence of calcification in the study group and the length and width of the calcification. Unpaired t-test was used to analyze the measurements between the groups. Ten patients' radiographs were re-measured and correlation coefficients were obtained to assess the reliability of the measuring techniques. For the insertional Achilles tendinitis group, the mean Haglund's deformity height was 9.6 (range, 5.3 to 15.3) mm and the mean Haglund's deformity peak angle was 105 (range, 87 to 123) degrees. Calcification was present in 35 of 48 or (73%) of patients with a mean length of 13.3 (range, 3.2 to 41.9) mm and mean width of 4.5 (range, 1.0 to 10.4) mm. In the control
Backman, L J; Andersson, G; Fong, G; Alfredson, H; Scott, A; Danielson, P
The histopathology of tendons with painful tendinopathy is often tendinosis, a fibrosis-like condition of unclear pathogenesis characterized by tissue changes including hypercellularity. The primary tendon cells (tenocytes) have been shown to express adrenoreceptors (mainly alpha-2A) as well as markers of catecholamine production, particularly in tendinosis. It is known that adrenergic stimulation can induce proliferation in other cells. The present study investigated the effects of an exogenously administered alpha-2 adrenergic agonist in an established in vivo Achilles tendinosis model (rabbit) and also in an in vitro human tendon cell culture model. The catecholamine producing enzyme tyrosine hydroxylase and the alpha-2A-adrenoreceptor (α2A AR) were expressed by tenocytes, and alpha-2 adrenergic stimulation had a proliferative effect on these cells, in both models. The proliferation was inhibited by administration of an α2A AR antagonist, and the in vitro model further showed that the proliferative alpha-2A effect was mediated via a mitogenic cell signaling pathway involving phosphorylation of extracellular-signal-regulated kinases 1 and 2. The results indicate that catecholamines produced by tenocytes in tendinosis might contribute to the proliferative nature of the pathology through stimulation of the α2A AR, pointing to a novel target for future therapies. The study furthermore shows that animal models are not necessarily required for all aspects of this research. PMID:22292987
Marcos, Rodrigo Labat; Arnold, Gilles; Magnenet, Vincent; Rahouadj, Rachid; Magdalou, Jacques; Lopes-Martins, Rodrigo Álvaro Brandão
For three decades, low level laser therapy (LLLT) has been used for treatment of tendinitis as well as other musculoskeletal diseases. Nevertheless, the biological mechanisms involved remain not completely understood. In this work, the effects of LLLT and of the widely used nonsteroidal anti-inflammatory drug, diclofenac, have been compared in the case of collagenase-induced Achilles tendinitis. Wistar rats were treated with diclofenac or laser therapy. The tensile behavior of tendons was characterized through successive loading-unloading sequences. The method considered 11 characteristic parameters to describe the mechanical behavior. It was shown that during the acute inflammatory process of the tendon, the mechanical properties were significantly correlated to the high levels of MMP-3, MMP-9 and MMP-13 expression presented in a previous paper (Marcos, R.L., et al., 2012). The treatment by non-steroidal anti-inflammatory drugs such as diclofenac sodium produces a low protective effect and can affect the short-term biochemical and biomechanical properties. On the contrary, it is shown that LLLT exhibits the best results in terms of MMPs reduction and mechanical properties recovery. Thus, LLLT looks to be a promising and consistent treatment for tendinopathies. © 2013 Elsevier Ltd. All rights reserved.
Bae, Seung Hwan; Lee, Ho-Seong; Seo, Sang Gyo; Kim, Sang Woo; Gwak, Heui-Chul; Bae, Su-Young
An infected Achilles tendon after tendon repair is particularly difficult to treat because of the poor vascularity of the tendon as well as the thin surrounding soft tissue. For treatment of an infected Achilles tendon following tendon repair, we first focused on complete debridement and then promoted fibrous scar healing of the Achilles tendon using functional treatment. We retrospectively reviewed all of the medical records of 15 tertiary referral patients with postoperative infection of the Achilles tendon occurring between 2007 and 2012. The mean follow-up time was 33 months (range, 22 to 97 months). The infected tissue and the necrotic tendon were debrided, and the ankle was placed in a short leg splint for 2 weeks. The splint was then replaced with an ankle brace for the next 4 weeks. Partial weight-bearing was allowed immediately, and full weight-bearing was allowed at 2 weeks postoperatively. We assessed and recorded the physical parameters such as the range of motion, calf circumference, ability to perform a single-limb heel rise, patient satisfaction, and Arner-Lindholm scale. Laboratory tests, postoperative ultrasonography, and isokinetic plantar flexion power tests were also performed. At a mean time of 17 days (range, 8 to 30 days) after debridement, infection signs such as discharge from the wound, redness, and local warmth resolved. The wound had healed and the stitches were removed at a mean of 17 days following the wound repair. At the time of the latest follow-up, there were no signs of active infection. Achilles tendon continuity recovered in all patients by fibrous scar healing. Compared with the contralateral side, there was no difference in the ankle range of motion in 8 patients. According to the Arner-Lindholm scale, 9 of the 15 results were excellent and 6 were good. Ten patients were able to perform a single-limb heel rise. Eleven of 15 patients returned to their pre-injury recreational activities. Diffuse homogeneous echotexture of the
Yeh, Chih-Kuang; Chen, Jia-Jiun; Li, Meng-Lin; Luh, Jer-Junn; Chen, Jia-Jin Jason
Achilles tendinitis is a common clinical problem with many treatment modalities, including physical therapy, exercise and therapeutic ultrasound. However, evaluating the effects of current therapeutic modalities and studying the therapeutic mechanism(s) in vivo remains problematic. In this study, we attempted to observe the morphology and microcirculation changes in mouse Achilles tendons between pre- and post-treatment using high-frequency (25 MHz) ultrasound imaging. A secondary aim was to assess the potential of high-frequency ultrasound in exploring therapeutic mechanisms in small-animal models in vivo. A collagenase-induced mouse model of Achilles tendinitis was adopted, and 5 min treatment of continuous-mode low-frequency (45 kHz) ultrasound with 47 mW/cm(2) maximum intensity and 16.3 cm(2) effective beam radiating area was applied. The B-mode images showed no focal hypoechoic regions in normal Achilles tendons either pre- or post-treatment. The Doppler power energy and blood flow rate were measured within the peritendinous space of the Achilles tendon. An increase in the microcirculation was observed soon after the low-frequency ultrasound treatment, which was due to immediate induction of vascular dilatation. The results suggest that applying high-frequency Doppler imaging to small-animal models will be an invaluable aid in explorations of the therapeutic mechanism(s). Our future work includes using imaging to assess microcirculation changes in tendinitis between before and after treatment over a long time period, which is expected to yield useful physiological data for future human studies.
Cenni, Marcos Henrique Frauendorf; Silva, Thiago Daniel Macedo; do Nascimento, Bruno Fajardo; de Andrade, Rodrigo Cristiano; Júnior, Lúcio Flávio Biondi Pinheiro; Nicolai, Oscar Pinheiro
Objective To evaluate the late-stage results from surgical treatment of patellar tendinopathy (PT), using the Visa score (Victorian Institute of Sport Tendon Study Group) and the Verheyden method. Methods This was a retrospective study in which the postoperative results from 12 patients (14 knees) who were operated between July 2002 and February 2011 were evaluated. The patients included in the study presented patellar tendinopathy that was refractory to conservative treatment, without any other concomitant lesions. Patients who were not properly followed up during the postoperative period were excluded. Results Using the Verheyden method, nine patients were considered to have very good results, two had good results and one had poor results. In relation to Visa, the mean was 92.4 points and only two patients had scores less than 70 points (66 and 55 points). Conclusion When surgical treatment for patellar tendinopathy is correctly indicated, it has good long-term results. PMID:26535202
Objective The purpose of this case study is to describe the treatment of a patient with tendinopathy using sonographically guided dry needling. Tendinopathies are a highly prevalent problem in musculoskeletal medicine, and no one form of treatment has gained universal acceptance as being superior to another. Clinical Features A 30-year-old woman with a 4-month history of anterolateral right shoulder pain was diagnosed with supraspinatus tendinopathy upon physical examination, which was confirmed with diagnostic sonography. Intervention and Outcome Sonography was used to guide an acupuncture needle into the pathologic tissue to induce a humoral healing response. Therapeutic exercise was also prescribed. At 10-day follow-up, increased echogenicity was found in the previously heterogenous hypoechoic areas. The patient also experienced a subjective resolution of her shoulder pain, which did not return with increased physical activity. Conclusions Sonographically guided dry needling was shown to be beneficial for this patient as evident by sonographic changes pre- and postprocedure. PMID:23997721
Grimaldi, Alison; Fearon, Angela
Synopsis Gluteal tendinopathy is now believed to be the primary local source of lateral hip pain, or greater trochanteric pain syndrome, previously referred to as trochanteric bursitis. This condition is prevalent, particularly among postmenopausal women, and has a considerable negative influence on quality of life. Improved prognosis and outcomes in the future for those with gluteal tendinopathy will be underpinned by advances in diagnostic testing, a clearer understanding of risk factors and comorbidities, and evidence-based management programs. High-quality studies that meet these requirements are still lacking. This clinical commentary provides direction to assist the clinician with assessment and management of the patient with gluteal tendinopathy, based on currently limited available evidence on this condition and the wider tendon literature and on the combined clinical experience of the authors. J Orthop Sports Phys Ther 2015;45(11):910-922. Epub 17 Sep 2015. doi:10.2519/jospt.2015.5829.
Sereysky, Jedd B; Flatow, Evan L; Andarawis-Puri, Nelly
Tendinopathies are common muskoloskeletal injuries that lead to pain and disability. Development and pathogenesis of tendinopathy is attributed to progressive pathological changes to the structure, function, and biology of tendon. The nature of this disease state, whether acquired by acute or chronic injury, is being actively investigated. Scarring, disorganized tissue, and loss of function characterize adult tendon healing. Recent work from animal models has begun to reveal the potential for adult mammalian tendon regeneration, the replacement of diseased with innate tissue. This review discusses what is known about musculoskeletal regeneration from a molecular perspective and how these findings can be applied to tendinopathy. Non-mammalian and mammalian models are discussed with emphasis on the potential of Murphy Roths Large mice to serve as a model of adult tendon regeneration. Comparison of regeneration in non-mammals, foetal mammals and adult mammals emphasizes distinctly different contributing factors to effective regeneration.
Sereysky, Jedd B; Flatow, Evan L; Andarawis-Puri, Nelly
Tendinopathies are common muskoloskeletal injuries that lead to pain and disability. Development and pathogenesis of tendinopathy is attributed to progressive pathological changes to the structure, function, and biology of tendon. The nature of this disease state, whether acquired by acute or chronic injury, is being actively investigated. Scarring, disorganized tissue, and loss of function characterize adult tendon healing. Recent work from animal models has begun to reveal the potential for adult mammalian tendon regeneration, the replacement of diseased with innate tissue. This review discusses what is known about musculoskeletal regeneration from a molecular perspective and how these findings can be applied to tendinopathy. Non-mammalian and mammalian models are discussed with emphasis on the potential of Murphy Roths Large mice to serve as a model of adult tendon regeneration. Comparison of regeneration in non-mammals, foetal mammals and adult mammals emphasizes distinctly different contributing factors to effective regeneration. PMID:23772908
Hollawell, Shane; Baione, William
More than 20% of acute Achilles tendon injuries are misdiagnosed, leading to chronic or neglected ruptures. Some controversy exists regarding how to best manage an acute Achilles tendon rupture. However, a general consensus has been reached that chronic rupture with ≥3 cm of separation is associated with functional morbidity and, therefore, should be managed operatively. It has been demonstrated that the functional outcomes of surgically treated Achilles ruptures are superior to the nonoperative outcomes in a chronic setting. In the present report, we reviewed 4 patients with chronic Achilles tendon ruptures that were successfully treated with an Achilles tendon interposition allograft and simultaneous augmentation with a xenograft. The median duration of rupture was 11 (range 8 to 16) weeks, the median gap between the proximal and distal segments of the tendon was 4.75 (range 3.5 to 6) cm, and the patients were able to return pain-free to all preinjury activities at a median of 14.5 (range 13.8 to 15.5) weeks, without the need for tendon transfer, lengthening, or additional intervention. The median duration of follow up was 37.25 (range 15.25 to 51.5) months, at which point the mean Foot and Ankle Outcomes Instrument core scale score was 97 ± 1 (mean normative score 53 ± 1), and the Foot and Ankle Outcomes Instrument shoe comfort core scale score was 100 ± 0 (mean normative score 59 ± 0). The combined Achilles allograft plus xenograft augmentation technique appears to be a reasonable option for the surgical treatment of chronic Achilles tendon rupture. Copyright © 2015 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Lewis, Jeremy; McCreesh, Karen; Roy, Jean-Sébastien; Ginn, Karen
Synopsis The hallmark characteristics of rotator cuff (RC) tendinopathy are pain and weakness, experienced most commonly during shoulder external rotation and elevation. Assessment is complicated by nonspecific clinical tests and the poor correlation between structural failure and symptoms. As such, diagnosis is best reached by exclusion of other potential sources of symptoms. Symptomatic incidence and prevalence data currently cannot be determined with confidence, primarily as a consequence of a lack of diagnostic accuracy, as well as the uncertainty as to the location of symptoms. People with symptoms of RC tendinopathy should derive considerable comfort from research that consistently demonstrates improvement in symptoms with a well-structured and graduated exercise program. This improvement is equivalent to outcomes reported in surgical trials, with the additional generalized benefits of exercise, less sick leave, a faster return to work, and reduced costs to the health care system. This evidence covers the spectrum of conditions that include symptomatic RC tendinopathy and atraumatic partial- and full-thickness RC tears. The principles guiding exercise treatment for RC tendinopathy include relative rest, modification of painful activities, an exercise strategy that initially does not exacerbate pain, controlled reloading, and gradual progression from simple to complex shoulder movements. Evidence also exists for a specific exercise program being beneficial for people with massive inoperable tears of the RC. Education is an essential component of rehabilitation, and attention to lifestyle factors (smoking cessation, nutrition, stress, and sleep management) may enhance outcomes. Outcomes may also be enhanced by subgrouping RC tendinopathy presentations and directing treatment strategies according to the clinical presentation and the patient's response to shoulder symptom modification procedures outlined herein. There are substantial deficits in our knowledge
Moulton, Kyle M; Aly, Abdel-Rahman; Rajasekaran, Sathish; Shepel, Michael; Obaid, Haron
Gluteal tendinopathy and greater trochanteric pain syndrome (GTPS) remain incompletely understood despite their pervasiveness in clinical practice. To date, no study has analyzed the morphometric characteristics of the hip on magnetic resonance imaging (MRI) that may predispose to gluteal tendinopathy. This study aimed to evaluate whether acetabular anteversion (AA), femoral neck anteversion (FNA), and femoral neck-shaft angle (FNSA) are associated with MRI features of gluteal tendinopathy. A total of 203 MRI examinations of the hip met our inclusion and exclusion criteria. A single blinded investigator measured AA, FNA, and FNSA according to validated MRI techniques. Two blinded subspecialty-trained musculoskeletal radiologists then independently evaluated the presence of gluteal tendinosis, trochanteric bursitis, and subgluteal bursitis. Statistical analysis was performed using a one-way analysis of variance (ANOVA; post-hoc Tukey's range test). At MRI, 57 patients had gluteal tendinosis with or without bursitis, 26 had isolated trochanteric bursitis, and 11 had isolated subgluteal bursitis. AA was significantly (p = 0.01) increased in patients with MRI evidence of gluteal tendinosis with or without bursitis [mean: 18.4°, 95 % confidence interval (CI): 17.2°-19.6°] compared with normal controls (mean: 15.7°, 95 % CI: 14.7°-16.8°). Similarly, AA was significantly (p = 0.04) increased in patients with isolated trochanteric bursitis (mean: 18.8°, 95 % CI: 16.2°-21.6°). No association was found between FNA or FNSA and the presence of gluteal tendinopathy. Interobserver agreement for the presence and categorization of gluteal tendinopathy was very good (kappa = 0.859, 95 % CI: 0.815-0.903). Our MRI study suggests that there is an association between increased AA and gluteal tendinopathy, which supports a growing body of evidence implicating abnormal biomechanics in the development of this condition.
Lee, James J.; Harrison, Julian R.; Boachie-Adjei, Kwadwo; Vargas, Elizabeth; Moley, Peter J.
-guided intratendinous PRP injections to be a safe and effective treatment option for chronic recalcitrant gluteus medius tendinopathy due to moderate to severe tendinosis and/or partial tendon tears. Well-powered randomized controlled studies are warranted to confirm our findings and further define the ideal candidates for this treatment. PMID:27868077
Carr, Ryan M; Shishani, Yousef; Gobezie, Reuben
Biceps tendon pain is frequently called biceps "tendinitis," or inflammation of the biceps tendon. Histologic analysis of biceps tendon biopsies demonstrates changes in tenocyte size, ground substance, collagen organization, and vascularity observed with many different tendinopathies. There are distinct symptoms of biceps tendinopathy and a few provocative maneuvers can help make the diagnosis. Imaging studies (eg, MRI) can show changes in signal sequence or tears. However, MRI has a low sensitivity and frequently results in missed or misdiagnosed biceps pathology. Clinical decision making is best guided by a strong clinical suspicion based on patient history, physical examination, and MRI. Copyright © 2016 Elsevier Inc. All rights reserved.
Baombe, Janos P; Ford, Rebecca
A shortcut review of the literature was carried out to establish whether the use of fluoroquinolones was associated with an increased risk of tendinopathy in adult patients. 10 trials were found to be directly relevant to the three-part question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that there is an association between the use of fluoroquinolones and a broad range of tendinopathies.
Greis, Ari C; Derrington, Stephen M; McAuliffe, Matthew
Rotator cuff calcific tendinopathy is a common finding that accounts for about 7% of patients with shoulder pain. There are numerous theories on the pathogenesis of rotator cuff calcific tendinopathy. The diagnosis is confirmed with radiography, MRI or ultrasound. There are numerous conservative treatment options available and most patients can be managed successfully without surgical intervention. Nonsteroidal anti-inflammatory drugs and multiple modalities are often used to manage pain and inflammation; physical therapy can help improve scapular mechanics and decrease dynamic impingement; ultrasound-guided needle aspiration and lavage techniques can provide long-term improvement in pain and function in these patients.
Rigby, Ryan B; Cottom, James M; Vora, Anand
Posterior heel pain caused by insertional Achilles tendinosis can necessitate surgical intervention when recalcitrant to conservative care. Surgical treatment can necessitate near complete detachment of the Achilles tendon to fully eradicate the offending pathologic features and, consequently, result in long periods of non-weightbearing. A suture bridge technique using bone anchors is available for reattachment of the Achilles tendon. This provides restoration of the Achilles footprint on the calcaneus, including not only contact, but also actual pressure between the tendon and bone. We performed a review of 43 patients who underwent surgical treatment of insertional Achilles tendinosis with reattachment of the Achilles tendon using the suture bridge technique. The mean age was 53 (range 29 to 87) years. The mean follow-up period was 24 (range 13 to 52) months. The mean postoperative American Orthopaedic Foot and Ankle Society score was 90 (range 65 to 100). The mean preoperative visual analog scale pain score was 6.8 (range 2 to 10) and the mean postoperative visual analog scale pain score was 1.3 (range 0 to 6). The mean interval to weightbearing was 10 (range 0 to 28) days. No postoperative ruptures occurred. Of the 43 patients, 42 (97.6%) successfully performed the single heel rise test at the final postoperative visit. Concomitant procedures were performed in 35 patients, including 33 (77%) requiring open gastrocnemius recession and 2 (5%) requiring flexor hallucis longus tendon transfer. A total of 42 patients (97.6%) returned to regular shoe gear, and 42 (97.6%) returned to their activities of daily living, including running for 20 athletic patients (100%). Complications included postoperative wound dehiscense requiring surgical debridement in 2 patients (5%) and soft tissue infection requiring antibiotics and surgical debridement in 1 (2%) patient. Our findings support using the Achilles tendon suture bridge for reattachment of the Achilles tendon in the
Mineta, Kazuaki; Suzue, Naoto; Matsuura, Tetsuya; Sairyo, Koichi
Here, we report the efficacy of the suture bridge technique for treating insertional Achilles tendinosis in an obese and athletic patient. A 48-year-old man presented to our department with a 6-month history of left posterior heel pain. The patient was an athlete (triathlon) and appeared obese (height: 197 cm, body weight: 120 kg, body mass index: 30.9). A diagnosis of insertional Achilles tendinosis was made. Because 6 months of conservative treatments had failed, we performed open resection of the calcaneal exostosis and Haglund's deformity along with debridement of the degenerative tissue of the tendon. Wide detachment of the insertion of the Achilles tendon was necessary, and reattachment of the tendon was performed using the Arthrex SpeedBridge(TM) system (Arthrex, Inc., Naples, FL). Six weeks postoperatively, this patient was allowed to walk with full weight bearing. Twelve weeks after surgery, this patient started jogging with neither pain nor evidence of Achilles tendon rupture. The suture bridge technique was effective for the reconstruction of the Achilles tendon in an obese and athletic patient. J. Med. Invest. 63: 310-314, August, 2016.
Barfod, Kristoffer Weisskirchner
Acute Achilles tendon rupture is a frequent and potentially disabling injury. Over the past decade a change in treatment of acute Achilles tendon rupture away from operative towards non-operative treatment has taken place. However, the optimal non-operative treatment protocol remains to be clarified, particularly the role of weight-bearing during early rehabilitation. Also, there is a need for a clinically applicable and accurate measurement to detect patients in risk of developing Achilles tendon elongation. The aim of this PhD thesis was to evaluate non-operative treatment of acute Achilles tendon rupture. In study I, a cross-sectional survey was performed investigating the chosen treatment protocols across Scandinavia. In study II, the effect of immediate weight-bearing on patient reported and functional outcomes was investigated in a randomized controlled trial (RCT). In study III, the effect of immediate weight-bearing on the biomechanical properties of the plantar flexor muscle-tendon complex was investigated in an RCT. In study IV, validity, reliability and agreement of a novel ultrasound measurement of Achilles tendon length and elongation was tested. Study I found surgery to be the preferred treatment in 83% of departments in Denmark, 92% in Norway, 65% in Sweden, and 30% in Finland (p < 0.001). Study II and III showed no statistically significant effects of controlled early weight-bearing at one year follow-up except from a better health-related quality of life in the weight-bearing group (p=0.009). Compared to the unaffected limb, the affected limb had decreased stiffness (77%, p < 0.001) and strength (93%, p = 0.009) of the plantar flexor muscle-tendon complex. Study IV showed excellent intra-rater reliability (ICC 0.96, SEM 3.7 mm and MDC 10.3 mm), inter-rater reliability (ICC 0.97, SEM 3.3 mm and MDC 9.3 mm) and validity (measurement error 2%). Treatment algorithms across Scandinavia showed considerable variation, though operative treatment and
Rupture of the Achilles tendon is a considerable cause of morbidity with reduced function following injury. Recent studies have shown little difference in outcome between the techniques of open and non-operative treatment using an early active rehabilitation programme. Meta-analyses have shown that non-operative management has increased risk of re-rupture whereas surgical intervention has risks of complications related to the wound and iatrogenic nerve injury. Minimally invasive surgery has been adopted as a way of reducing infections rates and wound breakdown however avoiding iatrogenic nerve injury must be considered. We discuss the techniques and outcomes of percutaneous and minimally invasive repairs of the Achilles tendon. PMID:22082172
Seitz, Amee L; McClure, Philip W; Finucane, Sheryl; Boardman, N Douglas; Michener, Lori A
The etiology of rotator cuff tendinopathy is multi-factorial, and has been attributed to both extrinsic and intrinsic mechanisms. Extrinsic factors that encroach upon the subacromial space and contribute to bursal side compression of the rotator cuff tendons include anatomical variants of the acromion, alterations in scapular or humeral kinematics, postural abnormalities, rotator cuff and scapular muscle performance deficits, and decreased extensibility of pectoralis minor or posterior shoulder. A unique extrinsic mechanism, internal impingement, is attributed to compression of the posterior articular surface of the tendons between the humeral head and glenoid and is not related to subacromial space narrowing. Intrinsic factors that contribute to rotator cuff tendon degradation with tensile/shear overload include alterations in biology, mechanical properties, morphology, and vascularity. The varied nature of these mechanisms indicates that rotator cuff tendinopathy is not a homogenous entity, and thus may require different treatment interventions. Treatment aimed at addressing mechanistic factors appears to be beneficial for patients with rotator cuff tendinopathy, however, not for all patients. Classification of rotator cuff tendinopathy into subgroups based on underlying mechanism may improve treatment outcomes. 2010 Elsevier Ltd. All rights reserved.
Rabago, David; Nourani, Bobby
Osteoarthritis and overuse tendinopathy are common chronic conditions of high societal and patient burden. The precise etiology of pain and disability in both conditions is multifactorial and not well understood. Patients are often refractory to conservative therapy. The development of new therapeutic options in both conditions is a public health priority. Prolotherapy is an injection-based outpatient regenerative therapy for chronic musculoskeletal conditions, including osteoarthritis and tendinopathy. The authors reviewed the basic science and clinical literature associated with prolotherapy for these conditions. Systematic review, including meta-analysis, and randomized controlled trials suggest that prolotherapy may be associated with symptom improvement in mild to moderate symptomatic knee osteoarthritis and overuse tendinopathy. Although the mechanism of action is not well understood and is likely multifactorial, a growing body of literature suggests that prolotherapy for knee osteoarthritis may be appropriate for the treatment of symptoms associated with knee osteoarthritis in carefully selected patients who are refractory to conservative therapy and deserves further basic and clinical science investigation for the treatment of osteoarthritis and tendinopathy.
Papalia, R; Moro, L; Franceschi, F; Albo, E; D'Adamio, S; Di Martino, A; Vadalà, G; Faldini, C; Denaro, V
Symptomatic tendon tears are one of the most important causes of pain and joint dysfunction. Among the intrinsic causes, vascularization recently gained a major role. Endothelial function is indeed a key factor, as well as vascular tone and thrombotic factors, in the regulation of vascular homeostasis and the composition of vascular wall. In this review, we studied systematically whether there is a relationship between endothelial dysfunction and tendinopathy. A literature search was performed using the isolated or combined keywords endothelial dysfunction and tendon,' 'nitric oxide (NO) and tendinopathy,' and 'endothelial dysfunction in tendon healing.' We identified 21 published studies. Of the selected studies, 9 were in vivo studies, 2 focusing on animals and 7 on humans, while 12 reported about in vitro evaluations, where 7 were carried out on humans and 5 on animals. The evidence about a direct relationship between tendinopathy and endothelial dysfunction is still poor. As recent studies have shown, there is no significant improvement in clinical and functional assessments after treatment with NO in patients suffering from tendinopathy in different locations. No significant differences were identified in the outcomes reported for experiment group when compared with controls treated with conventional surgical procedures or rehabilitation programs. Nitric oxide could be a marker to quantify the response of the endothelium to mechanical stress or hypoxia indicating the final balance between vasodilatating and vasoconstricting factors and their effects, but more ad stronger evidence is still needed to fully support this practice.
Oliva, F; Barisani, D; Grasso, A; Maffulli, N
We evaluated the expression of several genes involved in tissue remodelling and bone development in patients with calcific tendinopathy of the rotator cuff. Biopsies from calcified and non-calcified areas were obtained from 10 patients (8 women and 2 men; average age: 55 years; range: 40-68) with calcific tendinopathy of the rotator cuff. To evaluate the expression of selected genes, RNA extraction, cDNA synthesis and quantitative polymerase chain reaction (PCR) were performed. A significantly increased expression of tissue transglutaminase (tTG)2 and its substrate, osteopontin, was detected in the calcific areas compared to the levels observed in the normal tissue from the same subject with calcific tendinopathy, whereas a modest increase was observed for catepsin K. There was also a significant decrease in mRNA expression of Bone Morphogenetic Protein (BMP)4 and BMP6 in the calcific area. BMP-2, collagen V and vascular endothelial growth factor (VEGF) did not show significant differences. Collagen X and matrix metalloproteinase (MMP)-9 were not detectable. A variation in expression of these genes could be characteristic of this form tendinopathy, since an increased level of these genes has not been detected in other forms of tendon lesions.
Ejnisman, Benno; Andreoli, Carlos Vicente; Monteiro, Gustavo Cará; Pocchini, Alberto de Castro; Cohen, Carina; Tortato, Simone; Franklin, Marcelo Marques Khede; Machado, Arthur Beber; Cohen, Moisés
Objective: To evaluate the relationship between cases of calcifying tendinopathy of the shoulder and symptomatic metabolic diseases such as kidney stones, gallstones and gout. Methods: Calcifying tendinopathy of the shoulder was diagnosed in 63 patients between May 2007 and September 2011. All the patients were treated by the same orthopedic surgeon and were interviewed to gather the following data: age at diagnosis, sex, affected side, dominant side, body mass index (BMI), smoking status and previous histories of kidney stones, gallstones or gout. For statistical analysis, a control group of 63 patients with similar demographic characteristics was used. Results: Among the 63 patients with calcifying tendinopathy of the shoulder, 35 (56%) were male. The right side was affected in 38 patients (60%) and the average age was 48.2 years. Thirty-one patients (49%) had histories involving some of the metabolic diseases investigated: 20 patients (32%) reported kidney stones, six (9.5%) gallstones, four (6.3%) gout and one (2%) concurrent diagnoses of kidney stones and gout. In the control group, eleven patients (17%) had histories involving some of the metabolic diseases investigated: six patients (9.5%) reported kidney stones, four (6.3%) gallstones and one (1.6 %) gout. Conclusions: The high frequency of nephrolithiasis in patients with calcifying tendinopathy of the shoulder in our study suggests that there are common mechanisms in the pathophysiology of these disorders. Better understanding of these diseases may enable improvement of diagnostics and treatments. PMID:27047854
Chang, Yu-Jen; Kulig, Kornelia
Human movement is initiated, controlled and executed in a hierarchical system including the nervous system, muscle and tendon. If a component in the loop loses its integrity, the entire system has to adapt to that deficiency. Achilles tendon, when degenerated, exhibits lower stiffness. This local mechanical deficit may be compensated for by an alteration of motor commands from the CNS. These modulations in motor commands from the CNS may lead to altered activation of the agonist, synergist and antagonist muscles. The present study aimed to investigate the effect of tendon degeneration on its mechanical properties, the neuromechanical behaviour of the surrounding musculature and the existence of the CNS modulation accompanying tendinosis. We hypothesize that the degenerated tendon will lead to diminished tissue mechanical properties and protective muscle activation patterns, as well as an up-regulated descending drive from the CNS. Strong evidence, as reported in the present study, indicates that tendinotic tendons are more compliant compared to healthy tendons. This unilateral involvement affected the neuromuscular control on the involved side but not the non-involved side. The muscle–tendon unit on the tendinotic side exhibits a lowered temporal efficiency, which leads to altered CNS control. The altered CNS control is then expressed as an adapted muscle activation pattern in the lower leg. Taken together, the findings of the present study illustrate the co-ordinated multi-level adaptations to a mechanical lesion in a tendon caused by pathology. Key points Achilles tendinosis is a localized degenerative musculoskeletal disorder that develops over a long period of time and leads to a compliant human Achilles tendon. We demonstrate that the compliant Achilles tendon elicited a series of adaptations from different levels of the human movement control system, such as the muscle–tendon interaction, CNS control and other muscles in the lower leg. These results
Szaro, Paweł; Witkowski, Grzegorz; Smigielski, Robert; Krajewski, Paweł; Ciszek, Bogdan
The Achilles or calcaneal tendon is the structural base for the biomechanical work of the ankle joint. The purpose of this study is to describe the internal structure of the human Achilles tendon. The anatomy of the Achilles tendon has been described in lower mammals in which it has three parts which can be dissected from its beginning to the insertion onto the calcaneus. The partial ruptures of each part suggest that the human Achilles tendon may also be composed of parts. The Achilles tendon is one of the most commonly torn tendons in the human body. Each segment of the Achilles tendon described by us can be ruptured separately, which can cause a partial dysfunction in flexion of the ankle joint as observed in clinical practice. We dissected 20 Achilles tendons previously fixed in 10% formaldehyde and 20 fresh-frozen Achilles tendons, paying particular attention to the relationship between the lateral and medial heads of the gastrocnemius and the soleus muscles. The layer-by-layer method and a microscope were used in our study. We found that the medial group of fibers from the medial head of the gastrocnemius muscle constitutes the posterior layer of the tendon. The lateral border of the tendon is composed of the fibers from the lateral part of the medial head of the gastrocnemius muscle. The fibers from the lateral head of the gastrocnemius muscle constitute the anterior layer of the Achilles tendon. The fibers from the soleus muscle are located in the anteromedial part of the Achilles tendon. Our findings are supported by clinical descriptions and observations of the partial rupture of the Achilles tendon. 2009 Elsevier GmbH.
El Shazly, Ossama; Abou El Soud, Maged M; El Mikkawy, Dalia M E; El Ganzoury, Ibrahim; Ibrahim, Ayman Mohamed
To evaluate the clinical and functional outcome of endoscopic-assisted reconstruction of chronic ruptures of the Achilles tendon using free hamstring tendon autograft. We present a case series of 15 patients who had chronic ruptures of the Achilles tendon (>6 weeks earlier) and underwent endoscopic-assisted reconstruction with a free hamstring autograft. The graft loop was passed through and fixed to the proximal stump of the tendon. The graft was then passed through suture to the distal stump and finally inserted into a tunnel in the anterior calcaneus to the Achilles tendon insertion and fixed with an bioabsorbable interference screw. The mean follow-up period was 27 months (SD, 3 months; range, 24 to 33 months). All patients underwent magnetic resonance imaging preoperatively, immediately postoperatively, and at follow-up 2 years postoperatively. All patients were functionally evaluated with the American Orthopaedic Foot & Ankle Society (AOFAS) score for the hindfoot preoperatively and postoperatively. Calf muscle power was evaluated by isokinetic strength testing at 2 years' follow-up. The mean size of the gap on preoperative magnetic resonance imaging was 49 mm (SD, 9 mm). The mean preoperative AOFAS score was 32.6 (SD, 7.5). There was a statistically significant improvement in the postoperative AOFAS score after 2 years to 90.8 (SD, 3.54) (P < .05). The mean time of return to all daily activities (except running and other sports) was 12.6 weeks (SD, 1.39 weeks). Isokinetic testing showed a nonsignificant deficit (<10%) between the involved and uninvolved plantar flexors and dorsiflexors with regard to peak torque, average power, and total work. Endoscopic-assisted Achilles tendon reconstruction with free hamstring tendon autograft for chronic ruptures of the Achilles tendon showed good to excellent results in all patients. Isokinetic testing showed a nonsignificant deficit between the involved and uninvolved sides at 2 years' follow-up. Level IV, therapeutic
Gill, Thomas J.; Carroll, Kaitlin M.; Hariri, Sonaz
Background: Patellar tendinopathy can be treated surgically for patients that have failed at least 1 year of nonoperative treatment who continue to have debilitating symptoms. Patellar tendinopathy can cause significant functional deficits, yet little has been reported about the operative treatment of patellar tendinopathy. Hypothesis: A combined arthroscopic and open surgical technique for the treatment of recalcitrant patellar tendinopathy results in an improvement in function and pain at a minimum 2-year follow-up. The purpose of this study was to present the indications, combined surgical technique, rehabilitation protocol, and the 2-year minimum follow-up results of the operative treatment of recalcitrant patellar tendinopathy. Study Design: Retrospective case series. Methods: A retrospective review was performed of all patients who underwent a surgical primary patellar tendon debridement for recalcitrant patellar tendinopathy by a single surgeon between July 1999 and December 2005. Every patient failed at least 1 year of nonoperative treatment. Patients were excluded from the study if they had previous open knee surgery. Validated patient-reported outcome scores were used to assess function and pain levels pre- and postoperatively (Lysholm, International Knee Documentation Committee, Tegner activity, and visual analog pain score). Results: Thirty-four consecutive patients (37 consecutive cases) with mean follow-up 3.8 ± 1.6 years (range, 2-7.6 years) underwent the procedure with no complications. The mean age at surgery was 29 years (range, 14-51 years). Postoperatively, the visual analog score decreased by an mean of 6 points (range, 1 to −10, P < 0.001), and patients were able to return to their preinjury Tegner activity level. When asked if they were satisfied by the overall outcome of their surgery, 28 patients (82%) were completely or mostly satisfied with their surgical outcome on a particular knee; 6 (18%) were somewhat satisfied; and 2 (6%) were
Wearing, S C; Hooper, S L; Smeathers, J E; Pourcelot, P; Crevier-Denoix, N; Brauner, T
Measurement of loading patterns of the patellar tendon during activity is important in understanding tendon injury. We used transmission-mode ultrasonography to investigate patellar tendon loading during squatting in adults with and without tendinopathy. It was hypothesized that axial ultrasonic velocity, a surrogate measure of the elastic modulus of tendon, would be lower in tendinopathy. Ultrasound velocity was measured in both patellar tendons of adults with unilateral patellar tendinopathy (n = 9) and in healthy controls (n = 16) during a bilateral squat maneuver. Sagittal knee movement was measured simultaneously with an electrogoniometer. Statistical comparisons between healthy and injured tendons were made using two-way mixed-design ANOVAs. Axial ultrasound velocity in both symptomatic and asymptomatic patellar tendons in tendinopathy was approximately 15% higher than in healthy tendons at the commencement (F1,23 = 5.2, P < 0.05) and completion (F1,23 = 4.5, P < 0.05) of the squat. While peak velocity was ≈5% higher during both flexion (F1,23 = 5.4, P < 0.05) and extension (F1,23 = 5.3, P < 0.05) phases, there was no significant between-group difference at the midpoint of the movement. There were no significant differences in the rate and magnitude of knee movement between groups. Although further research is required, these findings suggest enhanced baseline muscle activity in patellar tendinopathy and highlight fresh avenues for its clinical management. © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
Freedman, Benjamin R.; Gordon, Joshua A.; Soslowsky, Louis J.
Summary This review highlights recent research on Achilles tendon healing, and comments on the current clinical controversy surrounding the diagnosis and treatment of injury. The processes of Achilles tendon healing, as demonstrated through changes in its structure, composition, and biomechanics, are reviewed. Finally, a review of tendon developmental biology and mechano transductive pathways is completed to recognize recent efforts to augment injured Achilles tendons, and to suggest potential future strategies for therapeutic intervention and functional tissue engineering. Despite an abundance of clinical evidence suggesting that current treatments and rehabilitation strategies for Achilles tendon ruptures are equivocal, significant questions remain to fully elucidate the basic science mechanisms governing Achilles tendon injury, healing, treatment, and rehabilitation. PMID:25332943
Björklund, Emmelie; Forsgren, Sture; Alfredson, Håkan; Fowler, Christopher J.
Background The endogenous cannabinoid system is involved in the control of pain. However, little is known as to the integrity of the cannabinoid system in human pain syndromes. Here we investigate the expression of the cannabinoid receptor 1 (CB1) in human Achilles tendons from healthy volunteers and from patients with Achilles tendinosis. Methodology Cannabinoid CB1 receptor immunoreactivity (CB1IR) was evaluated in formalin-fixed biopsies from individuals suffering from painful Achilles tendinosis in comparison with healthy human Achilles tendons. Principal Findings CB1IR was seen as a granular pattern in the tenocytes. CB1IR was also observed in the blood vessel wall and in the perineurium of the nerve. Quantification of the immunoreactivity in tenocytes showed an increase of CB1 receptor expression in tendinosis tissue compared to control tissue. Conclusion Expression of cannabinoid receptor 1 is increased in human Achilles tendinosis suggesting that the cannabinoid system may be dysregulated in this disorder. PMID:21931835
Milgrom, Yael; Milgrom, Charles; Altaras, Talya; Globus, Opher; Zeltzer, Ehud; Finestone, Aharon S
Whether the human Achilles tendon undergoes hypertrophic changes as measured by an increase in cross-sectional area, in response to endurance training exercise remains in question. We investigated the hypothesis that transition from civilian life through 6 months of elite infantry training would induce adaptive Achilles tendon hypertrophy. Seventy-two new elite infantry recruits had the cross-sectional area of their Achilles tendons measured at a point 2.5 cm proximal to the Achilles insertion by ultrasound before beginning elite infantry training. Measurements were repeated by the same ultrasonographer for those recruits who were still in the training program at 6 months. Prior to beginning the study the intraobserver reliability of the ultrasonographer's Achilles tendon measurements was calculated (intraclass correlation coefficient = .96). Fifty-five recruits completed 6 months of training. The mean cross-sectional area of their right Achilles tendon increased from 47.0 ± 11.2 to 50.2 ± 9.6 mm(2) (P = .037) and the left Achilles tendon from 47.2 ± 8.9 to 51.1 ± 8.3 mm(2) (P = .013). The change in cross-sectional area did not correlate with subject height, weight, prior sport history, or jumping and running abilities. An abrupt stimulus of 6 months of elite infantry training was adequate to induce hypertrophic changes in the Achilles tendon. This is the first human prospective study showing an increase in the Achilles tendon cross-sectional area in response to rigorous endurance type training. The finding supports the hypothesis that the Achilles tendon in response to sufficiently high and sustained loading can remodel its morphological properties and thereby strengthen itself. Level II, etiology study. © The Author(s) 2014.
Reiman, Michael; Burgi, Ciara; Strube, Eileen; Prue, Kevin; Ray, Keaton; Elliott, Amanda; Goode, Adam
Objective: To summarize and evaluate the current diagnostic accuracy of clinical measures used to diagnose Achilles tendon injuries. Data Sources: A literature search of MEDLINE, CINAHL, and EMBASE databases was conducted with key words related to diagnostic accuracy and Achilles tendon injuries. Study Selection: Original research articles investigating Achilles tendon injuries against an acceptable reference standard were included. Data Extraction: Three studies met the inclusion criteria. Quality assessment was conducted using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. DerSimonian-Laird random-effects models were used to pool sensitivity (SN), specificity (SP), and diagnostic odds ratios with their 95% confidence intervals (CIs). Data Synthesis: The SN and negative likelihood ratio (−LR) values for Achilles tendon rupture measures ranged from 0.73 (95% CI = 0.65, 0.81) and 0.30 (95% CI = 0.23, 0.40) to 0.96 (95% CI = 0.93, 0.99) and 0.04 (95% CI = 0.02, 0.10), respectively, whereas SP and positive likelihood ratio (+LR) values ranged from 0.85 (95% CI = 0.72, 0.98) and 6.29 (95% CI = 2.33, 19.96) to 0.93 (95% CI = 0.84, 1.00) and 13.71 (95% CI = 3.54, 51.24), respectively, with the highest SN and SP both reported in the calf-squeeze test. The SN and −LR values for Achilles tendinopathy measures ranged from 0.03 (95% CI = 0.00, 0.08) and 0.97 (95% CI = not reported) to 0.89 (95% CI = 0.75, 0.98) and 0.19 (95% CI = not reported), whereas SP and +LR values ranged from 0.58 (95% CI = 0.38, 0.77) and 2.12 (95% CI = not reported) to 1.00 (95% CI = 1.00, 1.00) and infinity, respectively, with the highest SN and SP reported for morning stiffness and palpation for crepitus. Pooled analyses demonstrated similar diagnostic properties in all 3 clinical measures (arc sign, palpation, and Royal London Hospital test), with SN and −LR ranging from 0.42 (95% CI = 0.23, 0.62) and 0.68 (95% CI = 0.50, 0.93), respectively, for the arc sign, to 0.64 (95% CI
Simonin, Marie-Agnes; Gegout-Pottie, Pascale; Minn, Alain; Gillet, Pierre; Netter, Patrick; Terlain, Bernard
Despite a relatively low incidence of serious side effects, fluoroquinolones and the fluoroquinolone pefloxacin have been reported to occasionally promote tendinopathy that might result in the complication of spontaneous rupture of tendons. In the present study, we investigated in rodents the intrinsic deleterious effect of pefloxacin (400 mg/kg of body weight) on Achilles tendon proteoglycans and collagen. Proteoglycan synthesis was determined by measurement of in vivo and ex vivo radiosulfate incorporation in mice. Collagen oxidative modifications were measured by carbonyl derivative detection by Western blotting. An experimental model of tendinous ischemia (2 h) and reperfusion (3 days) was achieved in rats. Biphasic changes in proteoglycan synthesis were observed after a single administration of pefloxacin, consisting of an early inhibition followed by a repair-like phase. The depletion phase was accompanied by a marked decrease in the endogenous serum sulfate level and a concomitant increase in the level of sulfate excretion in urine. Studies of ex vivo proteoglycan synthesis confirmed the in vivo results that were obtained. The decrease in proteoglycan anabolism seemed to be a direct effect of pefloxacin on tissue metabolism rather than a consequence of the low concentration of sulfate. Pefloxacin treatment for several days induced oxidative damage of type I collagen, with the alterations being identical to those observed in the experimental tendinous ischemia and reperfusion model. Oxidative damage was prevented by coadministration of N-acetylcysteine (150 mg/kg) to the mice. These results provide the first experimental evidence of a pefloxacin-induced oxidative stress in the Achilles tendon that altered proteoglycan anabolism and oxidized collagen. PMID:10722483
van Schie, H T M; de Vos, R J; de Jonge, S; Bakker, E M; Heijboer, M P; Verhaar, J A N; Tol, J L; Weinans, H
To assess whether three-dimensional imaging of the Achilles tendon by ultrasonographic tissue characterisation (UTC) can differentiate between symptomatic and asymptomatic tendons. Case-control study. Sports Medical Department of the Hague Medical Centre. Twenty-six tendons from patients with chronic midportion Achilles tendinopathy were included. The "matched" control group consisted of 26 asymptomatic tendons. Symptomatic and asymptomatic tendons were scanned using the UTC procedure. One researcher performed the ultrasonographic data collection. These blinded data were randomised, and outcome measures were determined by two independent observers. The raw ultrasonographic images were analysed with a custom-designed algorithm that quantifies the three-dimensional stability of echo patterns, qua intensity and distribution over contiguous transverse images. This three-dimensional stability was related to tendon structure in previous studies. UTC categorises four different echotypes that represent (I) highly stable; (II) medium stable; (III) highly variable and (IV) constantly low intensity and variable distribution. The percentages of echo-types were calculated, and the maximum tendon thickness was measured. Finally, the inter-observer reliability of UTC was determined. Symptomatic tendons showed less pixels in echo-types I and II than asymptomatic tendons (51.5% vs 76.6%, p<0.001), thus less three-dimensional stability of the echo pattern. The mean maximum tendon thickness was 9.2 mm in the symptomatic group and 6.8 mm in the asymptomatic group (p<0.001). The Intraclass Correlation Coefficient (ICC) for the interobserver reliability of determining the echo-types I+II was 0.95. The ICC for tendon thickness was 0.84. UTC can quantitatively evaluate tendon structure and thereby discriminate symptomatic and asymptomatic tendons. As such, UTC might be useful to monitor treatment protocols.
Brown, Karryn L; Seale, Kirsten B; El Khoury, Louis Y; Posthumus, Michael; Ribbans, William J; Raleigh, Stuart M; Collins, Malcolm; September, Alison V
Several genetic loci have been associated with risk of Achilles tendon pathology (ATP) within South African and Australian populations. The aim of this study was, therefore, to evaluate eight previously implicated genetic variants in an independent British population. A total of 130 asymptomatic controls (CON) and 112 participants clinically diagnosed with ATP comprising 87 individuals with chronic Achilles tendinopathy (TEN) and 25 with Achilles tendon ruptures (RUP) were included. All participants were genotyped for variants within the COL5A1, MIR608, IL-1β, IL-6 and CASP8 genes. Primary findings implicated COL5A1 and CASP8. Three inferred allele combinations constructed from COL5A1 rs12722, rs3196378 and rs71746744 were identified as risk modifiers. The T-C-D combination was associated with increased risk of ATP (P = 0.023) and RUP (P < 0.001), the C-A-I combination was associated with increased risk of ATP (P = 0.011), TEN (P = 0.011) and RUP (P = 0.011) and the C-C-D combination was associated with decreased risk of ATP (P = 0.011) and RUP (P = 0.004). The CASP8 rs3834129 DD genotype was associated with decreased risk of TEN (P = 0.020, odds ratio: 0.45, 95% confidence interval: 0.22-0.90) and the CASP8 I-G (rs3834129-rs1045485) inferred allele combination was associated with increased risk of TEN (P = 0.031). This study further highlights the importance of polymorphisms within COL5A1 and CASP8 in the aetiology of ATP.
Fukutani, Atsuki; Hashizume, Satoru; Kusumoto, Kazuki; Kurihara, Toshiyuki
Abstract Achilles tendon length has been measured using a straight‐line model. However, this model is associated with a greater measurement error compared with a curved‐line model. Therefore, we examined the influence of neglecting the curved path of the Achilles tendon on its length change at various ranges of motion. Ten male subjects participated in this study. First, the location of the Achilles tendon was confirmed by using ultrasonography, and markers were attached on the skin over the Achilles tendon path. Then, the three‐dimensional coordinates of each marker at dorsiflexion (DF) 15°, plantarflexion (PF) 0°, PF15°, and PF30° were obtained. Achilles tendon length in the curved‐line model was calculated as the sum of the distances among each marker. On the other hand, Achilles tendon length in the straight‐line model was calculated as the straight distance between the two most proximal and distal markers projected onto the sagittal plane. The difference of the Achilles tendon length change between curved‐line and straight‐line models was calculated by subtracting the Achilles tendon length change obtained in curved‐line model from that obtained in straight‐line model with three different ranges of motion (i.e., PF0°, PF15°, and PF30° from DF15°, respectively). As a result, the difference in Achilles tendon length change between the two models increased significantly as the range of motion increased. In conclusion, neglecting the curved path of the Achilles tendon induces substantial overestimation of its length change when the extent of ankle joint angle change is large. PMID:25303951
Silbernagel, Karin Grävare; Steele, Robert; Manal, Kurt
Whether an Achilles tendon rupture is treated surgically or not, complications such as muscle weakness, decrease in heel-rise height, and gait abnormalities persist after injury. The purpose of this study was to evaluate if side-to-side differences in maximal heel-rise height can be explained by differences in Achilles tendon length. Case series; level of evidence, 4. Eight patients (mean [SD] age of 46  years) with acute Achilles tendon rupture and 10 healthy subjects (mean [SD] age of 28  years) were included in the study. Heel-rise height, Achilles tendon length, and patient-reported outcome were measured 3, 6, and 12 months after injury. Achilles tendon length was evaluated using motion analysis and ultrasound imaging. The Achilles tendon length test-retest reliability (intraclass correlation coefficient = 0.97) was excellent. For the healthy subjects, there were no side-to-side differences in tendon length and heel-rise height. Patients with Achilles tendon ruptures had significant differences between the injured and uninjured side for both tendon length (mean [SD] difference, 2.6-3.1 [1.2-1.4] cm, P = .017-.028) and heel-rise height (mean [SD] difference, -4.1 to -6.1 [1.7-1.8] cm, P = .012-.028). There were significant negative correlations (r = -0.943, P = .002, and r = -0.738, P = .037) between the side-to-side difference in heel-rise height and Achilles tendon length at the 6- and 12-month evaluations, respectively. The side-to-side difference found in maximal heel-rise height can be explained by a difference in Achilles tendon length in patients recovering from an Achilles tendon rupture. Minimizing tendon elongation appears to be an important treatment goal when aiming for full return of function.
Elias, Ilan; Raikin, Steven M; Besser, Marcus P; Nazarian, Levon N
The purpose of this study was to evaluate the clinical outcomes and objective isokinetic dynamometry on a cohort of patients with chronic insertional Achilles tendinosis, who underwent surgical reconstruction using an FHL tendon autograft transfer through a single incision. Forty patients (16 male and 24 female; mean age, 57 years; age range, 39 to 76 years) with persistent chronic Achilles tendinosis were evaluated after surgical reconstruction at an average of 27 months after surgery. At the time of final followup, ankle strength and active range of motion (AROM) were evaluated using Biodex isokinetic dynamometry. Additionally, patients were assessed with AOFAS Ankle Hindfoot scores, pain on a Visual Analog Scale (VAS) and their self-reported level of satisfaction (Very Good, Good, Fair, Poor). We found no loss of plantarflexion strength or plantarflexion power in the operated ankles; an average of 4-degree loss of AROM was found. The study population scored an average of 96/100 for the total AOFAS-AH score post-repair. The average VAS decreased from 7.5 pre-op to 0.3 post-op. Thirty-eight of 40 patients (95%) were satisfied with their outcome (rated Very Good or Good), two patients rated their outcome as Fair and none as Poor. For individuals with chronic insertional Achilles tendinosis, operative repair using an FHL tendon with the single-incision technique achieved a high percentage of satisfactory results as well as excellent functional and clinical outcomes including significant pain reduction.
Amlang, M H; Zwipp, H
Tendinosis of the Achilles tendon is a degenerative-reparative structural change of the tendon with microdefects, increases in cross-section due to cicatricial tendon regeneration, neoangiogenesis and reduction of elasticity. The previously used term tendinitis is only rarely used for the chronic form since signs of inflammation such as redness and hyperthermia or elevated levels of inflammatory parameters on laboratory testing are generally absent. Duplex sonography with visualization of the neovascularization has become a valuable supplement not only for diagnostics but also for therapy planning. The classic, conservative therapy for painful tendinosis consists of oral anti-inflammatory drugs, pain-adapted load reduction, raising the heel, stretching the calf musculature, and various physiotherapeutic interventions. When conservative treatment over a period of 4 - 6 months fails to produce any or non-adequate pain relief, an indication for surgical treatment should be considered. In the therapy for fresh ruptures of the Achilles tendon further developments in minimally invasive techniques have led to a worldwide paradigm change over the past 10 years. The decisive advantage of minimally invasive surgical techniques is the lower risk of wound infection as compared to the sutures of the open technique. When compared with conservative functional therapy the minimally invasive repair has the advantage of being less dependent on the compliance of the patient since, in the early phase of tendon healing the suture prevents a separation of the tendon ends upon controlled movements. However, not every patient with a ruptured Achilles tendon should be treated with a minimally invasive repair. Open tendon reconstruction and functional conservative therapy are still justified when the correct indication is given. © Georg Thieme Verlag KG Stuttgart · New York.
Meinert, Ilka; Brown, Niklas; Alt, Wilfried
Achilles tendon injuries are known to commonly occur in runners. During running repeated impacts are transferred in axial direction along the lower leg, therefore possibly affecting the oscillation behavior of the Achilles tendon. The purpose of the present study was to explore the effects of different footwear modifications and different ground conditions (over ground versus treadmill) on oscillations at the Achilles tendon. Oscillations were measured in 20 male runners using two tri-axial accelerometers. Participants ran in three different shoe types on a treadmill and over ground. Data analysis was limited to stance phase and performed in time and frequency space. Statistical comparison was conducted between oscillations in vertical and horizontal direction, between running shoes and between ground conditions (treadmill versus over ground running). Differences in the oscillation behavior could be detected between measurement directions with peak accelerations in the vertical being lower than those in the horizontal direction, p < 0.01. Peak accelerations occurred earlier at the distal accelerometer than at the proximal one, p < 0.01. Average normalized power differed between running shoes (p < 0.01) with harder damping material resulting in higher power values. Little to no power attenuation was found between the two accelerometers. Oscillation behavior of the Achilles tendon is not influenced by ground condition. Differences in shoe configurations may lead to variations in running technique and impact forces and therefore result in alterations of the vibration behavior at the Achilles tendon. The absence of power attenuation may have been caused by either a short distance between the two accelerometers or high stiffness of the tendon. High stiffness of the tendon will lead to complete transmission of the signal along the Achilles tendon and therefore no attenuation occurs.
Meinert, Ilka; Brown, Niklas; Alt, Wilfried
Background Achilles tendon injuries are known to commonly occur in runners. During running repeated impacts are transferred in axial direction along the lower leg, therefore possibly affecting the oscillation behavior of the Achilles tendon. The purpose of the present study was to explore the effects of different footwear modifications and different ground conditions (over ground versus treadmill) on oscillations at the Achilles tendon. Methods Oscillations were measured in 20 male runners using two tri-axial accelerometers. Participants ran in three different shoe types on a treadmill and over ground. Data analysis was limited to stance phase and performed in time and frequency space. Statistical comparison was conducted between oscillations in vertical and horizontal direction, between running shoes and between ground conditions (treadmill versus over ground running). Results Differences in the oscillation behavior could be detected between measurement directions with peak accelerations in the vertical being lower than those in the horizontal direction, p < 0.01. Peak accelerations occurred earlier at the distal accelerometer than at the proximal one, p < 0.01. Average normalized power differed between running shoes (p < 0.01) with harder damping material resulting in higher power values. Little to no power attenuation was found between the two accelerometers. Oscillation behavior of the Achilles tendon is not influenced by ground condition. Conclusion Differences in shoe configurations may lead to variations in running technique and impact forces and therefore result in alterations of the vibration behavior at the Achilles tendon. The absence of power attenuation may have been caused by either a short distance between the two accelerometers or high stiffness of the tendon. High stiffness of the tendon will lead to complete transmission of the signal along the Achilles tendon and therefore no attenuation occurs. PMID:27010929
Matus-Jiménez, Juan; Avalos, Cecilia Henríquez
Due to incapacity caused by calcaneal tendon injuries for the reintegration of patients back to their daily activities and/or sparts it is necessary to decrease the time of reinstatement of patients. At present these times have improved by a good surgical technique and an early rehabilitation, and the patient is returned quickly as he sees less disability. It is proposed in this paper a type of surgical treatment and an early rehabilitation program, which have shortened the time of disability and incorporation to their daily activities and sports to eight weeks in 10 patients with Achilles tendon plasty.
Alajoulin, Omar A.; Alsbou, Mohammed S.; Ja’afreh, Somayya O.; Kalbouneh, Heba M.
Alkaptonuria (AKU) is a rare inborn metabolic disease characterized by accumulation of homogentisic acid (HGA). Excretion of HGA in urine causes darkening of urine and its deposition in connective tissues causes dark pigmentation (ochronosis), early degeneration of articular cartilage, weakening of the tendons, and subsequent rupture. In this case report, we present a rare case of a patient presented with unilateral spontaneous rupture of Achilles tendon due to AKU. The patient developed most of the orthopedic manifestations of the disease earlier than typical presentations. Alkaptonuria patients should avoid strenuous exercises and foot straining especially in patients developing early orthopedic manifestations. PMID:26620992
Stappers, Jeroen; Herregods, Piet; Chappel, Rudi; Surgeloose, Didier De; Stassijns, Gaëtane
We report the case of a 53-year-old male with a right Achilles tendinosis, who complains about a mild gait disorder starting after walking several kilometers. In the following months he develops neurological symptoms. MRI lumbar spine shows an intramedullary tumor at level Th12. A biopsy confirms the diagnosis of an intramedullary astrocytoma. Primary intramedullary tumors are relatively rare. Clinical presentation is often insidious. The authors want to make a point to reconsider a diagnosis in case it does not explain completely the anamnestic or clinical findings. According to the literature there is no optimal approach to the management of these tumors.
Chang, Yu-Jen; Kulig, Kornelia
Achilles tendinosis is a localized degenerative musculoskeletal disorder that develops over a long period of time and leads to a compliant human Achilles tendon. We demonstrate that the compliant Achilles tendon elicited a series of adaptations from different levels of the human movement control system, such as the muscle-tendon interaction, CNS control and other muscles in the lower leg. These results illustrate the human body's capacity to adapt to tendon pathology and provide the physiological basis for intervention or prevention strategies. Human movement is initiated, controlled and executed in a hierarchical system including the nervous system, muscle and tendon. If a component in the loop loses its integrity, the entire system has to adapt to that deficiency. Achilles tendon, when degenerated, exhibits lower stiffness. This local mechanical deficit may be compensated for by an alteration of motor commands from the CNS. These modulations in motor commands from the CNS may lead to altered activation of the agonist, synergist and antagonist muscles. The present study aimed to investigate the effect of tendon degeneration on its mechanical properties, the neuromechanical behaviour of the surrounding musculature and the existence of the CNS modulation accompanying tendinosis. We hypothesize that the degenerated tendon will lead to diminished tissue mechanical properties and protective muscle activation patterns, as well as an up-regulated descending drive from the CNS. Strong evidence, as reported in the present study, indicates that tendinotic tendons are more compliant compared to healthy tendons. This unilateral involvement affected the neuromuscular control on the involved side but not the non-involved side. The muscle-tendon unit on the tendinotic side exhibits a lowered temporal efficiency, which leads to altered CNS control. The altered CNS control is then expressed as an adapted muscle activation pattern in the lower leg. Taken together, the findings of
Kardouni, Joseph R; Seitz, Amee L; Walsworth, Matthew K; Michener, Lori A
A high prevalence of neovascularity in lower extremity tendinopathies has been reported. Neovascularity in those with rotator cuff tendinopathy exclusively has not been examined. The objective was to determine the prevalence of neovascularization in patients with rotator cuff tendinopathy compared with asymptomatic controls. Single-blind cross-sectional study. Research laboratory. Participants (n = 40; age = 44.9 years, 23-62 years; 20 females) with rotator cuff tendinopathy (n = 20) but without full-thickness rotator cuff tears, and asymptomatic controls that were age, gender, and hand dominance matched (n = 20) to the patients. The participants laying in supine had their shoulder positioned in internal rotation and extension. Ultrasound images were collected of the supraspinatus tendon and subacromial bursae in the transverse and longitudinal planes using a linear transducer in color Doppler mode. Images were assessed for neovascularization by 2 trained raters who were blinded to group (rotator cuff tendinopathy or asymptomatic group). No statistically significant difference in neovascularization was identified between participants with and without rotator cuff tendinopathy (χ = 0.13, df = 1, P = 0.72). Neovascularization was identified in 6 of 20 patients with rotator cuff tendinopathy (30%) and 5 of 20 asymptomatic control participants (25%). The authors found no differences in neovascularization rate in patients with rotator cuff tendinopathy (30%) and asymptomatic controls (25%). The study indicates that neovascularization is not related to presence of symptomatic tendinopathy in those with rotator cuff tendinopathy. Neovascularization may not be a relevant sonographic finding to aid the clinical assessment of those with rotator cuff tendinopathy.
Millar, Neal L.; Murrell, George A. C.
Tendon disorders—tendinopathies—are the primary reason for musculoskeletal consultation in primary care and account for up to 30% of rheumatological consultations. Whilst the molecular pathophysiology of tendinopathy remains difficult to interpret the disease process involving repetitive stress, and cellular load provides important mechanistic insight into the area of heat shock proteins which spans many disease processes in the autoimmune community. Heat shock proteins, also called damage-associated molecular patterns (DAMPs), are rapidly released following nonprogrammed cell death, are key effectors of the innate immune system, and critically restore homeostasis by promoting the reconstruction of the effected tissue. Our investigations have highlighted a key role for HSPs in tendion disease which may ultimately affect tissue rescue mechanisms in tendon pathology. This paper aims to provide an overview of the biology of heat shock proteins in soft tissue and how these mediators may be important regulators of inflammatory mediators and matrix regulation in tendinopathy. PMID:23258952
Jeong, D U; Lee, C-R; Lee, J H; Pak, J; Kang, L-W; Jeong, B C; Lee, S H
Platelet-rich plasma (PRP), a blood derivative with high concentrations of platelets, has been found to have high levels of autologous growth factors (GFs), such as transforming growth factor-β (TGF-β), platelet-derived growth factor (PDGF), fibroblastic growth factor (FGF), vascular endothelial growth factor (VEGF), and epidermal growth factor (EGF). These GFs and other biological active proteins of PRP can promote tissue healing through the regulation of fibrosis and angiogenesis. Moreover, PRP is considered to be safe due to its autologous nature and long-term usage without any reported major complications. Therefore, PRP therapy could be an option in treating overused tendon damage such as chronic tendinopathy. Here, we present a systematic review highlighting the clinical effectiveness of PRP injection therapy in patellar tendinopathy, which is a major cause of athletes to retire from their respective careers.
Jeong, D. U.; Lee, C.-R.; Lee, J. H.; Pak, J.; Kang, L.-W.; Jeong, B. C.
Platelet-rich plasma (PRP), a blood derivative with high concentrations of platelets, has been found to have high levels of autologous growth factors (GFs), such as transforming growth factor-β (TGF-β), platelet-derived growth factor (PDGF), fibroblastic growth factor (FGF), vascular endothelial growth factor (VEGF), and epidermal growth factor (EGF). These GFs and other biological active proteins of PRP can promote tissue healing through the regulation of fibrosis and angiogenesis. Moreover, PRP is considered to be safe due to its autologous nature and long-term usage without any reported major complications. Therefore, PRP therapy could be an option in treating overused tendon damage such as chronic tendinopathy. Here, we present a systematic review highlighting the clinical effectiveness of PRP injection therapy in patellar tendinopathy, which is a major cause of athletes to retire from their respective careers. PMID:25136568
Ahmad, Jamal; Jones, Kennis; Raikin, Steven M
Background When Achilles tendon ruptures become chronic, a defect often forms at the rupture site. There is scant literature regarding the treatment of chronic Achilles ruptures with defects of 6 cm or larger. We examined outcomes from combining a turndown of the proximal, central Achilles with a flexor hallucis longus (FHL) tendon transfer to treat this condition. Materials Between September 2002 and December 2013, 32 patients presented with a chronic Achilles rupture and a defect of 6 cm or more. Twenty patients were male and 12 were female. Patient age was between 20 and 74 years, with a mean of 53.3 years. Eighteen and 14 patients had their right and left Achilles tendon affected, respectively. The number of days between injury and surgery ranged from 30 to 315 days, with a mean of 102 days. Reconstruction of the Achilles involved a turndown of the proximal, central tendon and FHL augmentation. Final patient follow-up ranged from 18 to 150 months, with a mean of 62.3 months. At surgery, the gap between the ruptured ends of the Achilles ranged from 6 to 12 cm, with a mean gap of 7.5 cm. Full healing was achieved in all 32 patients (100%) by 5 months postoperatively. Mean Foot and Ankle Ability Measures scores increased from 36.3% to 90.2% between initial and latest follow-up (P < .05). Mean visual analogue scales of pain decreased from 6.6 to 1.8 of 10 between first and last encounter (P < .05). Postoperative complications occurred in 5 patients (15.6%), including 3 (9.4%) superficial wound problems, 1 (3.1%) deep wound infection, and 1 (3.1%) deep vein thrombosis. Discussion Outcomes from treating chronic Achilles ruptures with large defects are scant within the orthopaedic literature. Our method of Achilles reconstruction results in a high rate of improved function and pain relief. Therapeutic, Level IV: Case series. © 2016 The Author(s).
Grimaldi, Alison; Mellor, Rebecca; Hodges, Paul; Bennell, Kim; Wajswelner, Henry; Vicenzino, Bill
Tendinopathy of the gluteus medius and gluteus minimus tendons is now recognized as a primary local source of lateral hip pain. The condition mostly occurs in mid-life both in athletes and in subjects who do not regularly exercise. Females are afflicted more than males. This condition interferes with sleep (side lying) and common weight-bearing tasks, which makes it a debilitating musculoskeletal condition with a significant impact. Mechanical loading drives the biological processes within a tendon and determines its structural form and load-bearing capacity. The combination of excessive compression and high tensile loads within tendons are thought to be most damaging. The available evidence suggests that joint position (particularly excessive hip adduction), together with muscle and bone elements, are key factors in gluteal tendinopathy. These factors provide a basis for a clinical reasoning process in the assessment and management of a patient presenting with localized lateral hip pain from gluteal tendinopathy. Currently, there is a lack of consensus as to which clinical examination tests provide best diagnostic utility. On the basis of the few diagnostic utility studies and the current understanding of the pathomechanics of gluteal tendinopathy, we propose that a battery of clinical tests utilizing a combination of provocative compressive and tensile loads is currently best practice in its assessment. Management of this condition commonly involves corticosteroid injection, exercise or shock wave therapy, with surgery reserved for recalcitrant cases. There is a dearth of evidence for any treatments, so the approach we recommend involves managing the load on the tendons through exercise and education on the underlying pathomechanics.
Bustos, Aldo; Locaso, Fernando
Objectives: To perform a description of tendinopathies as an injury in volleyball high performance. Methods: An observational and prospective study was conducted from 2014-2016 in the senior Argentinian volleyball team. The same was held by two observers. Moreover, 78 athletes were evaluated. We support Dvorak’s claims that an injury is determined by the loss of at least one training session or a match. Results: 78 players were exposed to 21812 hours of training and matches. As a result 37 injuries were evaluated in 31 players. Taking into account tendinopathies, it can be said that 34 players consulted 412 times, showing a prevalence of 43.5% of the whole enquires but when we refer to the same pathology as injury the average lowers, presenting 8 lesions in 6 players and showing a prevalence of 7.6% as injuries. Incidence of tendon injuries is 0.32 per 1000 hours of exposure Tendon Injuries: 5 were patellar, 2 supraspinatus, 1 aquiles. 5 Slight, 2 moderate, 1 severe. Conclusion: Clearly, tendinopathy is a common problem in this sport but it is not a common cause of injury. This is demonstrated in prevalence rates whereas 43.5 % just consulted and 7,6 % suffer from real injuries. We think this might be due to several factors such as, advances in medical therapy, preventive protocols and increase in thresholds of pain that high-performance athletes can bear. In our experience this pathology was shown to be the third leading cause of injuries. In 2016 we did not deal with any case of injury for tendinopathy.
Docking, Sean I; Ooi, Chin Chin; Connell, David
Synopsis Tendinopathy is frequently associated with structural disorganization within the tendon. As such, the clinical use of ultrasound and magnetic resonance imaging for tendinopathy has been the focus of numerous academic studies and clinical discussions. However, similar to other musculoskeletal conditions (osteoarthritis and intervertebral disc degeneration), there is no direct link between tendon structural disorganization and clinical symptoms, with findings on imaging potentially creating a confusing clinical picture. While imaging shows the presence and extent of structural changes within the tendon, the clinical interpretation of the images requires context in regard to the features of pain and the aggravating loads. This review will critically evaluate studies that have investigated the accuracy and sensitivity of imaging in the detection of clinical tendinopathy and the methodological issues associated with these studies (subject selection, lack of a robust gold standard, reliance on subjective measures). The advent of new imaging modalities allowing for the quantification of tendon structure or mechanical properties has allowed new critical insight into tendon pathology. A strength of these novel modalities is the ability to quantify properties of the tendon. Research utilizing ultrasound tissue characterization and sonoelastography will be discussed. This narrative review will also attempt to synthesize current research on whether imaging can predict the onset of pain or clinical outcome, the role of monitoring tendon structure during rehabilitation (ie, does tendon structure need to improve to get a positive clinical outcome?), and future directions for research, and to propose the clinical role of imaging in tendinopathy. J Orthop Sports Phys Ther 2015;45(11):842-852. Epub 21 Sep 2015. doi:10.2519/jospt.2015.5880.
Patellar tendon pain is a significant problem in athletes who participate in jumping and running sports and can interfere with athletic participation. This clinical commentary reviews patellar tendon anatomy and histopathology, the language used to describe patellar tendon pathology, risk factors for patellar tendinopathy and common interventions used to address patellar tendon pain. Evidence is presented to guide clinicians in their decision-making regarding the treatment of athletes with patellar tendon pain. Level of Evidence 5 PMID:27904789
Bidell, Monique R; Lodise, Thomas P
Fluoroquinolone antibiotics recently have gained increased national attention due to safety concerns. A well-described and serious adverse event associated with receipt of fluoroquinolones is tendinitis and tendon rupture. These tendon injuries can result in long-term sequelae, including chronic pain and mobility restrictions, and may warrant surgery. Due to the severity of these adverse events, a black box warning is included in the product labeling of all fluoroquinolones. In light of the mounting concerns surrounding fluoroquinolone-associated toxicities, the purpose of this clinical review is to provide a comprehensive summary of the risk of tendinopathy associated with levofloxacin, one of the most widely prescribed antibiotics in the United States, across in vitro, animal, and clinical studies, relative to other antibiotics. As part of this review, clinical presentation and onset, proposed mechanisms, patient-specific risk factors, and management of fluoroquinolone-induced tendon injury are summarized. Data were obtained from a comprehensive PubMed literature search and a review of U.S. Food and Drug Administration documents. Although tendinopathy is considered a fluoroquinolone class-wide toxicity, data from in vitro studies, animal studies, patient-level analyses, and large national and international surveillance reports suggest that levofloxacin, as well as its parent compound ofloxacin, possess higher propensities to cause tendon damage relative to other fluoroquinolones. Risk with ofloxacin and levofloxacin appears to be exposure dependent, with higher doses and longer durations being most commonly associated with tendinopathy. Other well-described patient risk factors for fluoroquinolone-associated tendinopathy include older age (older than 60 yrs), receipt of concomitant corticosteroid therapy, presence of renal dysfunction, and history of solid organ transplantation. Given widespread use of levofloxacin across patient care settings, knowledge of both
Littlewood, Chris; Ashton, Jon; Chance-Larsen, Ken; May, Stephen; Sturrock, Ben
Shoulder pain due to rotator cuff tendinopathy is a common problem. Exercise is one intervention used to address this problem but conclusions from previous reviews have been mixed. To systematically review the effectiveness of exercise, incorporating loaded exercise (against gravity or resistance), for rotator cuff tendinopathy. An electronic search of AMED, CiNAHL, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PEDro and SPORTDiscus was undertaken from their inception to November 2010 and supplemented by hand searching related articles and contact with topic experts. Randomised controlled trials evaluating the effectiveness of exercise, incorporating loaded exercise, in participants with rotator cuff tendinopathy. Included studies were appraised for risk of bias using the tool developed by the Cochrane Back review Group. Due to heterogeneity of studies, a narrative synthesis was undertaken based upon levels of evidence. Five articles detailing four studies were included, all of which were regarded as presenting a low risk of bias. Overall, the literature was supportive of the use of exercise in terms of pain and functional disability. The results should be regarded with some degree of caution due to limitations associated with the studies including lack of blinding, no intervention control groups and limitations of the outcome measures used. CONCLUSION AND IMPLICATIONS OF KEY FINDINGS: The available literature is supportive of the use of exercise but due to the paucity of research and associated limitations further study is indicated. Copyright © 2011 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
Kachooei, Amir Reza; Nota, Sjoerd P.F.T; Menendez, Mariano E; Dyer, George S.M.; Ring, David
Background: Geographic and doctor-to-doctor variations in care are a focus of quality and safety efforts in medicine. This study addresses factors associated with variation in the rate of operative treatment of de Quervain tendinopathy. Methods: We used a database including all patient encounters at 2 large medical centers, to study the experience of 10 hand surgeons and 1 physiatrist working in a hand surgery office in the treatment of 2,513 patients with de Quervain tendinopathy over a 12-year period. Survival analysis using the Kaplan-Meier method was used to compare surgery rates and time to surgery. Cox multivariable regression analysis was applied to identify factors associated with operative treatment. Results: One hundred ninety nine (7.9%) patients had surgery. The odds of operative treatment were 1.7 times greater after corticosteroid injection and varied more than 10-fold among providers. There was substantial variation in the overall rate of surgery by provider. Corticosteroid injection delayed surgery slightly, but was associated with a higher rate of surgery. Conclusion: Providers have substantial influence on treatment of de Quervain tendinopathy. The use of decision aids and other methods that help involve the patient in decision-making merit investigation as interventions to help reduce doctor-to-doctor variation. PMID:26213704
Abate, Michele; Guelfi, Matteo; Pantalone, Andrea; Vanni, Daniele; Schiavone, Cosima; Andia, Isabel; Salini, Vincenzo
Summary Background Hormones can modify tendon homeostasis, some of them leading to tendon damage, while others are essentials for healing. This narrative review summarizes the current knowledge on the topic, focusing on the hormones normally secreted by endocrine glands. Methods A search in PubMed, Web of Knowledge and EMBASE, using the terms tendinopathy or tendon, combined with estrogens, testosterone, thyroid and parathyroid hormones, glucocorticoids and growth hormone, independently, was performed. Relevant articles focusing on the correlation between hormones and tendons, and their therapeutic use in tendinopathies, were selected. Results Tendon abnormalities observed in subjects with hyperparathyroidism, hypercortisolism and acromegaly are described. At present, experimental studies and preliminary observations in humans suggest that parathyroid and growth hormones, locally administered, are promising therapeutic tools in specific tendon disorders. Local injections of glucocorticoids are useful in several tendinopathies, exploiting their anti-inflammatory and anti-proliferative properties, but carry the risk of further tendon degeneration and ruptures, due to the detrimental direct effect of glucocorticoids on the tendon structure. Conclusion Because tendons injuries are frequent, often with long lasting sequels, it is important to improve our understanding concerning the therapeutic potential of hormones on healing. Level of evidence IV. PMID:28217565
Kachooei, Amir Reza; Nota, Sjoerd P F T; Menendez, Mariano E; Dyer, George S M; Ring, David
Geographic and doctor-to-doctor variations in care are a focus of quality and safety efforts in medicine. This study addresses factors associated with variation in the rate of operative treatment of de Quervain tendinopathy. We used a database including all patient encounters at 2 large medical centers, to study the experience of 10 hand surgeons and 1 physiatrist working in a hand surgery office in the treatment of 2,513 patients with de Quervain tendinopathy over a 12-year period. Survival analysis using the Kaplan-Meier method was used to compare surgery rates and time to surgery. Cox multivariable regression analysis was applied to identify factors associated with operative treatment. One hundred ninety nine (7.9%) patients had surgery. The odds of operative treatment were 1.7 times greater after corticosteroid injection and varied more than 10-fold among providers. There was substantial variation in the overall rate of surgery by provider. Corticosteroid injection delayed surgery slightly, but was associated with a higher rate of surgery. Providers have substantial influence on treatment of de Quervain tendinopathy. The use of decision aids and other methods that help involve the patient in decision-making merit investigation as interventions to help reduce doctor-to-doctor variation.
Bateman, Marcus; Adams, Nicola
To conduct a feasibility study to compare concentric and eccentric rotator cuff strengthening exercises for rotator cuff tendinopathy. A total of 11 patients with rotator cuff tendinopathy who were on the waiting list for arthroscopic subacromial decompression surgery were randomised to perform eccentric rotator cuff strengthening exercises, concentric strengthening exercises or no exercises. Patients were evaluated in terms of levels of pain and function using the Oxford Shoulder Score and a Visual Analogue Scale initially, at 4 weeks and at 8 weeks. The study design was found to be acceptable to patients and achieved a high level of 86% compliance. The drop-out rate was 0%. Two patients performing eccentric strengthening exercises improved sufficiently to cancel their planned surgery. Further research in this area is recommended. The study design was feasible and power calculations have been conducted to aid future research planning.
Park, Jin-Young; Lee, Jae-Hyung; Oh, Kyung-Soo; Chung, Seok-Won; Bang, Jin-Young; Noh, Young-Min
Tendinopathy of the long head of the biceps is often found as an intra-articular pathology in the glenohumeral joint. Because long head of the biceps lesions are common, surgical intervention to properly manage the long head of the biceps has become an important issue. Both tenodesis and tenotomy have been shown to provide benefits in biceps long head tendinopathy. But because of concerns about muscle power reduction, cramping, and "Popeye's deformity," which may result from biceps tenotomy, biceps tenodesis is a good option for treating biceps lesions. Here, we describe a time-saving, simple, and secure biceps tenodesis method during rotator cuff repairs, which is a combination of an adjacent soft-tissue tenodesis and a bony suprapectoral tenodesis, by performing a combined tenodesis (soft + bony), and we believe that the shoulder joint will gain more strength and loosening complications will be reduced.
Rui, Yunfeng; Guo, Yonggang; Lin, Yucheng; Ma, Liangyu; Cheng, Xinkun; Chen, Hui; Wang, Chen
To investigate the effects of bone morphogenetic protein 2 (BMP-2) on the chondrogenic differentiation of human Achilles tendon-derived stem cells (hATDSCs) in vitro. Achilles tendon was harvested from a voluntary donor with acute Achilles tendon rupture. And nucleated cells were obtained by digesting with collagenase and were cultured to the 3rd passage. The flow cytometry was used to measure the immunophenotyping; and Oil red O staining, alizarin red staining, and Safranin O/fast green staining were used to identify the adipogenic differentiation, osteogenic differentiation, and chondrogenic differentiation, respectively. The hATDSCs pellet was cultured in complete culture medium with (experimental group) or without recombinant human BMP-2 (rhBMP-2) (control grup) for 3 weeks. Chondrogenic differentiation of hATDSCs was evaluated by HE staining, Safranin O/fast green staining, and immunohistochemical staining for collagen type II; and the mRNA expressions of SOX9, collagen type II, and Aggrecan were detected by real-time fluorescence quantitative PCR. Primary hATDSCs cultured in vitro showed clonal growth; after cell passage, homogeneous spindle fibroblast-like cells were seen. The cells were positive for CD44, CD90, and CD105, while negative for CD34, CD45, and CD146. The results were positive for Oil red O staining at 3 weeks after adipogenic differentiation, for alizarin red staining at 4 weeks after osteogenic differentiation, and for Safranin O/fast green staining at 3 weeks after chondrogenic differentiation. After hATDSCs were induced with rhBMP-2 for 3 weeks, pellets formed in the experimental group, and the size of pellets was significantly larger than that in the control group; the results of HE staining, Safranin O/fast green staining, and immunohistochemical staining for collagen type II were all positive. The results of real-time fluorescence quantitative PCR showed that the mRNA expressions of SOX9, collagen type II, and Aggrecan in the experimental
Han, Soo-Hong; Choi, Wonchul; Song, Jiye; Kim, Jaehee; Lee, Seungyong; Choi, Youngrak; Byun, Seong-Eun; Ahn, Taekeun; Ahn, Heejung; Ding, Catherine; Baik, Lloyd; Ward, Spencer; Ting, Kang; Lee, Soonchul
It was reported that substance P had beneficial effects in the healing of acute tendon injury. However, the relationship between substance P and degenerative tendinopathy development remains unclear. The purpose of this study was to determine the role of substance P in the pathogenesis of tendinopathy. Healthy and tendinopathy tendon were harvested from human and tenocytes were cultured individually. The expression levels of genes associated with tendinopathy were compared. Next, substance P was exogenously administered to the healthy tenocyte and the effect was evaluated. The results showed that tendinopathy tenocytes had higher levels of COL3A1, MMP1, COX2, SCX, ACTA2, and substance P gene expression compared to healthy tenocytes. Next, substance P treatment on the healthy tenocyte displayed similar changes to that of the tendinopathy tenocytes. These differences between the two groups were also determined by Western blot. Additionally, cells with substance P had the tendinopathy change morphologically although cellular proliferation was significantly higher compared to that of the control group. In conclusion, substance P enhanced cellular proliferation, but concomitantly increased immature collagen (type 3 collagen). Substance P plays a crucial role in tendinopathy development and could be a future therapeutic target for treatment.
Han, Soo-Hong; Choi, Wonchul; Song, Jiye; Kim, Jaehee; Lee, Seungyong; Choi, Youngrak; Byun, Seong-Eun; Ahn, Taekeun; Ahn, Heejung; Ding, Catherine; Baik, Lloyd; Ward, Spencer; Ting, Kang; Lee, Soonchul
It was reported that substance P had beneficial effects in the healing of acute tendon injury. However, the relationship between substance P and degenerative tendinopathy development remains unclear. The purpose of this study was to determine the role of substance P in the pathogenesis of tendinopathy. Healthy and tendinopathy tendon were harvested from human and tenocytes were cultured individually. The expression levels of genes associated with tendinopathy were compared. Next, substance P was exogenously administered to the healthy tenocyte and the effect was evaluated. The results showed that tendinopathy tenocytes had higher levels of COL3A1, MMP1, COX2, SCX, ACTA2, and substance P gene expression compared to healthy tenocytes. Next, substance P treatment on the healthy tenocyte displayed similar changes to that of the tendinopathy tenocytes. These differences between the two groups were also determined by Western blot. Additionally, cells with substance P had the tendinopathy change morphologically although cellular proliferation was significantly higher compared to that of the control group. In conclusion, substance P enhanced cellular proliferation, but concomitantly increased immature collagen (type 3 collagen). Substance P plays a crucial role in tendinopathy development and could be a future therapeutic target for treatment. PMID:28598390
Helfenstein-Didier, C.; Andrade, R. J.; Brum, J.; Hug, F.; Tanter, M.; Nordez, A.; Gennisson, J.-L.
The shear wave velocity dispersion was analyzed in the Achilles tendon (AT) during passive dorsiflexion using a phase velocity method in order to obtain the tendon shear modulus (C 55). Based on this analysis, the aims of the present study were (i) to assess the reproducibility of the shear modulus for different ankle angles, (ii) to assess the effect of the probe locations, and (iii) to compare results with elasticity values obtained with the supersonic shear imaging (SSI) technique. The AT shear modulus (C 55) consistently increased with the ankle dorsiflexion (N = 10, p < 0.05). Furthermore, the technique showed a very good reproducibility (all standard error of the mean values <10.7 kPa and all coefficient of variation (CV) values ⩽0.05%). In addition, independently from the ankle dorsiflexion, the shear modulus was significantly higher in the proximal location compared to the more distal one. The shear modulus provided by SSI was always lower than C55 and the difference increased with the ankle dorsiflexion. However, shear modulus values provided by both methods were highly correlated (R = 0.84), indicating that the conventional shear wave elastography technique (SSI technique) can be used to compare tendon mechanical properties across populations. Future studies should determine the clinical relevance of the shear wave dispersion analysis, for instance in the case of tendinopathy or tendon tear.
O'Brien, Etienne John Ogilvy; Shrive, Nigel G; Rosvold, Joshua M; Thornton, Gail M; Frank, Cyril B; Hart, David A
Heterotopic mineralization may result in tendon weakness, but effects on other biomechanical responses have not been reported. We used a needle injury, which accelerates spontaneous mineralization of murine Achilles tendons, to test two hypotheses: that injured tendons would demonstrate altered biomechanical responses; and that unilateral injury would accelerate mineralization bilaterally. Mice underwent left hind (LH) injury (I; n = 11) and were euthanized after 20 weeks along with non-injured controls (C; n = 9). All hind limbs were examined by micro computed tomography followed by biomechanical testing (I = 7 and C = 6). No differences were found in the biomechanical responses of injured tendons compared with controls. However, the right hind (RH) tendons contralateral to the LH injury exhibited greater static creep strain and total creep strain compared with those LH tendons (p ≤ 0.045) and RH tendons from controls (p ≤ 0.043). RH limb lesions of injured mice were three times larger compared with controls (p = 0.030). Therefore, despite extensive mineralization, changes to the responses we measured were limited or absent 20 weeks postinjury. These results also suggest that bilateral occurrence should be considered where tendon mineralization is identified clinically. This experimental system may be useful to study the mechanisms of bilateral new bone formation in tendinopathy and other conditions.
Sugioka, Kaori; Nakagawa, Koichi; Murata, Ryo; Ochiai, Nobuyasu; Sasho, Takahisa; Arai, Momoko; Tsuruoka, Hiroaki; Ohtori, Seiji; Saisu, Takashi; Gemba, Takefumi; Takahashi, Kazuhisa
The purpose of this study was to test if radial shock waves could enhance the introduction of nuclear factor-kappa B (NF-kappaB) decoy oligodeoxynucleotides, which is reported to markedly inhibit NF-kappaB activation and suppress pro-inflammatory cytokine gene expression, using rat Achilles tendon cells. In the presence of NF-kappaB decoy labeled with or without fluorescein isothiocyanate (FITC) in culture media, radial shock waves were applied to the tendon cells in variable conditions and cultivated for 24 h. The transfection rate was assessed by counting FITC-positive cells, and IL-1-induced NF-kappaB activation in the cells was assessed. Radial shock waves significantly enhanced introduction of NF-kappaB decoy-FITC into the tendon cells. IL-1-induced NF-kappaB activation was significantly inhibited by pretreatment of the cells with NF-kappaB decoy combined with radial shock wave exposure. The present study demonstrated the effectiveness of radial shock waves on introduction of NF-kappaB decoy into tendon cells. Radial shock wave treatment combined with local NF-kappaB decoy administration could be a novel therapeutic strategy for chronic tendinopathy.
Toliopoulos, Panagiota; Desmeules, François; Boudreault, Jennifer; Roy, Jean-Sébastien; Frémont, Pierre; MacDermid, Joy C; Dionne, Clermont E
The objective of this study is to review randomized controlled trials evaluating the efficacy of surgery for the treatment of rotator cuff (RC) tendinopathy. Studies up to August 2013 were located in the PubMed, Embase, CINAHL, and PEDro databases using relevant keywords. Studies were included if: (1) participants had rotator cuff tendinopathy, (2) the trials were conducted on an adult population (≥18 years old), (3) at least one of the interventions studied was a surgical procedure, (4) study design was a randomized controlled trial (RCT), and (5) the article was written in English or French. Characteristics of the included studies were extracted using a standardized form. Two independent raters reviewed the methodological quality of the studies using the Risk of Bias Assessment tool developed by the Cochrane Collaboration Group. Differences were resolved by consensus. Fifteen trials met our inclusion criteria. After consensus, the mean methodological quality for all studies was 58.9 ± 10.8 %. In three out of four RCTs of moderate or low methodological quality, no significant difference in treatment effectiveness was observed between open or arthroscopic acromioplasty compared to exercises in the treatment of RC tendinopathy. Based on two studies of low or moderate methodological quality, no difference in treatment effectiveness was observed between arthroscopic and open acromioplasty. Two other RCTs of low to moderate quality, however, found that arthroscopic acromioplasty yielded better results in the short-term for shoulder range of motion in flexion but that both procedures were comparable in the long-term. One additional study favored open acromioplasty over arthroscopic acromioplasty for the treatment of RC tendinopathy. Based on low- to moderate-quality evidence, acromioplasty, be it open or arthroscopic, is no more effective than exercises for the treatment of RC tendinopathy. Low-grade evidence also suggests that arthroscopic acromioplasty may
Wang, Cong-hua; Feng, Yuan; Ren, Zhen; Yang, Xichao; Jia, Jun-feng; Rong, Meng-yao; Li, Xue-yi; Wu, Zhen-biao
Enthesitis is considered as the primary anatomical lesion in ankylosing spondylitis (AS). We aimed to investigate the potential of ultrasound to detect early changes after TNF-a antagonist therapy of Achilles enthesitis of AS patients. One hundred AS patients with active disease, requiring TNF-a antagonist therapy, were included (etanercept n = 25, infliximab n = 25, adalimumab n = 25, non-biologic disease-modifying antirheumatic drugs (DMARDs) n = 25). Physical examination was performed to evaluate disease activity and detect Achilles enthesitis and/or retrocalcaneal bursitis. Ultrasound of the Achilles enthesitis was performed bilaterally. Follow-up examinations were performed 3 months after the initiation of therapy. Gray scale (GS) scores, Power Doppler (PD) scores, and total additive scores (TS) decreased significantly during TNF-a antagonist therapy but not in traditional non-biologic traditional DMARDs group. The bath ankylosing spondylitis disease activity index (BASDAI), bath ankylosing spondylitis metrology index (BASMI), bath ankylosing spondylitis functional index (BASFI), and Maastricht ankylosing spondylitis enthesitis score (MASES) all showed significant improvements. When three different TNF-a antagonists were analyzed separately, no significant difference was observed in GS, PD, and total scores. Subclinical Achilles enthesitis, detected only with GS ultrasound, is present in a subset of AS patients and a significant improvement can be demonstrated after 3 months of TNF-a antagonist therapy. Doppler ultrasound provides a reliable estimation to monitor the therapeutic response to TNF antagonists in AS patients with Achilles enthesitis. TNF-a antagonists have been shown to be effective in decreasing ultrasound signs of enthesitis after 3 months of therapy in AS patients.
Griffin, Matthew J; Olson, Kirstina; Heckmann, Nathanael; Charlton, Timothy P
Acute complete Achilles tendon ruptures are commonly missed injuries. We propose the Realtime Achilles Ultrasound Thompson (RAUT) test, a Thompson test under ultrasound visualization, to aid in the diagnosis of these injuries. We hypothesized that RAUT testing would provide improved diagnostic characteristics compared with static ultrasound. Twenty-two consecutive patients with operatively confirmed acute Achilles tendon ruptures were prospectively evaluated with RAUT testing and static ultrasonography. RAUT video recordings and static ultrasound images from both ruptured and uninjured sides were randomized and graded by a group of novice reviewers and a group of expert attendings. From these observations, sensitivity, specificity, positive predictive value, and negative predictive value for RAUT and static ultrasound were calculated. In addition, κ interobserver coefficients were computed. Forty-seven novice reviewers and 11 foot and ankle attendings made a total of 4136 and 528 observations, respectively. For static ultrasound, sensitivity and specificity were 76.8% and 74.8% for the novice reviewers and 79.6% and 86.4% for the attendings, respectively. For RAUT testing, sensitivity and specificity were 87.2% and 81.1% for the novice group and 86.4% and 91.7% for the attending group, respectively. The κ coefficient was 0.62 and 0.27 for novice and attending RAUT reviewers, indicating substantial and fair agreement, respectively, but only 0.46 and 0.12 for static ultrasonography, representing moderate and slight agreement, respectively. RAUT testing was a sensitive and specific test, providing a cost-effective adjunct to the clinical examination when diagnosing acute Achilles tendon ruptures. This test can be used by surgeons with minimal training in ultrasonography. Level II, diagnostic study.
Nan, Jiang; Xiang, Dayong; Yu, Bin
To review the progress in the treatment of acute Achilles tendon rupture. Recent literature about the treatment of acute Achilles tendon rupture was reviewed and analyzed. Treatments of acute Achilles tendon rupture include operative and non-operative treatments. Operative treatments include open surgery and percutaneous minimally invasive surgery. Compared with non-operative treatment, operative treatment can effectively reduce the re-rupture incidence, but it had higher complication incidences of wound infection and nerve injury. Although early functional rehabilitation during non-operative treatment could reduce the re-rutpture incidence, there is no consistent orthopaedic device and guideline for functional rehabilitation. Both operative and non-operative treatments have advantages and disadvantages for the treatment of acute Achilles tendon rupture. No consistent conclusion is arrived regarding functional recovery. Future studies should explore the strategy of early functional rehabilitation during non-operative treatment and its mechanism of promoting tendon healing.
Patel, Vishal C; Chandrakant, Vishal; Lozano-Calderon, Santiago; McWilliam, James
Controversy exists regarding postoperative treatment of Achilles tendon repair. The purpose of this study was to evaluate the results of immediate weight bearing following modified percutaneous Achilles tendon repair using readily available materials. Fifty-two patients who were treated at a single center from 2000 to 2009 underwent percutaneous Achilles tendon repair by a single surgeon and were allowed immediate weight bearing. They were followed for on average of 2 years postoperatively and evaluated with functional and subjective outcomes. The average American Orthopaedic Foot and Ankle Society ankle-hindfoot scale was 96 points (range, 81 to 100), with 95% confidence interval ranging from 89.1 to 102.9. Subjective evaluation demonstrated that 47 patients (90%) were able to return to a desired level of activity, with an overall complication rate of 11.5%. Immediate weight bearing after percutaneous Achilles tendon repair had a low overall complication rate with good clinical and functional outcomes.
Singh, Amarjeet; Nag, Kushal; Roy, Shuvendu P; Gupta, Ramesh Chandra; Gulati, Vaibhav; Agrawal, Nikunj
To report 22 patients who underwent repair of compound Achilles tendon ruptures with peroneus brevis tendon augmentation. Records of 6 women and 19 men aged 21 to 42 (mean, 28) years who underwent repair of compound Achilles tendon ruptures with peroneus brevis tendon augmentation were reviewed. All the wounds were transverse/oblique, minimally contaminated, and could be closed primarily. Patients were evaluated at months 3, 9, and 12, using the Foot and Ankle Outcome Score (FAOS) questionnaire. Of the 22 patients, 3 developed superficial skin complications that healed gradually, and 2 developed a superficial discharging sinus and underwent minor debridement. No patient had a re-rupture of the Achilles tendon. At the one-year follow-up, all patients achieved good functional outcome in terms of the FAOS. Repair of Achilles tendon ruptures with peroneus brevis tendon augmentation achieved good functional outcome.
Monto, Raymond Rocco
Chronic Achilles tendinosis is a relatively common but difficult orthopedic condition to treat. In this study, autologous platelet rich plasma (PRP), a concentrated bioactive blood component rich in cytokines and growth factors, was evaluated to determine its potential long-term efficacy in treating chronic cases of Achilles tendinosis resistant to traditional nonoperative management. Thirty patients with chronic Achilles tendinosis who did not respond to a minimum of 6 months of traditional nonoperative treatment modalities were treated with a single ultrasound guided injection of PRP. AOFAS scoring was completed for all patients pretreatment and at 0, 1, 2, 3, 6, 12, and 24 months post-treatment. MRI and/or ultrasound studies were completed for all patients pre-treatment and at 6 months post-treatment. Prior to the PRP treatment all of the patients in this study were considering surgical Achilles repair for t